CERTIFICATE OF LIABILITY INSURANCE (450) GANIC-1 OP ID: SILA
CERTIFICATE OF LIABILITY INSURANCE
DATE 05102/20/ YY)
�-----�'' o5ro2r2o17
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 pollcy(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 941-758-3861 WCT Stacey Shankle
Dick,Johnson&Jefferson,Inc PHONE 941-758-3861 FAX 941-758-5947
Suite 200 (AIC,No,Ext): (A/C,No):
1429 60Th Avenue W A oRESS:Stacey.Shankl@djjinc.com
jjlnc.com
,Bradenton, FL 34207
'Sharon MetZelaar INSURERS AFFORDING COVERAGE NAIC Y
INSURERA:Southern Owners Insurance Co 10190
INSURED GA Nichols Co Wor Florida INSURERB:Owners Insurance Company 32700
Highway Maintenance Inc INSURER C:FCCI Insurance Company 10178
2271 Belleair Rd
Clearwater, FL 33764-2851 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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.
INSR TYPE OF INSURANCE IN DL SUBR, POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR IN SD'WVD! MMfDDfYYYY MMIDDfYYYY
A X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000!
'CLAIMS-MADE GCCUR X 20719088 01!27!2017 j 01!27!2018 DRMAGETO RErrTED e $ 300,000..
X Non-Owned Auto Li MECEXP An y one Pe rsc.n $ 10,000!
X Hired Auto Liab 1,000 000
PERSONA_&ADV INJURY $ '
GEN'L AGGREGATE L.M T APPL''ES PER. GENERAL AGCREGATE $ 3'000,000
POLICY I PEA LCC PRODUCTS-CCMP.IOP AGG $ 3'000'000
OTHER: $
B AUTOMOBILE LIABILITY B;NED S NG'-E'_IMIT 1,000,000.,
'Ea a adent� _$
X ANY AUTO X 4446843001 05/25/2017 05125!2018 B0D_Y IN_UPY Per;er=_on $
O'✓JNED SCHEDULED "' I
AUTOS ONLY AUTOS I BODILY IN {per accident! $
-:HIRE[, NCti-�'�VV'N�l� PROPERTYDAP.A_E
AUTOS ONLY AUTOS O LY Per accident $
A X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 1,000'000'
EXCESS LIAB CLAIMS-MADE 5098976800 0112712017 i 01/2712018 AGGREGATE $ 1,000,0001
CED I X I RETENTION$ 10000 $
C AND O V E R S E L I S A B I L p T Y I N X STAT E ^TH ER
AIYY PROPR ETOR,FARTNERAD(ECUTIVE 001 WC16A72405 06!2312016 06123!2017 1,000,000
pFFICER'MEMg F_R EXCLUDED'? NIA - E_ EACH ACCIDENT $
{6Aandatory io NH) 1,000,000'
E_ DISEASE EA EMPLOYEE $
(ryes describe under —'—"-
DESCRIPTION OF OPERATIONS belcvr ( 1000,000
..—.--- -------. _. _.- .. - E'_ DISEASE P��LI�Yt.IMI. $ '
P0 b�R�P6� �' LJ TI iJt A(ileBiwaL LESFtCORD 101,Additional Remarks Schedule,may be attached if more space Is required)
Per Ins Requirements, City of Clearwater is listed as additional insured
with respects to General Liability and Auto Policies.
CERTIFICATE HOLDER CANCELLATION
CITYC10
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Clearwater ACCORDANCE WITH THE POLICY PROVISIONS.
Engineering Dept.
100 South Myrtle Ave j AUTHORIZED REPRESENTATIVE
Clearwater, FL 33756
i
ACORD 25(2016/03) O 1988-2015 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD