CERTIFICATE OF LIABILITY INSURANCE (863) RATE(MMDDNM)
ACaRV CERTIFICATE OF LIABILITY INSURANCE o9rQlar�Qtr
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 endorsements.
PRODUCER CONTACT
MCGRiFF,SEISELS&WILLIAMS,INC. NAME-
PHONE `
P.Q.Box 10285 (A10 Fx0:800476-2211 { Not:
Birmingham,AL 35202 E-MAIL
ADDRESS:
tNSURER(S)AFFORDING COVERAGE NAIC 0
ENSURER A:The Travelers indemnity Company of America 25666
INSURED INSURER B:Midwest Em to ers Cas ualty Cod ASIWCP
M.T.Deason Co.,Inc.;MTO Manufacturing,Inc.;Deason Family Partnership
2820 Commerce Boulevard ENSURER C:Sen Insurance Grow
Irondale,AL 3 52 10
INSURER D
INSURER E:
ENSURER F
COVERAGES CERTIFICATE NUMBER:UATAW80T REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN 18SUE❑TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATE[). NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THfS
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.
1NSR
LTR TYPE OF INSURANCE IN L OBR POLICY NUMBER Mkt AD EFF (MWOOffMI LIMtTs
A X COMMERCIAL GENERAL uAsiLrTY 63DIG92767ATIAI 7 09/01/2017 09/0112018 EACH OCCURRENCE $ 1,000,O00
DAMAGE TO RENTED
CLAIMS-MADE FRI OCCUR PREMISES Ea occeirrence $ 300.000
MED EXP(Any one person) $ 10,000
X X PERSONAL&ADV fNJURY $ 1,00O,OOD
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000.000
X POLICY 0 PR6-JECT ❑LOC PRODUCTS-COMPIOP AGG $ 2,000,000
OTHER: I 1 1 $
A AUTOMOBILE LIABILITY SAIG94902217CAG 09101/2017 09{011201$ COMBINED SINGLE LIMIT 1,00(),000 Ea accident
N ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED X X BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS HIRED NON-O'NNE{1 PROPERTY DAMAGE $
AUTOS ONLY X AUTOS ONLY (Per accident
Comp Ded$1ODO toll Oed$1000
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEO RETENTIONS $
B WORKERS COMPENSATION Member#332400 01/01/2017 01101/2018 X PER OTH-
C AND EMPLOYERS'LtAwLITY YIN PNAL129001[AL]
ANY PROPRIETORIPARTNERIEXECUTIVE 9053 1 1 70 1 00ii71[AOS) E.L,EACH ACCIDENT $ 1,000.0.00
OFFICERIMEMBEREXCLUDED? NIA 1,000,000
fMandatory In NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under 1,000 000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
S
$
S
$
$
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addi6anal Remarks Schedule,may be attached if more space is required)
Certificate Holder is included as Additional Insured as respects General Liability ari d Auto Liability per written contract. General Liability applies as Primary and
Non-Contributory per written contract. Waiver Of Subrogation applies in favor of the Certificate Holder as respects General Liability and Auto Liability per written contract.
In the eventcf cancellation by the insurance companies,the General Liability and Auto Liability policies have been endorsed to provide 30 days notice of Cancellation
except for nonpayment to the Certificate Holder shown below.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THERE=OF, NOTICE WELL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater
P.O.B Purchasing(]apartment,ITS#53-15 AUTiiORIXED REPRESENTATIVE o
P.O.Box 4748
Clearwater,FL 33758-4748
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