SPECTRUM FIELD - 16-0023-PR-A - CERTIFICATE OF LIABILITY INSURANCEDATE (M0.AtGD1YYYY)
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"�FdiS CEF&THFIC{ATE i5 3SSUED A5 A i�ATTEt2 �a�= In9FOi2PdiATIQPV O(dLY AP4D C�3P�F��2S 1�0 RiGFiTS UPflN TFiE GE1�T€FICATE 6iOLdE'2. THIS
�ERTtFI�ATE �OES NO�' AFFiRA+IATtVELY flR :'dEGIaTIVE? Y AME�ID, EX�LiUD OR ALTER THE Cd1fERAGE AFFCDRDEi3 BY T4,1E PC)LIC9ES
�ELOW. :'HIS CERTlFICAT� OF INSURANCE Dt3ES �ICDT Ct7N5T{Ti1TE A CO�iT62ACT BE"f'dVVEEiV THE ISSUING INSt9FtER(S}, AUT4ic3RIZED
REPRESEPd7ATlVE OR PRODUCER_ ANo'�HF �=RrsFt�nr� uns nGa
EIaAP062t/aNT: 0f Phe cer4isicage holder is an faD�fi�9CahIP�L IP3SURED, 4he policy(ies) must be endorsed. 6f Sl1�RpGATl�f� IS UU�s14'ED, suiajecf to
the Yerms and canditions of the policy, certain p=�licies may require an endorsement. A siatement on this certificate does not cvnfer right:; 4o tfie
certificate holder in lieu efi such er�dorsement(s}.
PRODUCEFt �a�E"�C��� Angie Kavoukiis
New Cer;tury Insurance Inc. �'Ho"�E 727 934 3500 _ FA� 7?7 93A 1360
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F'.O. Qox 764 w�o��ess: �C13500@aol.com
iarpon Sprin,ys, Ft. 346�38 _ __ _ I_ _
. INSURER(S) AFFORDtP1G COVERRGE ��, NAIC #
. ....... . . ... . . . .. . .. ... ... . . ._.. _. .. ...
irasuxeRa: Scottsdale Insurance Company
_ — _ ._. . . _ _ __. _ _ _ . _ _ � _ _ _._ —___ _.
i�vsuHEo tt�suRER a: Nationai General Irysurance Co.
_--- --.. . _ — _...---_ _ _..__, _ ---
Viktor Construction Corp. �NsuR�R �_ Commerce & Industry Ins. co.
_ ____ _ _ _
P.O. E3ox 1366 1NSURERD:
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Tarpon S�rings, FL 34688 iwsuKerz �. _ __------_ I
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INSURER F : I
COdER�at�ES CERTIFlCAl'E P�tUIVIBER: t2EV1S10N �IUMi�ER•
TNIS SS TC} CEk7IFY THAT TI{E F�OLICIES OF WSURANCE LISTED E3ELOW HAVE BEEV ISSIJED TQ TFiE INSURED NAMEQ ABOVF FOR TFiE POLiCY ?ERlOD
INDICl4TFD. NOTWI"CHSTAtJDING ANY REQUIREMEidl, TERM OR CONDI710N OF ANY CONTRACT OR flTtiER D(�CUMEN'i W(TH RESPFCT TO WMCH THIS
CER'iIF1CAT"t MAY l3E ISSIJED OR NiAY PERTAIN, TI I� WSURP,NCE AFFORDED BY 1'NE POLICIES DF.SCRIBED NEREIN IS SUBJECi' TO ALL THE TERMS,
EXCLUSIONS AND GONDI'T1QNS OF SUCFi POLICIES. LI�NtIfS SHONJN MAY HAVE BEEN REDUCEO 8Y PAtD CLAIMS
IPdSR . . . TYPE OF iNSURANCE � AD(SL SUB�i. . .. . . __.. . . ..POL.6CY �EFF � � POLICY EXP . . . . . . .._. _ _._. . . _.
t.TR 1N NND , POUCY NUMBER �(pdP�7JpD/YYYY1 (N1FPIlOD/YYYY) �� LIFAITS
GE-WI:72A�iJABIUTY ' '�; EACt?OCCURRENCE , ^y 1;000,000
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COMMERCIAi. GCNERht LIAQII.IN � � 1(}O,dQU
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a i Y Y CnS2F�517ia ' 02/25/2017 � 02l25l2018 �Er�son�� rs nov 3N�uRv g 1,000,000
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j UE N L l:rGfiF,UATE JM I r APPL;F:S PFR: ' � • J,�fl�r00�
r'R0t7UCTS - C�MP!OP F�GG $
I p.,OLICY PRO LOC _ q
AU70MOE1(LE LIAF]ILlTY � ��, Y �W � �� GOi�tk3iNED SINC;LE LIMIT
� � 1,000,000
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� +tJY RUT6 . � I. �. 3UDILV INJURY (Pcr person),� $
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�� a- :. aUVNro �/ ;cs{Eoui.co y .�004156429 40 08(25l2017 "; 08125l2018 BOUILY INJURv (r e�acGaP�� �
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UFd16RELLA LIAB �� .���-�. � v�m� �: � �
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� � � � � � EACH UC.GURRENCE �� $ �.��Q,�4�
_ c;l.amas-rn�oF ! BU00864878271 05l15/2017 '' _-- _. . .____ ,
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'� A�ID EPJIPLQYEF3u' LIABlLI7Y Y ���-� �
'ANY �20�RIETORrPARTNrF2%EXECUiNE ��
�.t;f t( '.?tMEP1F3EF2EXCLUf7FC7� (. �IP`%/A�
(Mandatary in NH)
�� tf �� s, rJescrit�e under ��
Df SCRIf"�TION qF pPERA7lONS below �
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. !: T�RY LIMITS J : E�R ; . . .
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� E.i. QiSC^ASE - EA FRnPl.OYt�(-... $ �.. . �' � �
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DESCRIPTIOCd OF OPERATIONS ( lOCA77UNS I VEHICLES (Attach ACOR0101, Additional RemarRs Schedule, if more space is requireG)
Generaf Contractor- F�r�ject �lo. 16-OD23-PR-A-Speccrum Field - Structural Concrete ReNairs & Painting of Exposed Sieel
Additic�nal Insured: City oi Ciearwater, Enc�ineeriag Dapartment, Attn: Construction Ofiice Special,f'.O. F3ox 4748, Clearwater, FL 33758-47�15
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City of Clearwater
Engineering C�epartment
Atten:Construction Qffice Specialis
P.O. Sox 474&, Clearwaier FL. 33758-4748
aco�� zs �ao7oras�
CAIPUCELtATiOfd
SHOULD ANY OF THE ABOVE DE5CR[BED POLICIES BE CRNCEL6�EG BEFORE
THE EXPIRATION QATE iHEREOF, htOTICE WILL BE DELIVC=RED ItJ
ACCORDANCE Wl�H THE POLICY PfiOVI510NS.
AUTHORIZELYREPFtESENTATtV E
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,�' �" OO 198$-20,70 AGQRfl CORPORATiOPl. AU eigh4s resenred.
3he AC3RD naraie and logo are r�st�red mardcs of ACORd
CERTIFICATE OF LIABILITY INSURANCE 10/10/2017
Producer: Plymouth I nsurance Agency This Certificate is issued as a matter of information only and confers no
2739 ll.s. iilghWBy 19 N. rights upon the Certificate Holder. This Certificate does not amend, e�ctend
HOlidBy, FL 34691 or alter the coverage afforded by the policies beiow,
(727) 938-5562 Insurers Affording Covera e
�nsured: South East Personnel Leasing, Inc. & Subsidiaries �nsurerA:
2739 U.S. HighwBy 19 N. �nsurer e:
HolidBy, FL 34691 �nsurerC:
Insurer D:
Insurer E:
Coverages
9
Lion Insurance Comoanv
NAIC #
----�-- ��-�••-- ���•� ��� ���= N����y v���oo ���u�w�ea. rvo�mscanamg any requirement, term or wndition of any conhact 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.
INSR ADDL
LTR INSRD Type of Insurance
Commercial General Liability
] Claims Made � Occur
erai aggregate limit applies per:
Policy ❑ Project ❑ LOC
�iAs��mr
My Auto
All Owned Autos
Scheduled Autos
Hired Autos
Non-Owned Autos
EXCESS/UMBRELLA LIABILITY
Occur ❑ Claims Made
Deductible
A Workers Compensation and
Employers' Liability
Any proprietorlpartner/executive officer/member
excluded? NO
If Yes, describe under special provisions below.
Policy Number
y tttective Policy Expiration
Date Date Limits
I/DD/YY) (MM/DDlYY)
Each Occurrence
Damage to rented premises (EA
occurrence)
Med Exp
Personal Adv Injury
General Aggregate
Products - Comp/Op Agg
Combined Single Limit
(EA Accident)
(Per Person)
Bodily Injury
(Per Accident)
Property Damage
(Per Accident)
Each Occurrence
Aggregate
WC 71949 01/01/2017 01/01/2018 X WC Statu- OTH-
to Limits ER
E.L. Each Accident $1,000,000
E.L. Disease - Ea Employee $�.00o,o00
E.L. Disease - Policy Limits $t,00o,000
other � Lion Insurance Company is A M Best Company rated A(Excellent) AMB # 12616
Descriptions of Operations/LocationsNehicles/Exclusions added by Endorsement/Special Provisions:
ClientID: 41-66-233
Coverage only applies to active employee(s) of South East Personnel Leasing, Inc. & Subsidiaries that are Ieased to the following "Client Company":
Viktor Construction, Corp.
Coverege only applies ts injuries incurred by South East Personnel Leasing, Inc. & Subsidiaries active employee(s;, while working in: FL.
Coverage does not apply to statutory employee(s) or independent contractor(s) of the Client Company or any other entity.
A list of the active employee(s) leased to the Client Company can be obtained by faxing a request to (727) 937-2138 or by calling (727) 938-5562.
Project Name: N0. 16-0023-PR-A-SPECTRUM FIELD
ISSUE 10-10-17 (RK)
ATTN: CONSTRUCTION OFFICE SPECIALIST
PO BOX 4748
CLEARWATER, FL 33758
�houitl any of the above described policies be cancelled before the expiretion date thereof, the issuing
insurer will endeavor to mail 30 days written notice to the certificate holder named to the left, but failure to
da so shall impose no obligation or liability of any kind upon the insurer, its agents or representatives.
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