CERTIFICATE OF LIABILITY INSURANCE
Y-ACORD
TM
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMlDDIYYYY)
OS/29/2007
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER (865)691-4847 FAX (865)694-4847
TIS Insurance Services, Inc.
1900 Winston Road, Suite 100
P.O. Box 10328
Knoxville, TN 37939-0328
INSURED Phil 1 ips and Jordan, Incorporated
Attention: Steve Thompson
6621 Wilbanks Rd
Knoxville, TN 37912
American Contractors Insurance C
ACIG Insurance Company A VII
Zurich/American GuarantyjWSRB A
NAIC#
RRG A VII
INSURERS AFFORDING COVERAGE
INSURER A:
INSURER B:
INSURER C
INSURER D:
INSURER E
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~f: ~~~ TYPE OF INSURANCE POUCY NUMBER ~ EFFECTIVE POLICY EXPIRAl10N LIMITS
GENERAL UABlUTY GL07000038 06/01/2007 06/01/2008 EACH OCCURRENCE $ 2,000,000
~ COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000
I CLAIMS MADE [K] OCCUR MED EXP (Anyone person) $ 5,000
-~------- - -
A PERSONAL & ADV INJURY $ 2,000,000
-
GENERAL AGGREGATE $ 4,000,000
-
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 4,000,000
I POLICY m j~gi n LOC
AUTOMOBILE UABILlTY AL07000019 06/01/2007 06/01/2008 COMBINED SINGLE LIMIT
- $
X ANY AUTO (Ea accident) 2,000,000
- RI CEIVED
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
A -
X HIRED AUTOS JU i 0';' 2007 BODILY INJURY
X $
NON-OWNED AUTOS (Per accident)
-
- OFFICIAl RECORDS AN PROPERTY DAMAGE $
,.-",^. (Per accident)
GARAGE UABlLlTY .. .;l1(VL,;::l UEP AUTO ONLY - EA ACCIDENT $
=1 ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA UABILlTY AUC913794500 06/01/2007 06/01/2008 EACH OCCURRENCE $ 10,000,000
:KJ OCCUR o CLAIMS MADE AGGREGATE $ 10,000,000
C $
~ DEDUCTIBLE $
X RETENTION $ 10,000 $
WORKERS COMPENSAl10N AND WC07000074 06/01/2007 06/01/2008 X I WC STATU- I IOJ~-
EMPLOYERS' LIABILITY _~C0700007S 06jOl/2007 06/01/2008 500,000
B- -ANY PROPRJETORIPARTNERlEXECUTIVE - bL EACH ACC!llli'IL ..... $ ..... ....
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 500,000
Ilyes, describe under 500,000
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT $
OlliER
p~RlPl1ON OF OPERAl10NS / LOCAl10NS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
roject: Disaster Debris Removal, Reduction, and Disposal
~he Certificate Holder is Additional Insured regarding General Liability and Automobile Liability with
regard to work performed by the Insured on this project.
R
CANC LATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRAl10N DATE THEREOF, lliE ISSUING INSURER WILL ENDEAVOR TO MAIL
-1L DAYS WRITTEN NOl1CE TO THE CERl1ACATE HOLDER NAMED TO lliE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBUGATlON OR LIABILITY
City of Clearwater
Attention: William B. Horne II
P. O. Box 4748
Clearwater, FL 33758-4748
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTAllVES.
AUTliORlZED REPRESENTATIVE
Construction Div./BECHEN
fiJlk-
ACORD 25 (2001/08) FAX: (727)562-4052
@ACORD CORPORATION 1988
I..
-,,~.
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificale of Insurance on the reverse side of this form does not constitute a contract between
the issuing inSiJrer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)