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CERTIFICATE OF LIABILITY INSURANCE (457)
DATE(MMIDDIYYYY) A�R" CERTIFICATE OF LIABILITY INSURANCE 7/26/2017 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 NAME: Certificates/Commercial Lines Wallace,Welch&Willingham PHONE 727.522.7777 FAX P.O. Box 33020 E-MAIL certificates@w3ins.com INSURERS AFFORDING COVERAGE NAIC# INSURER A:Phoenix Ins. Co. 25623 INSURED INSURERB:Old Dominion Ins. CO. 40231 Driggers Engineering Services, Inc. INSURERC:Travelers Indemnity Co. 25658 PO Box 17839 INSURERD:Amerisure Ins. Co. 19488 INSURER E: _ INSURER F COVERAGES CERTIFICATE NUMBER: 120462438:3 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 I TYPE OF INSURANCE POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MMIDD/YYYY A X `COMMERCIAL GENERAL LIABILITY Y Y X6601 C729473PHX17 8/10/2017 8/10/2018 EACH OCCURRENCE $2,000,000 _ CLAIMS-MADE ❑X OCCUR DAMAGE TO RENTED PREMISES Ea occurrence $100,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $4,000,000 POLICY I x JET ❑ LOC PRODUCTS-COMP/OP AGG $4,000,000 OTHER: $ B AUTOMOBILE LIABILITY Y Y '61T6102X .�t ` } �+ 8/10/2017 8/10/2018 COMBINED SINGLE MI $ p, .W Ea accident 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY IN $ AUTOS ONLY AUTOS JURY(Per accident) HIRED NON-OWNED PROPERTY DAMAGE X AUTOS ONLY EX AUTOS ONLY Per accident $ C X UMBRELLA LIAB X OCCUR Y XSMCUP3950T0731ND17 8/10/2017 8/10/2016 EACH OCCURRENCE $5,000,000 _ EXCESS LIAB CLAIMS-MADE AGGREGATE $5,000,000 DED X I RETENTION$10,000 $ D WORKERS COMPENSATION y WC20637110801 8/10/2017 8/10/2018 X PER OE AND EMPLOYERS'LIABILITY YIN STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000 I OFFICER/MEMBER EXCLUDED? N N/A ----......-........--- (Mandatory In NH) E.L.DISEASE-EA EMPLOYE $1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000 DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attn:Engineering Department ACCORDANCE WITH THE POLICY PROVISIONS. PO Box 4748 Clearwater FL 33758 AUTHORIZED REPRESENTATIVE v' ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD