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CERTIFICATE OF LIABILITY INSURANCE (4) KHORCON-01BJONES DATE (MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 11/27/2017 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). CONTACT PRODUCER NAME: ASSOCIATES AGENCY, INC. PHONEFAX (813) 988-1234(813) 988-0989 (A/C, No, Ext):(A/C, No): 11470 N 53rd St E-MAIL certs@associatesins.com Temple Terrace, FL 33617 ADDRESS: INSURER(S) AFFORDING COVERAGENAIC # National Builders Insurance Company16632 INSURER A : NGM Insurance Company14788 INSURED INSURER B : American Builders Insurance Company11240 Khors Construction, Inc INSURER C : 12222 ANNE KENIA DRIVE Undewriters at Lloyds London15792 INSURER D : Thonotosassa, FL 33592 INSURER E : INSURER F : COVERAGESCERTIFICATE NUMBER: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. POLICY EFFPOLICY EXP INSRADDLSUBR TYPE OF INSURANCEPOLICY NUMBERLIMITS (MM/DD/YYYY)(MM/DD/YYYY) LTRINSDWVD A 1,000,000 X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE$ 100,000 DAMAGE TO RENTED X PKG0149693 0409/05/201709/05/2018 CLAIMS-MADEOCCUR $ PREMISES (Ea occurrence) 5,000 MED EXP (Any one person)$ 1,000,000 PERSONAL & ADV INJURY$ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER:GENERAL AGGREGATE$ 2,000,000 PRO- POLICYLOC PRODUCTS - COMP/OP AGG$ JECT OTHER:$ B 1,000,000 COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY $ (Ea accident) X B1P8733D09/25/201709/25/2018 ANY AUTO BODILY INJURY (Per person)$ OWNEDSCHEDULED AUTOS ONLYAUTOSBODILY INJURY (Per accident)$ PROPERTY DAMAGE XX HIREDNON-OWNED (Per accident)$ AUTOS ONLYAUTOS ONLY PIP10,000 $ C 1,000,000 XX UMBRELLA LIAB OCCUR EACH OCCURRENCE$ UMB02480440011/25/201709/05/2018 1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE$ 10,000 X DEDRETENTION$ $ C PEROTH- X WORKERS COMPENSATION STATUTEER AND EMPLOYERS' LIABILITY Y / N WCV-0166202-0309/05/201709/05/2018 1,000,000 ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT$ N / A OFFICER/MEMBER EXCLUDED? 1,000,000 (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE$ If yes, describe under 1,000,000 DESCRIPTION OF OPERATIONS belowE.L. DISEASE - POLICY LIMIT$ A Equipment FloaterPKG0149693 0409/05/201709/05/2018 Rented/Leased Equip35,000 D Errors & OmissionsANE1851279 1711/23/201711/23/2018 Claim$1,000,000 Agg1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) City of Clearwater is an additional insured with regard to the general liability for ongoing operations where required by written contract. CERTIFICATE HOLDERCANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Clearwater ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Engineering Contract Specialist, RFQ #24-16 PO Box 4748 Clearwater, FL 33758-4748 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03)© 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD