CERTIFICATE OF LIABILITY INSURANCE (431)ACO/20®
�..._- CERTIFICATE OF LIABILITY INSURANCE
DATE(MM /DD/YYYY)
12/22/2016
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 have ADDITIONAL INSURED provisions or 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
AOn Risk Services South, Inc.
Franklin TN Office
501 Corporate Centre Drive
Suite 300
Franklin TN 37067 USA
CONTACT
NAME:
(A/C. No. Ext): (866) 283 -7122 FAX 800- 363 -0105
(A/C. No.):
E -MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURED
Malcolm Pi rni e, Inc.
44 South Broadway
15th Floor
White Plains NY 10601 USA
INSURER A: Greenwich insurance company
22322
INSURER B: XL Specialty Insurance Co
37885
INSURER C: XL Insurance America Inc
24554
INSURER D:
$1,000,000
INSURER E:
INSURER F:
General Li abi 11 t
SIR applies per
COVERAGES
CERTIFICATE NUMBER: 570064870630
-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. Limits shown are as requested
INSR
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MM/DD
POLICY-EX?
MM/D�'.
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
GEC001076115
01/01.
r
S rj7'
F
c ),, _�
C I
$ ANT
./Ol/CUIS
tions
EACH OCCURRENCE
$1,000,000
CLAIMS -MADE X OCCUR
General Li abi 11 t
SIR applies per
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$1,000,000
{/ 0
p^a
CL4 RF�r,.�0fi1
MED EXP (Any one person)
$10,000
PERSONAL & ADV INJURY
$1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE
$2,000,000
POLICY X PRO- X LOC
JECT
PRODUCTS - COMP /OP AGG
$2,000,000
OTHER:
B
AUTOMOBILE LIABILITY
Auto (A75815I r -(+w,!f ; SS ,,/�,
Auto (AOS) � ° "'i i Y
F�'� `
"�i/� (
E-'I 01 /2018
� 1
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000
X
ANY AUTO
BODILY INJURY ( Per person)
OWNED
AUTOS ONLY
HIRED AUTOS
ONLY
—
_
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
B
X
UMBRELLALIAB
EXCESS LIAB
X
—
OCCUR
CLAIMS -MADE
UEC001075915
umbrella
01/01/2017
01/01/2018
EACH OCCURRENCE
$1,000,000
AGGREGATE
$1,000,000
DED I X (RETENTION $10 000
C
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
N / A
RWD943516311
01/01/2017
01/01/2018
"
PER I
STATUTE
OTH-
ER
ANY PROPRIETOR / PARTNER / EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
If describe
Y / N
N
E.L. EACH ACCIDENT
$1,000,000
E.L. DISEASE -EA EMPLOYEE
$1,000,000
yes, under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE- POLICY LIMIT
$1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Re: All operations of the Named Insured. city of Clearwater is included as Additional Insured as required by written contract,
but limited to the operations of the Insured under said contract, with respect to the General Liability, Auto Liability and
Umbrella Liability policies. General Liability and Auto Liability evidenced herein is primary and non - contributory to other
insurance available to the Additional Insured, but only to the extent required by written contract with the insured. A waiver
of Subrogation is granted in favor of Additional Insured as required by written contract but limited to the operations of the
Insured under said contract, with respect to the General Liability, Auto Liability, umbrella Liability and Workers'
Compensation policies.
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Attn: City Clerk
P.O. Box 4748
Clearwater FL 33758 USA
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
ACORD 25 (2016/03)
01988 -2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Holder Identifier :
r-
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0
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Certificate No
5
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