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CERTIFICATE OF LIABILITY INSURANCE - RFQ 34-15 (18)
DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/4/2016 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 Vicky Van Wormer PRODUCER NAME: Brown & Brown Insurance - Clearwater FAX PHONE 727 442-7695 (A/C, No): (A/C, No, Ext): 83 Park Place Blvd., Suite 101 E-MAIL vvanwormer@bbpinellas.com Clearwater FL 33757-2456 ADDRESS: INSURER(S) AFFORDING COVERAGENAIC # Admiral Insurance Company24856 INSURER A : The Travelers Indemnity Company of 25666 INSURED INSURER B : Kisinger Campo & Assoc. Corp. The Charter Oak Fire Insurance Comp25615 INSURER C : Campo & Associates, PLLC, KCCS, Inc. Travelers Casualty and Surety Compa19038 INSURER D : 201 N. Franklin Street, Ste. 400 Tampa FL 33602 INSURER E : INSURER F : 61097856 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) LTRINSDWVD CY630-8254A6049/1/20169/1/2017 COMMERCIAL GENERAL LIABILITY X 1,000,000 EACH OCCURRENCE$ DAMAGE TO RENTED X 300,000 CLAIMS-MADEOCCUR$ PREMISES (Ea occurrence) X 10,000 MED EXP (Any one person)$ Contractual X 1,000,000 PERSONAL & ADV INJURY$ XCU Liability 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ PRO- X 2,000,000 POLICYLOCPRODUCTS - COMP/OP AGG$ JECT $ OTHER: COMBINED SINGLE LIMIT B Y9/1/20169/1/2017 $ AUTOMOBILE LIABILITY 8108254A604 1,000,000 (Ea accident) X BODILY INJURY (Per person)$ ANY AUTO ALL OWNEDSCHEDULED BODILY INJURY (Per accident)$ AUTOSAUTOS NON-OWNED PROPERTY DAMAGE XX $ HIRED AUTOS AUTOS (Per accident) $ BXXYCUP8254A6049/1/20169/1/2017 UMBRELLA LIAB 4,000,000 EACH OCCURRENCE$ OCCUR EXCESS LIAB 4,000,000 CLAIMS-MADEAGGREGATE$ X 10,000 $ DEDRETENTION$ PEROTH- WORKERS COMPENSATION DUB2G64156010/3/201610/3/2017 XXU.S.L.H. STATUTEER AND EMPLOYERS' LIABILITY Y / N 500,000 ANY PROPRIETOR/PARTNER/EXECUTIVEE.L. EACH ACCIDENT$ N N / A OFFICER/MEMBER EXCLUDED? 500,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ If yes, describe under 500,000 E.L. DISEASE - POLICY LIMIT$ DESCRIPTION OF OPERATIONS below A Professional LiabilityEO0000272050111/2/201511/2/2016Per Claim5,000,000 Claims MadeAggregate5,000,000 Deductible250,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be 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 HOLDERCANCELLATION 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. 100 S. Myrtly Ave. CLEARWATER FL 33756 AUTHORIZED REPRESENTATIVE © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01)The ACORD name and logo are registered marks of ACORD