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CERTIFICATE OF LIABILITY INSURANCE - RFQ 34-15 (17) A� DATE(MM/DD/YYYY)" CERTIFICATE OF LIABILITY INSURANCE 9/2/2016 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 NAME: Vicky Van Wormer Brown &Brown Insurance-Clearwater PHONE FAx 727 442-7695 83 Park Place Blvd., Suite 101 A/C NO Clearwater FL 33757-2456 ADDRESS:vvanwormer @bbpinellas.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:Admiral Insurance Company 24856 INSURED INSURERB:The Travelers Indemnity Company of 25666 Kisinger Campo&Assoc. Corp. INSURERC:The Charter Oak Fire Insurance Comp 25615 Campo&Associates, PLLC, KCCS, Inc. INSURER D:Travelers Casualty and Surety Compa 19038 201 N. Franklin Street, Ste. 400 Tampa FL 33602 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 1234972543 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 TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYY MM/DD/YYY C X COMMERCIAL GENERAL LIABILITY Y 630-8254A604 9/1/2016 9/1/2017 EACH OCCURRENCE $1,000,000 IX OCCUR PREMISES CLAIMS-MADE PREMISES Ea Occurrence) $300,000 X Contractual MED EXP(Any one person) $10,000 X XCU Liability PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $2,000,000 POLICY jECT El LOC PRODUCTS-COMP/OP AGG $2,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y 8108254A604 9/1/2016 9/1/2017 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS (Per accident) B X UMBRELLA LAB X OCCUR Y CUP8254A604 9/1/2016 9/1/2017 EACH OCCURRENCE $4,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000 DED X RETENTION$10,000 $ D WORKERS COMPENSATION UB2G641560 10/3/2016 10/3/2017 X PER X OTH- U.S.L.H. AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $500,000 OFFICER/MEMBER EXCLUDED? ❑N N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000 A Professional Liability E000002720501 11/2/2015 11/2/2016 Per Claim 5,000,000 Claims Made Aggregate 5,000,000 Deductible 250,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Certificate Holder is an additional insured with respect to general liability, auto liability and umbrella liability. Explosion, collapse and underground hazard included in CGL. . SERVICES UNDER ENGINEER OF RECORD AGREEMENT, RFQ#34-15 AND ALL TASK WORK ORDERS ISSUED THEREUNDER. A thirty-day written notice of cancellation shall be provided,with the exception of ten-day notice for non-payment. (KCA Project#6201508.00) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF CLEARWATER THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ENGINEERING, RFQ#34-15 ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 4748 CLEARWATER FL 33758-4748 AUTHORIZED REPRESENTATIVE ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD