CERTIFICATE OF LIABILITY INSURANCE (430)�����
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CERTIFICATE OF LIABILITY INSURANCE
�ATE (MMI��lYYYY)
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THIS CERTIFICATE IS ISSIJED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS IJPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSIJRANCE DOES NOT CONST1TlJTE A CONTRACT BETWEEN THE ISSIJING INSURER{S}, Al1THORIZED
REPRESENTATIVE OR PRODIJCER, AND THE CERl1FICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDIl10NAL INSl1RED, the policy[ies} must have ADDITIONAL INSl1RED provisions or be endorsed.
If Sl1BROGATION 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}.
PRO�UCER 941-758-3861 NAMEACT Stacey Shankle
Dick, Johnson S�Jefferson, Inc PHONE 941-758-3861 FAx 941-758-5947
Suite 200 (arc, No, Ext]: [AlC, No�:
1429 60Th Avenue W a' oR�ESS: Stacey.Shankle�djjinc.com
Bradenton, FL 34207
Sharon Metzelaar INSURER S AFFOR�ING COVERAGE NAIC A'
,,,�„e�e n. Southern Owners Insurance Co 10190
INSURE� GA Nichols Co 8dor Florida
Highway Maintenance Inc
2271 Belleair Rd
Clearwater, FL 33764-2851
�r,suReRS:Owners Insurance Company
wsuRERC: FCCI Insurance Company
INSURER � :
INSURER F :
10178
COVERAGES CERTIFICATE NUMBER: REVI510N NUMBER:
THIS IS TO CERTIFYTHAT THE POLICIES OF INSIJRANCE LISTED BELOW HAVE BEEN ISSIJED TO THE INSIJRED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOIWITHSTANDING ANY REQIJIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCIJMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSl1ED OR MAY PERTAIN, THE INSl1RANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS Sl1BJECT TO ALL THE TERMS,
EXCLl1SIONS AND CONDITIONS OF Sl1CH POLICIES. LIMITS SHOWN MAYHAVE BEEN REDl10ED BY PAID CLAIMS.
INSR 7ypE OF INSURANCE A��L SU8 pOLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INS❑ WV� MMl��IYYYY MMl��lYYYY
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ �I,OOO,OOO
CLAIMS-MADE X OCCUR ZO7'I9OHH O'IIZ7IZO'I� O'IIP7IZO'IH DRMAGETO RENTED 300,000
X PREMISES Ee occurrence $
X Non-Owned Auto Li MEO ExP n� o�e e�5o� $ 10,000
X H ire Auto Lia6 PERSONn� a nov iN�uRV g 1,000,000
GEN'L RGGREGATE LIMIT APPLIES PER: GENERAL RGGREGRTE $ 3,000,000
POLICY � jECT � LOC PRODUCTS- COMPfOP AGG $ 3,000,000
OTHER $
B AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT �I,OOO,OOO
Ea accldent $
X ANY AUTO X 4446843001 0§�23/20�6 05/25/2017 gODILY INJURY Per erson $
OWNED SCHEDULED
AUTOS ONLY AUTOS BODILY INJURY Peraccident $
HIRED NON-OWNED PROPERTY DRMRGE
AUTOS ONLY AUTOS ONLY Per acndent $
$
A X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ �I,OOO,OOO
EXCESSLIAB CLAIMS-MADE 5098976800 'IZIO7IZO'IB 'IPIO7IZO'I7 AGGREGRTE $ �I,OOO,OOO
oEO X RETENTioN $ Waived g
C WORKERS COMPENSATION X PER OTH-
AN� EMPLOYERS' LIA8ILITY 001 WC16A72405 06/2312016 06/23/2017 STRTUTE ER �'000,000
RNY PROPRIETORfPRRTNERfEXECUTIVE Y� E.L ERCH RCCIDENT $
OFRCERfMEMBER EXCLUDED? N! A
{Mandatory in NH] E.L. DISERSE - ER EMPLOYEE $ ���������
If yes, describe under 9,000,000
DESCRIPTION OF OPERATIONS below EL DISEASE- POLICY LIMIT $
pOE$CR`P��jJ �LqpE,�T1,pJ,VS,! �4CA�qea'rwa�e`r;�LCOR� 101, Additional Remarks Schedule, may be attached if more space is required}
J�] 9 6 ILACC I hi N.
Per Ins Requirements, City of Clearwater is listed as additional insured
with respects to General Liability and Auto Policies.
CITYC10
City of Clearwater
Engineering Dept.
100 South Myrtle Ave
Clearwater, FL 33756
SHOl1LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZE� REPRESENTATIVE
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