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CERTIFICATE OF LIABILITY INSURANCE (460) ACOOROr CERTIFICATE OF LIABILITY INSURANCE DATL WMODIYYYYj ](.',112712017 - - THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDF k 7FH_is CERTIFICATE DOES NOT AFFIRPAATIVELY 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 staterrient on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME, AJG Service Team Arthur J. Gallagher Risk Management Services, Inc, PHONE FAX 250 Park Ave lue, 5101 Floor (AJ.C,,No,E,,,,. 212-981-2485, 212-994-7047 EMAIL New York IVY 10177 ADDRESS:_, INSURERS)AFFORDING COVERAGE NAIL P INSURER A:Zurich American Insurance Company 16535 NSURI"D WSPGLOB-01 INSURER 9;Liberty Insurance Corporation 42404 WSP USA inc� INSURER c:American Guarantee and Liability Ins Co 26247 i,eggetLe Brashe,,zJl & Giahiaii"i, Inc 4 [)rlvn, Suite 204 INSURER o:Q13E Specialty Insurance Company 11515 Shelton CT 06484 INSURER-EA111IG Specialty Insurance Company 26883 INSURER F CO M COVERAGES _ CERTIFICATE NUBER:937472640 -------------- REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 'THE INSURED NAMED ABOVE FOR THL- P(d C',/ PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION Or ANY CONTRACT OR OTHER DOCUMENT"WITH RESPEC 1 10 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT T0 ALL., THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH,POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INsk- LTR TYPE OF INSURANCE _ADDL SUSR POLIC-Y-E.1 F-F ---P C-L I IC I Y EXP INSD WVQ POLICY NUMBER (MMIDWYYYY MMIDDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY GLO983581904 911/2017 411/2018 EACH OCCURRENCr $2.000,000 - AMAOL To RENTLI� CLAIMS-MADE X OCCUR IJPREMISES?E a occoirmc,; $300.000 , . ....... PALL?E X P(Any one person) $5,000 PERSONAL&AOV INJURY $2,000,000 GENT AGGREGATE LIMIT APPLIES PER: GENERAL PRO- R V, AGGREGATE s5.000,000 POLICY JECT LOC lip r PRODUCTS-COMROP AGG S2,O0E,cOO OTHER: -SIN 0 C0MH B AU TOMO Ell L E LIABI LIT Y 911 12JLI 7 411 12 018 (Ea a BTNLccident) $21000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED AUTOS ONLY AUTOS i,,,In, r r na c,r'; BODILY NU U RY(Per accidert) $ HIRED NON-0%IINED AUTOS ONLY AUTOS ONLY 1*01DERTY DAMAGE ci C X UM13RELLA LIAS X OCCUR AUC0144313601 9/112017 41112018 EACH OCCURRPNCE $10.000,000 EXC 11 ES.1 S LIAR ct AIM`,MADE. AGGREGATE $10,000,000 DED RETENTION$ $ B 'WORKERS COMPENSATION WA762DO94060017(ACS) 9/1/2017 411/2018 PE R 3TH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PRGPRlETOP PARTNER.eEXECUTIPVE OFFIC ERAAE MBE R EXCLU 0 E D7 NIA E-L,EACH ACCIDENT S21000-0011.......... (Mandatory in NH) E L DISEASE E A E IT as.describe under - . - MPLOYEE $2.000.000 D as. OF OPERATIONS belo,-,%, E L,DISEASE-POLICY I-PAIT $2,00,0.o04 Professional Liability QPLOO22630 1111 Q011 10131/2018 Per C�aim/Aqgregate S5,000.000 E Pollution Liability CPO 282384,95 1 V112D11 11/112018 PP r C airl/Aggregate 5.000,000 CLAIMS-MADE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks.Schedule,may be altaohod if more space is required) City of Clearwater is included as an Additional Insured under the General Liability and Automobile Liability policies when required in a written agreement in accordance with policy terms, conditions, and exclusions for Work and activities perforned by the Named Insured. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANrFL!_FD RIFFORIF City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE L)FLIVERED IN Attn: Engineering ACCORDANCE WITH THE POLICY PROVISIONS. P.J.Box 4748 CLEARWATER FL 33758-4748 USA AUTHORIZED REPRESENTATIVE C 1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE D A T E mM wfy Y Y Y) '10/271,2017 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE-FIOLDER, THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POI,-IrIES 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(ios) 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 CRNT A cT AJG Service Team Aminur J. Gallagher Risk Management Services, Inc. NAME 0 PHONE -981-2485 FAX -994 - 2'0 Park Avenue 5th Floor WC,-No,E,,,�: 212111, 2 -7047 New York NY 10177 E-MAIL ADDRESS; INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Zurich American Insurance Company 16535 INSURED VVSPGLOB-01 "INSURER B,Liberty oration Qy Insurance Corp 42404 LISP USA Inc. Legette Brashears & Graham, Inc. INSURER_C American Guarantee and Liability Ins Co 26247 4 Research Drive. Suite 204 IN-SURER o:Q BE Specialty I n s ura rice Compa Fly 11515 Shelton CT 06484 -INSURERS AIG, Specialty Insurance Company 26883 INSURER F; COVERAGES .239903232 CERTIFICATE NUMBER. REiIISdON NUMBER: THIS 'S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THI Y PERIOD NOTWITH STAND:ING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPEC'! I-0 WH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN 15 SUBJECT TO ALL THE ICH TERMS, EXCLUSIONS,,AND CONDITIONS OF SUCH POLICIES.LINTITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS, INsR __ADDL_SU13R_ LTR TYPE OF INSURANCE POLICY y EU POLICY EXP IN-SO WvR POLICY NUMBER (MOILD Dty YY I_(M MDIY YYX) LIMITS A X COMMERCIAL GENERAL LIABILITY GLO983581904 9r1 12U17 4012018 EACH OCCURRENCE $2,000,000 CLAIMS-MADE X OCCUR DAMA(;t TO RENTED PREMISES(Eaw urrence), S300,000 ME D EXP(Any one person) $5,000 PERSONAL a.ADV INJURY s 2,0G0X)DO GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S5.000,0100 POUCY IEC: LOC PRODUC-,5,COMP,'O P AG I G 1�2,0 0 1 0.0 1 00 OTHER: AS762 0�i,106003; 90001 4111 AUTOMOBILE LIABIr X ANY AUTO iEa derlt) $-2,000,000 "M BODI LY 1N,1URY(Per person) OWNED SCHEDULED BODILY NJ U RY(Per accident' S AUTOS ONLY AUTOS NON-OVVNED HIRED AUTOS ONLY AUTOS ONLY PROPERTY DAMAGE"- -- $ (Per accident) C X UMBRELLA LIAS X OCCUR AUC01 4438601 9/712017 41112018 EACH OCCURRENCE 001000r000 EXCESS LIAR CLAIMS-MAIDE AGGREGATE $10.000.000 DEE) RETENTION S B WORKERS COMp­ENjATION WA762DO94060017(AOS) 91112017 41112018 'E ITI. AND EMPLOYERS",ASILITY YIN STA�IUTE EP ------------- ANY PROPRJETORiPARTNERiEXECUTIVE OFFICERMEMBER EXCLUDED? 171 NIA E.L.EACH ACCIDENT _$2.0100.000 (Mandatory in NH) If ns�de5cribe under E1,DISEASE-EA EMPLOYEE $2,000,om D 5CRIPTIOri OF OPERATIONS belo,,p., D Prole Sinn -.I - E, DISEASE-POLICY LIMIT $2,000,000 E -na-I Liab�Ay QPL0022630 111112017 10/31 x201 B Per Claim/Aggregate s s,©00 0[10 Poflhtion Liability CPO 28238455 11/112017 lV112018 Pe r C airtniA CLAIMS-MADE re ate $5.000.000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached If mere spade is required) City of Clearwater, its Council, the Community Redevelopment Agency of the City of Clearwater, its duly appointed officers, or other public bodies, officers, erriploye�es, representatives and agents are included as an Additional Insured under the General Liability policy, on a primary and non contributory basis, and Automobile Liability policy when required in a written a reement in accordance with policy terms, conditions and exclusions for services performed by the Named Insured. 30 Day Notice of Cancellation in favor of the First Named insured and the certificate holder on the General Liability policy when required by written agreement in accordance with policy terms, conditions and exclusions CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Cit of Clearivater: Engineering FQ @)34-15 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P. .Box 4748 ACCORDANCE WITH THE POLICY PROVISIONS. CLEARWATER FL 33758-4748 USA AUTHORIZED REPRESENTATIVE 1988.2015 ACORD CORPORATION, All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD CERTIFICATE OF LIABILITY INSURANCE I'r WP.11DDtYV)'Y) 1 " 12612017 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 POtAGICS 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 rpquire an endorsement A statement on this certificate does not confer jilghts.,to the certificate holder in fieu of Lich e rida rs"�ntryqs CUN" AJG Service Team PRODUCER NAME: Arthur J, GnPr9qher Risk Management Services, Inc. PHONE 212-981-2485 FAX 12 - - ue, 5th Floor (Alc No); -994-7047 25r)Park Avet� U%iG,No E,,�, AU New Y E-M ork NY 10177 ADDRESS- INSURER(S)AFFORDING COVERAGE NAIC Jr INSURER A;Zurich American Insurance Company 16535 INSURED WSPGLOB-01 INSURERB:Liberlty Insurance Corporation 42404 WASP USA Inc. INSURER c:American Guarantee and Liability Ins Cc 26247 Leggette Brashears& Graham, Inc. 4 Research Drive, Suite 204 INSURES Specialty Insurance Company 11515 Shelton CT 06484 Specialty Insurance Company —— 26883 iNSU RER FI: COVERAGES CERTIFICATE NUMBER: 1775289087 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOVV HAVE BEEN �SSUED To THE INSURED NAMED ABOVE FOR T1 a! I U4i','Y PF'R-163— INDICATED- NOTWITHSTANDING ANY REOUIREMENT, 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 15 SUBJECT T(r-) ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR SUBR __POLICY ' POLICY EIP LTR TYPE OF INSURANCE IN§Q MQ POLICY NUMBER (MM1DDNYYYJ JMM/DDIYYYYi LIMITS A X COMMERCIAL GENERAL LIABILITY GLO983581904 91112017 V112018 EACH OCCURRENCE S2,00010M DANIAGE TO D RENTE C1,AIMS-MADE X OCCUR MISES $300.000 PRE (E a occurrence) ce) MED EXP(Any one per,,;Gn) PERSONAL. AQV INJURY s2,000,00,0 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE x Po PRO: ,-ICY JECT OC J, PRODUCTS-COMPIOP AGG s 2,000,000 OTHER: 13 AUTOMOBILE LIABILITY A 1;6,, 1�2 17 411 1201 B COMBINEccident)DSN71!CIP11 $2,000,000 (Ea a x ANY AUTO 4 BODILY INJ U RY'Per person) OWNED 5C1 d C,11 t I AUTOS ONLY AU 1 BODILY INJURY(Per accident) HIRED (Per acrident) AUTOS ONLY Al T05 ONLY r YR OPERW DAMAGE C X UMBRELLA LIAR X AUC01 4438601 91112017 41112018 EACH OCCURRENCE 10,000,000 EXCESS LIAR t A,rj,,,VAnF7 AGGREGATE 10,000,000 DED RETENTION s B WORKERS COMPENSATION WA762DO94060017(AOS) 9;112017 4eV2018 x PER TH- AN D EMPLOYERS'LIABILITY YIN STATUTE E OR ANY PRO FRIETOWPARTNERIEAC. 1 1 Vt EACH ACCIDENT—--- OFFICERIMFMI3E�FXCLUDED? NIA '(Mondatofy in NH) E.L.DISEASE-EA EMPLOYEE $2.000,000 describe Under If r-de"-RIPcr DESCRIPTION OF OPERATIONS belv.,2 E .DISEASE-POLICY LIMIT s2,000.000 Professional Liability QPLOO72630 91112014 7 111112017 Per Claim/Aggregate PiAlUtion Liability CP028238455 9,1112017 111112017 Per Claim/Aggregate �'C('1'0()O CLAIMS-MADE DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may Be attached if more space Is required) City of Clearwater is included as an Additional Insured under the General Liability and Automobile Liability policies when required in a written agreement in accordance with policy terms, conditions, and exclusions for work and activities perforned by the Named Insured, CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Cleawdater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Attw Engineering ACCORDANCE WTH THE POLICY PROVISIONS. P.O.Box 4748 CLEARWATER FL 33758-4748 USA AUTHORIZED REPRESENTATIVE 0 1988-2015 ACORD CORPORATION. All rights reserved, ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD F LIABILITY DATE(MMIDDrYYYVI CERTIFICATE O INSURANCE 1,),2(512 01 7 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H01 DER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY IrHE 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 riot confer rights to the certificate holder in lieu of such endnirsement(s). PRODUCER ZNAONTACT—, — ME: AiG Service Team Arthur J. Gallagher Risk Management Services, Inc. PHONE, 212-981-2485 FAX 212-994-7047 250 Park Avenue, 5th Floor WC-fto EXQ: 011 Nok E-MAIL New York NY 10177 ADDRESS: INSURER(S)AFFORDING COVERAGE NAIL INSURER A:Zurich American Insurance Company 16535 INSURED WSPGLOB-01 -IN SURER 13,Liberty Insurance Corporation 42404 WSP USA Inc. INSURER C America can Guarantee and Liability Ins Co 26247 Legette Brasihears& Graham, Inc, 4 esearch Drive, Suite 204 WKIRER D:QB-E Specialty Insurance Company 11515 Shelton CT 06484 INSURER E:A111G,Specialty Insurance Compa Fly 26883 INSURER F: COVERAGES CERTIFICATE NUMBER: 564272384 REVISION NUMBER: THIS 15 TO CERTIFY THAT THE POLICIES Or INSURANCE LISTED BELOW HAVF BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TI-H D,- - '! 7,7-, 1 E R FOE— INDICATED, NOTWITH STAN DINO ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR 01HER DOCUMENT WITH RESPEC; I U�Wh UH THIS CERTIF?CATE MAY BE ISSUED OR MAY PERTAIN, THE iNSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TrD ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR -ADt)L-SU13R LTR TYPE OF INSURANCE IMSIT WVD POLICY NUMBER POLICNEFF 156LI&EXP LIMITS —(*MIDDNYYY) (MMIDWYYYY A X COMMERCIAL GENERAL LIAMLITY GLO983581904 911/2017 41712018 EACH OCUiRRENCE $2.000,000 CLAIMS-NIADE X OCCUR DAMAGE TO RENTLO PREP,11SES iEa occurrence] $300,0010 EXP(Any,one person) $5,000 PERSONAL&ADV INJURY 2 000.000 GFN'L AGGREGATE LIMtT APPLIES PER: GENERAL AGGREGATE S5,000,000 POLICY PRO- X11111. SECT LOC ,,,PR,ODU-C,T,S,,,-CO,h.I,P(OPAGG $2,000,000 9 f OTHER $ AUTOMOBILE LIABILITY S762109406006i 9 01 7 413/2018 C OM BIN E D S IN G L-E-E1N7T­-­- (Ea accident) $2.000,0010 X ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AUTOS ONLY AUTOS BODILY INJURY(Per accident)' S NONLOV;NED HIRED PrWPEATY DANIAGE- AUTOS ONLY AU70S ONLY (Per accident) C X UMBRELLA LIAR OCCUR AUCC14438601 911/2017 411/2018 EACH OCCURRENCE EXCESS LIAR C 1A I MS�NIA DE G E- ....... I I, T $10,000,000- DED RETENTION$ B WORKERS COMPENSATION WA762DD94060017(AC)S) 9/112017 41112018 X PER OTH• AND EMPLOYERS'LIABILITY YIN L ERI ANY PROPRIETORIPARTNERIEA �U I P.L OFFICERiMEN!BEP EXCLUDED? NIA 'E.L EACH ACCIDENT s2,000,000 (Mandatory in INH) L L lIrs do 1,11be . .DISEASE-EA EMPLOYEE s2,000,000 under OF Q PE RAT I ON 5 be E.L.DISEASE-POLICY LIMIT $2,DOO,009. D 'Professional Liability QPL0022630 911/2017 1111/2017 Per Claim/Aggregate F Pollution Liability CP028238455 911/2017 1111l2017 Per C alm./Aggregate CLAIMS-MADE DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACOR❑101,Additional Remarks Schedule,may be attached If mare!space is required) City of Clearwater, its Council, the Community Redevelopment Agency of the City of Clearwater, its duly appointed officers, or other public bodies, officers, employees, representatives and agents are included as an Additional Insured under the General Liability policy. on a primary and non contributory basis, and Automobile Liability policy when required in a written agreement in accordance with polic tcjms, Conditions r and exclusions for services performed by the Nampd Insured, 30 Day Notice of Cancellation in favor of the First Named nsured and the certificate holder on the Genm-,a I I.. ab0ity policy vO,en required by written agreement in accordance with policy terms, conditions and exclusions CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCFLI,,FD BEFORE Cit of Cearivater-Engineering FQ QZ34-15 THE EXPIRATION DATE THEREOF, NOTICE WILL IBM DELIVERED IN P-9,Box 4748 ACCORDANCE WITH THE POLICY PROVISIONS. CLEARWATER FL 33758-4748 USA AUTHORIZED REPRESENTATIVE 1988.2015 ACORD CORPORATION, All rights reserved, ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD