CERTIFICATE OF LIABILITY INSURANCE (818)ACORO� DATE (MM/DD/YYYV)
�� CERTIFICATE OF LIABILITY INSURANCE 11/30/2016
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 poticy, 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 , C NTACT xe16II Brown
NAME:
McGowan Insurance Group, Inc. acNN Ext: (317) 464-5000 �C No; (317)466-5001
355 Indiana Avenue ADOR�ess:helenb@mcgowaninc.com
SUlt.2 ZOO INSURER S AFFORDING COVERAGE NAIC #
Indianapolis IN 46204 INSURERA:COZOII Insurance Com an 36927
iNSURED
R2J Chemical Services, Inc.
12345 62nd St. North
Unit #D
Largo FL 33773 �
COVERAGES CERTIFICATE NUMBER:16-17 Liab
INSURER B:FCCI Insurance Grou 10178
INSURERC:FEDERAL INSURANCE COMPANY 20281
INSURER E :
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. NOTIMTHSTANDING 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 ADDL BR POLICY EFF POLICY EXP
LTR NPE OF INSURANCE POLICY NUMBER MM/D /YY V MM/ D YYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1, OOO , OOO
A CLAIMS-MADE ❑X OCCUR PREM SES Ea occur ence E lOO , OOO
X Contractors Pollution PACE304197 12/2/2016 12/2/2017 MED EXP (Any one person) $ 10, 000
X ErrOrS S Omi33iOns PERSONAL&ADVINJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2, 000 , 000
POLICY � jER� ��. LOC PRODUCTS - COMP/OP AGG $ 2, 000 , 000
X OTHER:Contractual Liabilit $
AUTOMOBILE LIABILITY � COMBINED SINGLE LIMIT g 1, 000 , OOO
Ea accident
ANY AUTO BODILY INJURY (Per person) $
B ALLOWNED SCHEDULED
X AUTOS AUTOS � 0031380 12/2/2016 12/2/2017 BODILY INJURY (Peraccident) $
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
$
UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5 000 000
C X EXCESS LIAB CLAIMS-MADE 93646465 AGGREGATE $
DED RETENTION$ 12/2/2016 12/2/2017 g
WORKERS COMPENSATION Y PER OTH-
AND EMPLOYERS' LIABILITY Y� N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1 000 000
B OFFICER/MEMBER EXCLUDED? ❑N N �A
(Mandatory in NH) O10-WC16A-74339 1/1/2016 1/1/2017 E.L. DISEASE - EA EMPLOYE $ 1 000 000
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POIJCV LIMIT $ 1- �00 000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additlonal Remarks Schedule, may be attached Ii more space is requlred)
The following applies when required by written agreement: General Liability Primary and Non-contributory
Additional Insured, including Completed Operations and Waiver of Subrogation, per form EPACE001-0415;
Auto Liability Additional Insured Primary/Non Contributory per form CAU 042 (12 08); Auto Liability
Waiver of Subrogation per form CAU 014 (04/04). Excess Liability follows form of the above captioned
General Liability, Auto, and Work Comp policies. Workers compensation blanket waiver of subrogation. This
Certificate is subject to the terms and conditions of the scheduled policies.
CITY OF CLEARWATER:
MARSHALL ST PLANT
100 S. MYRTLE AVENUE
Clearwater, FL 33756
ACORD 25 (2014/01)
INS025 �2oiaoi�
CANCELLATION
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
H M. McGowan/DANIEL n"'�"� �'`���
O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD