CERTIFICATE OF LIABILITY INSURANCE - RFQ 34-15 (9)Client#: 1048826 INTERENG2
DATE 1(MM,1DD7.11YYYY)
m"' yyyy'
ACORD-,, CERTIFICATE OF LIABILITY INSURANCE T 0 01
06/09P'20
16
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 IN$URER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
I-c"a,te-Folder Is a-n-ADDITIONAL —"
INSURED, the POIICY0eS) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy, certain policies may require an endorsement, A staterrient on this certificate does not confer rights to the
certcate holder in lieu of such enclorsement(s),
PRODUCER
COARME;
USN Insurance Services, LLC, P�M �NE . .....
_C4
1715 N. Westshore Blvd. Suite 700 C, -7500 FJW
No, Ell: 813 321 813 321-7525
E-MAIL
Tampa, FL 33607 ADDRESS:_.
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
TI OS IS TO CER7IFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORTHE POUCYPEROD
BNM TFD, ANY REQUIREMENT. TERM OR CONDfTON0F ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
G'ERFIFICATE 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, LIM,17S SHOWN, MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Y_ Y EFF ... . . .. . . . ......
INSR_WVD.. POLICY NUMBER
1509usiff'— 061LIC71 —1 Q16V XF
TR PE OF INSURANCE �MWDWYYYYJ I W "I"..... LIMITS
(MM DO/YYYY)
A X COMMERCIAL GENERAL LIABILITY
.1 . i F X X 68019221_734 0161016L, 011 6 06/06/2017 EACH OCCURRENCE C-2,000,000
Oi J
LAIMS-MADE i k I TO RENTED
GEN1 AGGREGATE LIMIT APPLIES PER:
F PRO
POLICY JE'CT LOC
OTHER,
A AUTOMOBILE L I A B ILITY
X X 6801
ANY AUTO
ALL CWNEr� SCHEDULED
AU70S ALYTO',,
X HIRED AUTOS X 01ANED
AUTOIS
UMBRELLA LJAS OCCUR
EXCESS LIAR "i
LCLAIM9 MADE,
P
B WORKERS COMPENSATION
I AND EMPLOYERS' LIABILITY Y -'N X U89096Y735
,ANY PROPRIE'roR/PART,NER,(EXECJTIVE-
OFFICERJOEMBER EXCLUDEC? jr N, A'. L, EACH ACCIDENT
(Mandatory In NH) _ i $1 tQ901poo
I f ns. des c be u ndef [.KJ_ MSE Sin - EA EMPLDYEE� S 1 000
D . SCRIPTION 0 OPERATIONS b,Llow . ..... . ...... . 1000,
E.L DISEASE - POLICY LIMIT $1,000,000
C Professional DPS9724407 6/0612016 06/0-6/-2-017 $1,000,000 per' . clat - im
Liability
$1,000,000 anni aggr,
DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (ACORD 101 . Additional Remarks Schedule, may OL attached If mDre space is requlred)
Professional Liability coverage is written on a claims-made basis.
REFERENCE. RFQ #34-15
Certificate holder is an additional insured with respect to the General Liability arkAW6`d,"1 Tmy'0201") icy
as required by written contract.
City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBM9Q=4AACr,�ED BEF611ri
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Engineering Dept. ACCORDANCE WITH THE POLICY PROVISIONS.
100 S. Myrtle Ave., #220
Clearwater, FL 33756 AUTHORIZED REPRESENTATIVE
C 1988.2014 ACORD92APORATIlON�. N. I., eserme
ACC} 25 (2014101) 0 g h �t�g r ;1�rma
1 of The ACORD name and logo are registered marks of ACORD
#S17999568/M17999564 GITEW
PN FS-E 5JyR
MED EXP (Any one person) $I 91NO
& ADV lkJ,JRY s2',000,00
/t
.PERSONAL
GENERAL' AGGREGATE s4,000,00
11R0DUC7$.00MR0PAGG $4000,00
COMBINED-SNG-E LIM,�7
5/06!2616 06/06/2017'kag...i
0 dent 0 OQ
J __$2!Lql�
BODILY INJURY (Per LSD lSan) S
BODILY INJURY yPer acodeit)'S
rr[111PEI � DAMAGE...... - ............. -
�y accident . . $
d r ..... .
. . ........ . . ....
. ....... . .. .... . ..... . . .... . S
EACH OCCURRENCE
AGGREGATE
. . ...... . .... . __ ... . ...... .
3 03/1212i �lj'-X_T�F czTATI ER
/12/2016 fTr OTH
OFFICERJOEMBER EXCLUDEC? jr N, A'. L, EACH ACCIDENT
(Mandatory In NH) _ i $1 tQ901poo
I f ns. des c be u ndef [.KJ_ MSE Sin - EA EMPLDYEE� S 1 000
D . SCRIPTION 0 OPERATIONS b,Llow . ..... . ...... . 1000,
E.L DISEASE - POLICY LIMIT $1,000,000
C Professional DPS9724407 6/0612016 06/0-6/-2-017 $1,000,000 per' . clat - im
Liability
$1,000,000 anni aggr,
DESCRIPTION OF OPERATIONS I LOCATIONS i VEHICLES (ACORD 101 . Additional Remarks Schedule, may OL attached If mDre space is requlred)
Professional Liability coverage is written on a claims-made basis.
REFERENCE. RFQ #34-15
Certificate holder is an additional insured with respect to the General Liability arkAW6`d,"1 Tmy'0201") icy
as required by written contract.
City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBM9Q=4AACr,�ED BEF611ri
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Engineering Dept. ACCORDANCE WITH THE POLICY PROVISIONS.
100 S. Myrtle Ave., #220
Clearwater, FL 33756 AUTHORIZED REPRESENTATIVE
C 1988.2014 ACORD92APORATIlON�. N. I., eserme
ACC} 25 (2014101) 0 g h �t�g r ;1�rma
1 of The ACORD name and logo are registered marks of ACORD
#S17999568/M17999564 GITEW