CERTIFICATE OF LIABILITY INSURANCE (699)P526W27iW2
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� ACORO DATE�YMIDDIYYYY)
��. CERTIFICATE OF LIABILITY INSURANCE I osizsiaoi6
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER 1-813-229-8021 CONTAC7 Sher He
M. 6. Wi180II CO., IaC. NAME: ='Y YWOOd• CRIS
PHONE 813-984-3603 �'F� 813-229-2795
(NC, Nq, Ext): '�,. �NC, No):
' 7
300 W. Platt St.
Ste 200
Tampa, FL 33606
INSURED . .. .. .
Adama Tank & Lift Inc.
AT & L Conetruction Services Inc.
4568 131at Ave N
Clearwater, PL 33762
E-MAIL Bbeywood2mewilson.com
ADDRES$: _. _
INSURER(S) AFFORDING COVERAGE
INSURER A: t7NDBRWRITERS AT LLOYDS LONDON
INSURERB:�'STFIELD INS CO
INSURER C :
INSURER D :
INSURER E :
NAIC Jt
15792
2aiia
COVERAGES CERTIFICATE NUMBER: 46914233 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDiCATEU. NO'fWiTiiSTANGING ANY REt�UIkEMENT, TcRM OR CONDITION OF qNY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INTRR �I � � TypE OF INSURANCE '��ADDL�,SUBR'�� pOLICY NUMBER II MMIDDY/YYVY �� MNIDDIVYYV '� LIMITS
A %� COMMERCULGENERALLIABILfTY I �pGI1�RR0215103 '�i07/20/15 ���, 07/20/16 '�� EACHOCCURRENCE '', j 1,000,000
�'� CLAIMS-MADE x'� OCCUR � ���. I ! ' DAMAGE TO RENTED � 100� 000
i �, . I ,., I II PREMISES (Ea occurrence) �', 3
i. �.,, .. . . ' ;I . ��i MED EXP (My one person) � $ 10 • 000
� X'i BF PD/COIItiaCtual �I II ��PERSONALSADVINJURY ij 1,000,000
i GEN'L AGGREGATE LIMIT APPLIES PER: �: I �I � GENERAL AGGREGATE I$ 2, 000, 000
i
�� � POLICY I X�I �E � I� I �p� il ,�. I '�. PRODUCTS - COMP/OP AGG '$ Z. 000, 000
' ' I �
' ��I OTHER: . i , � ,. E
8�I AUTOMOBILELIABILITV � �ClII�S1681102 I07/20/15 ',. 07/20/16 '� COMBINEDSINGLELIMIT i E 1,000,000
I (Ea accidenl)
� g '�.. ANY AUTO �. �',. I, .. � BODILY INJURY (Per person) ����.' E
�I �� ALL OWNED i ; SCHEDULED I, �� �� BODILY INJURY (Per accltlen!)'', $
� AUTOS I. i AUTOS
i i � NON-0WNED j � � PROPERTY DAMAGE
�I � HIREDAUTOS �.i � I � ��., I�� _
i AUTOS �, {Per accident)
� I% �Co�p/Co1118'0 , �
'Camp/Coll Deduct. 's $1,000
A UMBRELLALWB 'i X OCCUR I 'PGIXS0003603 107/20/15 '' 07/20/16 ', EACHOCCURRENCE S 4,000,000
' i � ' I t
$ i FJ(CESSLIAB I CLAIMS-MA�Ei �il I� I '� AGGREGATE I s 4�000�000
i
� DED I! I RETENTION $ ' � ' $
IWORKERS COMPENSATION �, I ! PER � . OTH-
AND EMPLOYERS' LUBILITY Y� N!, i I I ��I li �, STATUTE �I, ; ER �
ANY PROPRIETORIPARTNERIEXECUTIVE � � I
OFFICERIMEMBER EXCLUDED? � N/ A i I I � EL EACH ACCIDENT I, $
(Mandatory in NM) i �, �� '� ''� �'! E.L. DISEASE - EA EMPLOYE� $
� if yes, descdbe undet '� �� � �
��, DESCRIPTION OF OPERATIONS below � ' I ��. E.L. DISEASE - POLICY LIMIT '$
A �Contractor Poll/Prof Liab , PGIARR0215103 i07/20/15 !07/20/16 :8ach Claim 1,000,000
I I I IClaima Made I Aggregate 2,000,000
i
DESCRIPTION OF OPERATIONS / LOCATION51 VEHICLES (ACORD 101, Additbnal Ramarks Schedule, may ba attachsd if more space is required)
City of Clearwater ia named as an additional insured for general liability coverage.
City of Cleazwater
100 S. Myrtle Ave.
Clearwater, FL 33756-5520
ACORD 25 (2014101)
SH004
46914233
SHOULO ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTiCE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
��• µ,:i( 1�. ��h'Y�
USA 0
O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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