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CERTIFICATE OF LIABILITY INSURANCE (764)ACORiJ CERTIFICATE OF LIABILITY INSURANCE . DATE (MM/DD/YYYY) 7/28/2016 THJS 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 Bowen, Miclette & Britt of Florida, LLC 1020 N. Orlando Avenue Suite #200 Maitland FL 32751 NAMETACT Pam Medley PHONE (407) 647 -1616 FAX 628-1635 (arc, Nn, ExtL (A/C. No): ( 407 ) E -MAIL ADDRESS: certificates @bmbinc.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Amerisure Mutual Insurance Company 23396 INSURED ATLANTICSO Atlantic Southern Paving & Sealcoating, LLC P.O. Box 15591 Fort Lauderdale FL 33318 -5591 INSURER B :Amerisure Partners Insurance CO. 11050 INSURER C :Amerisure Insurance Company 19488 INSURER D $1,000,000 INSURER E : INSURER F : X COVERAGES :1696284543 • 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 ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y Y GL2093478 7/28/2016 7/28/2017 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 PERSONAL & ADV INJURY $1,000,000 GE 'L AGGREGATE POLICY OTHER: X LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP /OP AGG $2,000,000 $ B AUTOMOBILE X X LIABILITY ANY AUTO AUT OWNED HIRED AUTOS X SCHEDULED NON -OWNED AUTOS Y Y CA2093476 7/28/2016 7/28/2017 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ C X UMBRELLA UAB EXCESS LIAB X OCCUR CLAIMS -MADE Y Y CU2093480 7/28/2016 7/28/2017 EACH OCCURRENCE $4,000,000 AGGREGATE $4,000,000 DED X RETENT ON $0 $ C 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 N / A Y WC210043000 4/1/2016 4/1/2017 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 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space Is required) The following policy provisions and /or endorsements form part of the policies of insurance represented by this certificate of insurance. The terms contained in the policies and /or endorsements supersede the representations made herein. Electronic copies of the policy provisions and /or endorsements listed below are available by emailing: certificates @bmbinc.com When required by written contract, those parties listed in said contract, including the Certificate Holder, are added as an additional insured with respect to the General Liability, Auto Liability, and Umbrella Liability as afforded by the policy and /or endorsements. See Attached... CERTIFICATE HOLDER CANCELLATION City of Clearwater 100 S. Myrtle Ave., Suite 210 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 a� AGENCY CUSTOMER ID: ATLANTICSO LOC #: ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY Bowen, Miclette & Britt of Florida, LLC NAMED INSURED Atlantic Southern Paving & Sealcoating, LLC P.O. Box 15591 Fort Lauderdale FL 33318 -5591 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE. CERTIFICATE OF LIABILITY INSURANCE When required by written contract, waiver of subrogation is granted with respect to the General Liability, Auto Liability, Workers Compensation, and Umbrella Liability to those parties listed in said contract, including the Certificate Holder. The General Liability, Auto Liability, and Umbrella Liability certified herein are primary and non - contributory to other insurance available, but only to the extent required by written contract. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTOR'S BLANKET ADDITIONAL INSURED ENDORSEMENT - FORM A This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART Policy Number GL2093478 Agency Number Policy Effective Date 7/28/2016 Policy Expiration Date 7/28/2017 Date Account Number Named Insured Atlantic Southern Paving Sealcoating, LLC & Agency Bowen, Miclette of Florida, LLC & Britt Issuing Company Amerisure Mutual Insurance Company 1. a. SECTION II - WHO IS AN INSURED is amended to add as an additional insured any person or organization: (1) Whom you are required to add as an additional insured on this policy under a written contract or written agreement relating to your business; or (2) Who is named as an additional insured under this policy on a certificate of insurance. b. The written contract, written agreement, or certificate of insurance must: (1) Require additional insured status for a time period during the term of this policy; and (2) Be executed prior to the "bodily injury', "property damage ", or "personal and advertising injury" leading to a claim under this policy. c. If, however: (1) "Your work" began under a letter of intent or work order; and (2) The letter of intent or work order led to a written contract or written agreement within 30 days of beginning such work; and (3) Your customer's customary contracts require persons or organizations to be named as additional insureds; we will provide additional insured status as specified in this endorsement. 2. The insurance provided under this endorsement is limited as follows: a. That person or organization is an additional insured only with respect to liability caused, in whole or in part, by: (1) Premises you: (a) Own; (b) Rent; (c) Lease; or (d) Occupy; (2) Ongoing operations performed by you or on your behalf. Ongoing operations does not apply to "bodily injury" or "property damage" occurring after: Includes copyrighted material of Insurance Services Office, Inc. CG 70481015 Pages 1 of 4 (3) (a) All work to be performed by you or on your behalf for the additional insured(s) at the site of the covered operations is complete, including related materials, parts or equipment (other than service, maintenance or repairs); or (b) That portion of "your work" out of which the injury or damage arises is put to its intended use by any person or organization other than another contractor working for a principal as a part of the same project. Completed operations coverage, but only if: (a) The written contract, written agreement, or certificate of insurance requires completed operations coverage or "your work" coverage; and (b) This coverage part provides coverage for "bodily injury" or "property damage" included within the "products- completed operations hazard ". However, the insurance afforded to such additional insured only applies to the extent permitted by law. b. If the written contract, written agreement, or certificate of insurance: (1) Requires "arising out of" language; or (2) Requires you to provide additional insured coverage to that person or organization by the use of either or both of the following: (a) Additional Insured — Owners, Lessees or Contractors — Scheduled Person Or Organization endorsement CG 20 10 10 01; or (b) Additional Insured — Owners, Lessees or Contractors — Completed Operations endorsement CG 20 37 10 01; then the phrase "caused, in whole or in part, by" in paragraph 2.a. above is replaced by "arising out of". c. If the written contract, written agreement, or certificate of insurance requires you to provide additional insured coverage to that person or organization by the use of: (1) Additional Insured — Owners, Lessees or Contractors — Scheduled Person Or Organization endorsement CG 20 10 07 04 or CG 20 10 0413; or (2) Additional Insured — Owners, Lessees or Contractors — Completed Operations endorsement CG 20 37 07 04 or CG 20370413; or (3) Both those endorsements with either of those edition dates; or (4) Either or both of the following: (a) Additional Insured — Owners, Lessees or Contractors — Scheduled Person Or Organization endorsement CG 20 10 without an edition date specified; or (b) Additional Insured — Owners, Lessees or Contractors — Completed Operations endorsement CG 20 37 without an edition date specified; then paragraph 2.a. above applies. d. Premises, as respects paragraph 2.a.(1) above, include common or public areas about such premises if so required in the written contract or written agreement. e. Additional insured status provided under paragraphs 2.a.(1)(b) or 2.a.(1)(c) above does not extend beyond the end of a premises lease or rental agreement. f. The limits of insurance that apply to the additional insured are the least of those specified in the: (1) Written contract; (2) Written agreement; (3) Certificate of insurance; or (4) Declarations of this policy. The limits of insurance are inclusive of and not in addition to the limits of insurance shown in the Declarations. Includes copyrighted material of Insurance Services Office, Inc. Page 2 of 4 CG 70 48 10 15 9. The insurance provided to the additional insured does not apply to "bodily injury", "property damage ", or "personal and advertising injury" arising out of an architect's, engineer's, or surveyor's rendering of, or failure to render, any professional services, including but not limited to: (1) The preparing, approving, or failing to prepare or approve: (a) Maps; (b) Drawings; (c) Opinions; (d) Reports; (e) Surveys; (f) Change orders; (g) Design specifications; and (2) Supervisory, inspection, or engineering services. h. SECTION IV — COMMERCIAL GENERAL LIABILITY CONDITIONS, paragraph 4. Other Insurance is deleted and replaced with the following: 4. Other Insurance. Coverage provided by this endorsement is excess over any other valid and collectible insurance available to the additional insured whether: a. Primary; b. Excess; c. Contingent; or d. On any other basis; but if the written contract, written agreement, or certificate of insurance requires primary and non- contributory coverage, this insurance will be primary and non - contributory relative to other insurance available to the additional insured which covers that person or organization as a Named Insured, and we will not share with that other insurance. If the written contract, written agreement, or certificate of insurance as outlined above requires additional insured status by use of CG 2010 11 85, then the coverage provided under this CG 70 48 endorsement does not apply except for paragraph 2.h. Other Insurance. Additional insured status is limited to that provided by CG 20 10 11 85 shown below and paragraph 2.h. Other Insurance shown above. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Blanket Where Required by Written Contract, Agreement, or Certificate of Insurance that the terms of CG 20 10 11 85 apply (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work' for that insured by or for you. CG 20 10 11 85 Copyright, Insurance Services Office, Inc., 1984 CG 70 48 10 15 Includes copyrighted material of Insurance Services Office, Inc. Pages 3 of 4 J. The insurance provided by this endorsement does not apply to any premises or work for which the person or organization is specifically listed as an additional insured on another endorsement attached to this policy. Includes copyrighted material of Insurance Services Office, Inc. Page4of4 CG70481015 If you.would like to receive your certificate of insurance and attachments Electronically, please email certificates @bmbinc.com and advise the named insured on the certificate. Thank you and we hope you will join BMB in our "Go Green" initiative. City of Clearwater 100 S Myrtle Ave Ste 210 Clearwater FL 33756 -5520 m