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COUNTRYSIDE BRANCH LIBRARY - 11-0059-LI - CERTIFICATE OF LIABILITY INSURANCE (3)
Page 1 of 2 A1COR�® �.... CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 06/27/2017 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 Willis of Florida, Inc. c/o 26 Century Blvd P.O. Box 305191 Nashville, TN 372305191 USA CONTACT NAME: PHONE 1 -877- 945 -7378 FAX 1- 888 - 467 -2378 (A/C. No. Ext): (A/C, No): E-MAIL RSS: certificates@willis.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Zurich American Insurance Company 16535 INSURED Ajax Building Corporation 1080 Commerce Blvd. Midway, FL 32343 INSURER B : American Guarantee and Liability Insurance Campany 26247 INSURER C: Indian Harbor Insurance Company 36940 INSURER D : $ 1,000,000 INSURER E : INSURER F : OCCUR COVERAGES CERTIFICATE NUMBER: N2788425 • 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/YYYY) POLICY EXP (MM/DD/YYYY) UNITS A X COMMERCIAL GENERAL LIABILITY Y Y y •� GLO 0173927-' "' JUL 0 5 g� 0 - /-yPt 7 2011 06/30/2018 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 300,000 X X GEN'L ECU Included MED EXP (Any one person) $ 10,000 Contractual Liability PERSONAL 8 ADV INJURY $ 1,000,000 AGGREGATE POLICY OTHER: X LIMIT APPLIES JECOT- PER: LOC GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 $ B AUTOMOBILE X X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY X SCHEDULED AUTOS NON -OWNED AUTOS ONLY Y N C I OF. !COAL ,RECD LE�j I�I� �^y i ; BAP 0173925 -03 Ji'. J rl't .!X. AND J ( 4 0%30'/27( / 6/30/2018 COMBINED SINGLE LIMIT COMBINED 8 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LIRE EXCESSLIAB X OCCUR CLAIMS -MADE N N ADC 0178749 -02 06/30/2017 06/30/2018 EACH OCCURRENCE $ 20,000,000 AGGREGATE $ 20,000,000 DED RETENTION $ $ B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBEREXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N/A N WC 5761206 -04 06/30/2017 06/30/2018 X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 A Equipment Floater N N CPP 0173926 -03 06/30/2017 06/30/2018 Rented 500,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) Job No. 201335 Countryside Branch Library, City of Clearwater Project 11- 0059 -LI 2650 Sabel Springs Dr, Clearwater, FL 33761 SEE ATTACHED CERTIFICATE HOLDER CANCELLATION City Of Clearwater Attention: City Clerk Po Box 4748 Clearwater, FL 33758 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) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 14764748 BAs: 363810 ACORD® AGENCY CUSTOMER ID: LOC #: ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Willis of Florida, Inc. NAMED INSURED Ajax Building Corporation 1080 Commerce Blvd. Midway, 8/ 32343 POLICY NUMBER See Page 1 CARRIER See Page 1 NAIC CODE See Page 1 EFFECTIVE DATE: See Page 1 MARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance City of Clear Water is Additional Insured regarding General Liability and Automobile Liability . Waiver of Subrogation in Favor of Additional Insured applies on The General Liability. INSURER AFFORDING COVERAGE: Indian Harbor Insurance Company POLICY NUMBER: CE07446412 EFF DATE: 06/30/2017 EXP DATE: 06/30/2018 ADDITIONAL INSURED: N SUBROGATION WAIVED: N TYPE OF INSURANCE: LIMIT DESCRIPTION: Professional /Pollution Liability LIMIT AMOUNT: $5M / $5M NAIC #: 36940 ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SR ID: 14764748 BATCH: 363810 CERT: W2788425