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CERTIFICATE OF LIABILILTY INSURANCE
AjRb® �� CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DDmrYY) 6/24/2016 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 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 Bouchard Insurance P 0 Box 6090 Clearwater FL 33758 -6090 CONTACT NAME: PHONE 727.447 -6481 FAX 727- 449 -1267 (A/C, No, Ext): No): _(A/C E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Zurich American Insurance Co 16535 INSURED Hawkins Construction Inc P O Box 1636 Tarpon Springs FL 34688 INSURER B :American Guarantee & Liability 26247 INSURERC:St Paul Fire & Marine Ins Co 24767 INSURER D: $1,000,000 INSURER E : INSURER F : X COVERAGES CERTIFICATE NUMBER: 21474944 • 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 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. INSR LTR TYPE OF INSURANCE ADD[ISUBR INSD W VD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP (MM /DD/YYYY) LIMITS A x COMMERCIAL GENERAL LIABILITY Y Y GL000173260 RECEIVED v'�1 t ,JUN 3 f� 2016 OFFICIAL RC-C,pRDS 7/1/2016 /�® 7/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $1,000,000 MED EXP (Any one person) $10,000 X CONTRACTUAL PERSONAL &ADV INJURY $1,000,000 GEN'L AGGREGATE POLICY X OTHER:C��y��}��/� LIMIT APPLIES PE� PER: LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP /OP AGG $2,000,000 B AUTOMOBILE X LIABILITY ANY AUTO ALL OSVNED HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS Y Y p�� BAP00173259 -'— TI • ESMSetpT r ! 7/1/2017 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ C X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE Y Y ZUP41M6000516NF 7/1/2016 7/1/2017 EACH OCCURRENCE $10,000,000 AGGREGATE $10,000,000 DED X RETENT ON $0 $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N /A Y WC017326201 7/1/2016 7/1/2017 x PER STATUTE OTH- ER E.L. EACH ACCIDENT $1,000,000 E.L. DISEASE - EA EMPLOYEE $1,000,000 E.L. DISEASE - POLICY LIMIT $1 ,000,000 B RENTED & LEASED EQUIPMENT CPP00173263 7/1/2016 7/1/2017 LIMIT $150,000 DEDUCTIBLE $2,500 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) Please note that Bouchard Insurance is required to comply with the licensing agreement we hold with ACORD. ACORD, in conjunction with the Department of Insurance, creates and enforces the rules and regulations pertaining to proper use of the Certificate of Liability Insurance form. We are required to mark a "Y" or "N" (Yes or No) next to the line of business in which the Additional Insured or Waiver of Subrogation coverage applies. According to ACORD, the Description of Operations section must be limited to describing "information necessary to See Attached... CERTIFICATE HOLDER CANCELLATION CITY OF CLEARWATER 100 S MYRTLE AVE CLEARWATER FL 33756 SHOULD 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 ACORD 25 (2014/01) ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC R AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Pagel of 1 AGENCY Bouchard Insurance NAMED INSURED Hawkins Construction Inc P O Box 1636 Tarpon Springs FL 34688 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: CERTIFICATE OF LIABILITY INSURANCE identify the operations, locations and vehicles for which the certificate was issued." Please note the Description of Operations section of the Certificate cannot be used to add additional information except as just described. Marking a "Y" or "N" next to the line of business adequately documents coverage. Equally important, it satisfies the rules and regulations governing the proper use of the Certificate of Liability Insurance form. LICENSE HOLDERS:JOHN B MCCAUGHERTY JR LICENSE # CGC059737DONALD E ONDREJCAK LICENSE # CGC1512245MICHAEL S BEAUSIR LICENSE # CGC061198 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD