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CERTIFICATE OF LIABILITY INSURANCE - RFQ 24-16 (7) KHORCON-01JFAVA DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 8/26/2016 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). CONTACT PRODUCER NAME: ASSOCIATES AGENCY, INC. FAX PHONE (813) 988-1234(813) 988-0989 (A/C, No): (A/C, No, Ext): 11470 N 53rd St E-MAIL certs@associatesins.com Temple Terrace, FL 33617 ADDRESS: INSURER(S) AFFORDING COVERAGENAIC # National Builders Insurance Company16632 INSURER A : American Builders Insurance Company11240 INSURED INSURER B : INSURER C : Khors Construction, Inc 12222 ANNE KENIA DRIVE INSURER D : Thonotosassa, FL 33592 INSURER E : INSURER F : COVERAGESCERTIFICATE NUMBER: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. ADDLSUBR POLICY EFFPOLICY EXP INSR TYPE OF INSURANCELIMITS POLICY NUMBER (MM/DD/YYYY)(MM/DD/YYYY) LTR INSDWVD AX 1,000,000 COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE$ DAMAGE TO RENTED X GLP-0149693 0209/05/201609/05/2017 100,000 CLAIMS-MADEOCCUR$ PREMISES (Ea occurrence) 5,000 MED EXP (Any one person)$ 1,000,000 PERSONAL & ADV INJURY$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ PRO- 2,000,000 POLICYLOCPRODUCTS - COMP/OP AGG$ JECT $ OTHER: COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $ (Ea accident) BODILY INJURY (Per person)$ ANY AUTO ALL OWNEDSCHEDULED BODILY INJURY (Per accident)$ AUTOSAUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS (Per accident) AUTOS $ UMBRELLA LIAB EACH OCCURRENCE$ OCCUR EXCESS LIAB CLAIMS-MADEAGGREGATE$ $ DEDRETENTION$ PEROTH- WORKERS COMPENSATION X STATUTEER AND EMPLOYERS' LIABILITY Y / N B WCV-0166202-0209/05/201609/05/2017 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. EACH ACCIDENT$ Y N / A OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ If yes, describe under 1,000,000 E.L. DISEASE - POLICY LIMIT$ DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Clearwater ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Engineering Contract Specialist, RFQ #24-16 PO Box 4748 AUTHORIZED REPRESENTATIVE Clearwater, FL 33758-4748 © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01)The ACORD name and logo are registered marks of ACORD