CERTIFICATE OF LIABILITY INSURANCE (300)OP ID: JT
ACOR U
4...,,... -..— CERTIFICATE OF LIABILITY INSURANCE
DATE (MM /DD/YYYY)
02/22/2017
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 813 - 636 -4000
Hockman Insurance Agency, Inc.
3438 Colwell Avenue
Tampa, FL 33614
CONTACT Jason Travis
NAME:
PHONE FAX
(A/C, No, Ext): 813 - 636 -4000 I (A/C, No) :813- 281 -1086
E -MAIL
ADDRESS:
INSURER(SI AFFORDING COVERAGE
NAIC #
INSURER A : Phoenix Insurance Co.
25623
INSURED Advanced Systems Engineering,
Inc.
13555 Automobile Blvd., #330
Clearwater, FL 33762
INSURER B : Travelers Indemnity Co.
25658
INSURER C : Travelers Casualty & Surety Co
31194
Liberty Ins. Underwriters, Inc
INSURER D : ' t7
$ 1,000,000
INSURER E :
100,000
$
INSURER F :
COVERA
BER:
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.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MM /DD/YYYYI
POLICY EXP
(MM /DD/YYYYI
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
X
X
r�`
660 -1 C9140R L CE IV E D08
2 7
FEB [D 2017
OFFICIAL RECORDS
/17/2016
AND
08/17/2017
EACH OCCURRENCE
$ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
100,000
$
CLAIMS -MADE
X
OCCUR
MED EXP (Any one person)
$ 5,000
PERSONAL 8 ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
GE
'L AGGREGATE
POLICY
OTHER:
X
LIMIT APPLIES
j eT
PER:
LOC
PRODUCTS - COMP /OP AGG
2,000,000
$
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
OWNED UTEOS ONLY
AUTOS ONLY
X
AUTOS
AUTOS ONLYY
X
x
LEGISLATIVE SI' VCS
660-1C914015
DEPT.
08/17/2016
08/17/2017
COMBINEDtSINGLE LIMIT
$ 1,000,000
BODILY INJURY (Per person)
$
BODILY BODILY INJURY (Per accident)
$
(Per acEcident) DAMAGE
$
$
B
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
X
x
CUP- 3951T198
08/17/2016
08/17/2017
EACH OCCURRENCE
_$ 5'000'000
_$__ 5,000,000
$
AGGREGATE
DED X
RETENTION $ 10,000
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR /PARTNER /EXECUTIVE
OFFICER /MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y/ N
N / A
x
UB- 3951T162
08/17/2016
08/17/2017
X
PER
STATUTE
0TH -
ER
E.L. EACH ACCIDENT
$ 500,000
E.L. DISEASE - EA EMPLOYEE
$ 500,000
E.L. DISEASE - POLICY LIMIT
500,000
$
D
Professional
Liability
AEE101878 -0002
03/10/2017
03/10/2018
Per Claim
Ann Agg
2,000,000
2,000,000
ES RIPTIPN OF P� T GNS / LOCATIONS /,VEHIC4 S (ACORD to Additional Remarks Schedule, may a attached If more space is required)
Professlonal°Llability coverage is wr tten on a claims made and reported
basis. Certificate holder is listed as an additional insured with respects
to General Liability, Auto Liability, Excess Liability policies on a primary
and non - contributory basis. Waiver of Subrogation in favor of the additional
insured applies to the GL, Auto Liab,Excess Liability, & WC Policy
1
CITYOFC
City Of Clearwater
City Clerk
PO Box 4748
Clearwater, FL 33758 -4748
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
�L.sh `o��.sss�
ACORD 25 (2016/03)
.LU79 AI.URU VVRrVRN11V1 \. •
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