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CERTIFICATE OF LIABILITY INSURANCE (780)ACORD ® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 08/15/2016 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 Willis of Maryland, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA CONTACT NAME: PHONE FAX jAIC, No. Extl:1- 877 - 945 -7378 (A/C. No):1- 888 - 467 -2378 E -MAIL ADDRESS: certificates @willis.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Admiral Insurance Company 24856 INSURED Diversified Inspections /Independent Testing Laboratories, Inc. P.O. Box 39669 Phoenix, AZ 85069 INSURER B: � �, {r MU V 2 ? LU {� OFFICIAL RECORDS INSURER C : INSURER D $ INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER:w1585587 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 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 SUER WVD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP (MM/DOIYYYY) LIMITS COMMERCIAL GENERAL LIABILITY � �, {r MU V 2 ? LU {� OFFICIAL RECORDS _` ` I �. AND EACH OCCURRENCE � $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ PRODUCTS - COMP /OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS LEGISLATIVE SRVC S DEPT (Ea aBcddeDtSINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) Y / N N / A __.. --- -._.__ - PER STATUTE OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ A Professional Liability E0000021695 -04 04/01/2016 04/01/2017 $1,000,000 Each Claim $1,000,000 Aggregate DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION City of Clearwater 100 S Myrtle Avenue Flearwater, 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 SR ID:12967353 BATCH:Batch #: 245975 / KE, CERTIFICATE OF LIABILITY INSURANCE °ATE`MMIDD/YYYY) 08/15/2016 ' THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. . HOLDER. THIS BY THE POLICIES AUTHORIZED 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). PRODUCERWillis of Maryland, Inc. Y • c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA CONTACT • NAME: PHONE (A/C FAX (A/C No. Ext1:l -877- 945 -7378 (A/C No):1 -888- 467 -2378 E -MAIL ADDRESS: certificates @willis .com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Travelers Indemnity Company 25658 INSUREDDiversified Inspections /Independent Testing Laboratories, Inc. P.O. Box 39669 Phoenix, AZ 85069 INSURER B:Travelers Property Casualty Co P V y mpany of Americ 25674 INSURER C :Admiral Insurance Company 24856 INSURER D GEN'L INSURER E : MED EXP (Any one person) INSURER F : W1585603 - - - - - _ _ .__- vn I Irrocrl. 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 P- 630- 9D980174- IND -16 POLICY EFF (MM /DD/YYYY) 04/01/2016 POLICY EXP (MM/DD/YYYY) 04/01/2017 LIMITS EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR DAMAGE PREMISES OEa occurrence) $ 100,000 GEN'L MED EXP (Any one person) $ 5,000 PERSONAL &ADVINJURY $ 1,000,000 AGGREGATE POLICY OTHER: X LIMIT APPLIES PECOT- PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OPAGG $ 2,000,000 Contractual Liability $ Included A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS P- 810- 9D980174- IND -16 04/01/2016 04/01/2017 COaBINEDtSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE • PSM- CUP- 9D980174- TIL -16 04/01/2016 04/01/2017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED X RETENT ON $0 $ WORKERS AND EMPLOYERSCOMPENSATION I Y ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N - N/A PJUB- 9D98951 -3 -16 - -- 04/01/2016 04/01/2017 -- X STATUTE EERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 _ - - - -- E.L. DISEASE - POLICY LIMIT $ 1,000,000 C Professional Liability E0000021695 -04 04/01/2016 04/0'1/2017 $1,000,000 Each Claim $1,000,000 Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This Voids and Replaces Previously Issued Certificate Dated 08/15/2016 WITH ID: W1585587. Subject to the terms and conditions of the policy form CGD4671208 , International Xtend -one or more of the following applies: When required by written contract: CERTIFICATE HOLDER CANCELLATION City of Clearwater 100 S Myrtle Avenue Clearwater, FL 33756 AUG 2 3 201E OFFICIAL IC -CORDS AND LEGISLATIVE, SRVCS DEPT 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) CO 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID:12869328 BATCH:Batch #: 245988 ACS AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Willis of Maryland, Inc. NAMED INSURED Diversified Inspections /Independent Testing Laboratories, P.O. Box 39669 Phoenix, AZ 85069 Inc. POLICY NUMBER See Page 1 CARRIER See Page 1 NAIC CODE See Page 1 EFFECTIVE DATE: See Page 1 THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Blanket Additional Insured- Broad Form Vendors. Blanket Additional Insured - Owners, Managers or Lessors of Premises. Blanket Additional Insured - Lessors of Leased Equipment. Blanket Waiver of Subrogation. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 12869328 Batch #: 245988 W1585603 A RDm CERTIFICATE OF LIABILITY INSURANCE DATE(MMDD/YYYY) 08/26/2016 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 Willis of Maryland, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA ACT NAME: PHONE FAX (A/C, No. Extl:l -877- 945 -7378 (A /C, No) :1 -888- 467 -2378 E -MAIL ADDRESS: certificates @willis.com INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Travelers Indemnity Company 25658 INSUREDDiversified Inspections /Independent Testing Laboratories, Inc. P.O. Box 39669 Phoenix, AZ 85069 INSURER B :Travelers Property Casualty Company of Americ 25674 INSURER C :Admiral Insurance Company 29856 INSURER D DAMAGE TO RENTED PREMISES (Ea occurrence) INSURER E : INSURER F : MED EXP (Any one person) CERTIFICATE NUMBER :41595811 • 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 Y SUER WVD POLICY NUMBER P- 630- 9D98017'4 , 'l:6' -- % C "f POLICY EFF (MM /DD/YYYY) ' ‘84/-01J2016 � ' "k POLICY EXP (MM/DDIYYYY) 04/01/2017 LIMITS EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100, 000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1,000,000 GEN'L AGGREGATE POLICY OTHER: X LIMIT APPLIES PRO- JECT PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 Contractual Liability $ Included A AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS _ SCHEDULED AUTOS NON -OWNED AUTOS ., P- 810- 9D4so174= YND -ie- `" i, ta}'dl /2016 04/01/2017 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE )Per accidentl $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE PSM- CUP - 90980174- TIL -16 04/01/2016 • 04/01/2017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED X RETENT ON $0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) ____.... _._._ If yes, describe under DESCRIPTION OF OPERATIONS below Y 1 N _.._.. N/A _.. PJUB- 9D98951 -3 -16 04/01/2016 04/01/2017 X STATUTE ERH E.L. EACH ACCIDENT $ 1,000,000 E . DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1, 000 , 000 C Professional Liability E0000021695 -04 04/01/2016 04/01/2017 $1,000,000 Each Claim $1,000,000 Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This Voids and Replaces Previously Issued Certificate Dated 08/26/2016 WITH ID: W1595420. The City of Clearwater is an Additional Insured under the blanket Additional Insured endorsement with respects to General Liability when required by written contract. ERTIFICATE HOLDER CEL City of Clearwater 100 S Myrtle Avenue 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 ' <- °'y' 0 ACORD 25 (2014/91) © 1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID:12989374 BATCH:Batch #: 248881 ACG AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Willis of Maryland, Inc. NAMED INSURED Diversified Inspections /Independent Testing Laboratories, Inc. P.O. Box 39669 Phoenix, AZ 85069 POLICY NUMBER See Page 1 CARRIER See Page 1 NAIC CODE See Page 1 EFFECTIVE DATE: See Page 1 NAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Subject to the terms and conditions of the policy form CGD4671208 , International Xtend -one or more of the following applies: When required by written contract: Blanket Additional Insured- Broad Form Vendors Blanket Additional Insured - Owners, Managers or Lessors of Premises Blanket Additional Insured - Lessors of Leased Equipment Blanket Waiver of Subrogation ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 12989374 Bach #: 248881 W1595811 ACCORD 0 ../.' CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY) 08/26/2016 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 Willis of Maryland, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA CONTACT NAME: PHONE FAX (A/C. No. Extl:1- 877- 945 -7378 (A /C, No):1- 888 -467 -2378 E -MAIL ADDRESS: certificates @willis.com INSURER(S) AFFORDING COVERAGE NAIC # ' INSURER A :Travelers Indemnity Company 25658 INSUREDDiversified Inspections/Independent Testing Laboratories, Inc. P.O. Box 39669 Phoenix, AZ 85069 INSURERB:Travelers Property Casualty Company pany of Americ 25674 INSURER C :Admiral Insurance Company 24856 INSURER D : $ 1,000,000 INSURER E : INSURER F : X COVERAGES CERTIFICATE NUMBER:W1595420 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 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 /DDIYYYY) POLICY EXP (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITY ?g P- 630 -9D98/ S EF `: L' air .`/91/2016 04/01/2017 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR PRRENTED PREEMIMI ESES S (RENTED occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 . GEN'L PERSONAL &ADVINJURY $ 1,000,000 AGGREGATE POLICY OTHER: X LIMIT APPLIES PROT - JEC PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OPAGG $ 2,000,000 Contractual Liability $ Included AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS ,*1,,..„ r- •r� r r .1, y ,.: It../ ,`. IV. '., &,.�'t.i.✓,5 °' �- r(,� P- 810- 91?9S.b2'I4LI1 1.6V;'.d' „_ tl ,*, 1/0212016 04/01/2017 COMBINED SINGLE LIMIT (Ea accidenq $ 1,000,000 BODILY INJURY Per person) ( p ) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ X UMBRELLALIAB EXCESSLIAB X OCCUR CLAIMS -MADE PSM- CUP- 9D980174- TIL -16 04/01/2016 04/01/2017 EACH OCCURRENCE $ 5,000,000 AGGREGATE $ 5,000,000 DED X RETENTION $0 $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If DESCRIPTION IPTIOeunder DESCRIPTION OF OPERATIONS below Y / N N/A PJUB- 9D98951 -3 -16 04/01/2016 04/01/2017 X O STATUTE ETH E.L. EACH ACCIDENT $ 1,000 , 000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 C Professional Liability E0000021695 -04 04/01/2016 04/01/2017 $1,000,000 Each Claim $1,000,000 Aggregate DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) This Voids and Replaces Previously Issued Certificate Dated 08/24/2016 WITH ID: W1592796. The City of Clearwater is an Additional Insured under the blanket Additional Insured endorsement with respects to General Liability. Subject to the terms and conditions of the policy form CGD4671208 , International Xtend -one or more of the following applies: CERTIFICATE HOLDER CANCELLATION City of Clearwater 100 S. Myrtle Avenue (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 <;. -, /�% !' [�i` ACORD 25 (2014/01) © 1988-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACOI'D SR ID:12984845 BATCH:Batch #: 248771 ACO AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Willis of Maryland, Inc. NAMED INSURED Diversified Inspections /Independent Testing Laboratories, Inc. P.O. Box 39669 Phoenix, AZ 85069 POLICY NUMBER See Page 1 CARRIER See Page 1 NAIC CODE See Page 1 EFFECTIVE DATE: See Page 1 NAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE' Certificate of Liability Insurance When required by written contract: Blanket Additional Insured- Broad Form Vendors Blanket Additional Insured - Owners, Managers or Lessors of Premises Blanket Additional Insured - Lessors of Leased Equipment Blanket Waiver of Subrogation ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD a 12984895 Bch #: 298771 W1595420