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CERTIFICATE OF LIABILITY INSURANCE (790)AC4OR D CERTIFICATE OF LIABILITY INSURANCE M /DD/YYYY) 8/25/2016 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 Wallace Welch & Willingham, Inc. 300 1st Ave. So., 5th Floor Saint Petersburg FL 33701 CONTACT NAME: Edward Buggy PHONE 727 - 522 -7777 FAX 727- 521 -2902 (A/C No Ext): (A/C. Nor E-MAIL certificates @w3ins.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA:Old Dominion Ins. Co. 40231 INSURED CULLWAT -01 Gulf Coast Water Conditioning, Inc 13075 66th St N Largo FL 33773 INSURER B : FFVA Mutual Insurance Co MPT1255T INSURER C: 9/1/2017 INSURER 0 $1,000,000 INSURER E : INSURER F : X COVERAGES CERTIFICATE NtlM °ER: 2015928319 - 7? -F1/t Ink NIIMRCD• 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 TYPE OF INSURANCE I S WVBD POLICY NUMBER (MMI DYE) (MM /DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY MPT1255T 9/1/2016 9/1/2017 EACH OCCURRENCE $1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $500,000 MED EXP (Any one person) $10,000 GE PERSONAL &ADV INJURY $1,000,000 'L AGGREGATE POLICY OTHER: X LIMIT APPLIES JECOT PER: LOC GENERAL AGGREGATE $2,000,000 PRODUCTS - COMP/OP AGG $2,000,000 $ A AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED HIRED AUTOS X SCHEDULED NON -OWNED AUTOS B1T1255T 9/1/2016 9/1/2017 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE CUT1255T 9/1/2016 9/1/2017 EACH OCCURRENCE $5,000,000 AGGREGATE $5,000,000 DED X RETENT ON $10,000 $ 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 / N N N / A WC8400031832 -2016A 9/1/2016 9/1/2017 PER X 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) Named Insureds: Gulf Coast Water Conditignjpg fic,co an Water, Culligan Pinellas Water Conditioning, Culligan of Pasco /Hernando ''.1 lY tit. 0 20Th CERTIFICATE HOLDER ` L CANCELLATION ` =1'SIAT-Vw SRVCS DEPT 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 7 ACORD 25 (2014/01) ©1988 -2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD