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CERTIFICATE OF LIABILITY INSURANCE (404)ACOR" CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD YYYY) CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, 06/21/2016 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 have ADDITIONAL INSURED provisions or 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 CONTACT NAME: Lawrence Graves Talbert Insurance Services ,C, No EXt: (770)497 -9400 (,,/c No): (770)813 -8535 ADDARESS: Italbert @talbertservices.com 3473 Satellite Blvd, Suite 114 INSURER(S) AFFORDING COVERAGE NAIC# Duluth, GA 30096 INSURERA: Auto Owners Insurance 10190 INSURED INSURER B: Auto Owners Insurance 18988 Cribb Philbeck Weaver Group, Inc INSURERC: RLI 13056 DBA and CPWG Constructors LLC MED EXP (Anyone person) $ 10,000 3918 N Highland Ave INSURER D: Tampa, FL 33603 -4724 INSURER E: PERSONAL & ADV INJURY $ 1,000,000 INSURER F: COVERAGES CERTIFICATE NUMBER: 00000000 -91921 REVISION NUMBER: 37 THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Vu1TH 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF MM /DD/YYYY POLICY EXP MM /DD/YYYY LIMITS A X COMMERCIAL GENERAL LIABILITY Y 80376192 06/03/2016 06/03/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE [XI OCCUR DAMAGE RENTED PREM SESOEa ... rrrence $ 300,000 MED EXP (Anyone person) $ 10,000 PERSONAL & ADV INJURY $ 1,000,000 AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 GEN'L POLICY PR 1:1 LOC PRODUCTS - COMP /OP AGG $ 2,000,000 $ OTHER: B AUTOMOBILE LIABILITY 5037622000 06/03/2016 06/03/2017 COMBINED (Ea acccdentsINGLELIMIT $ 1 000 000 ,, BODILY INJURY (Per person) $ X ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per accident $ X HIRED NON -OWNED AUTOS ONLY X AUTOS ONLY $ X AUTOMATIC APP(q APP( INSURED STATUS A X UMBRELLA LIAB OCCUR 5037624900 06/03/2016 06/03/2017 EACH OCCURRENCE $ 2,000,000 AGGREGATE $ 2,000,000 EXCESS LIAB X CLAIMS -MADE DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y❑ 80040655 06/03/2016 06/03/2017 X PER OTH- STATUTE ER E.L. EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? (Mandatory in NH) N/A E.L. DISEASE - EA EMPLOYEE $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 1,000,000 C PROFESSIONAL RDP0023472 02/06/2016 02/06/2017 PER CLAIM $1,000,000 LIABILITY AGGREGATE $3,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) GENERAL LIABILITY INCLUDES BLANKET ADDITIONAL INSURED (FORM #55373 01/07) GENERAL LIABILITY INCLUDES BLANKET WAIVER OF SUBROGATION (FORM #55352 10/08) CERTIFICATE HOLDER CANCELLATION CITY OF CLEARWATER ENGINEERING RFQ #34 -15 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. POST OFFICE BOX 4748 CLEARWATER, FLORIDA 33758 -4748 AUTHORIZED REPRESENTATIVE / ti..._2 (LEG) © 1988 -2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Printed by LEG on June 21, 2016 at 03:08PM AGENCY CUSTOMER ID: 00000000 LOC #: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Talbert Insurance Services Cribb Philbeck Weaver Group, Inc DBA and CPWG Constructors LLC POLICY NUMBER N/A CARRIER NAIC CODE Multiple Carriers EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance CITY OF CLEARWATER IS ADDITIONAL INSURED WITH REGARD TO THE GENERAL LIABILITY ON A PRIMARY and NON - CONTRIBUTORY BASIS (FORM #55373 01/07 BLANKET). (30) DAY WRITTEN NOTICE OF ANY CANCELLATION, NON - RENEWAL, TERMINATION, MATERIAL CHANGE or REDUCTION IN COVERAGE APPLIES. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by LEG on June 21, 2016 at 03:08PM