CERTIFICATE OF LIABILITY INSURANCE (843) S017913
�r
r DATE(MMfDD1YY'YY)
AC L> CERTIFICATE OF LIABILITY INSU NCE 2/22/2018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATEHOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER TIME COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE, OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INISURER(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 CONTACT
NAME:
Commercial Lines PHONE FAx
_iAlc,Ma, 888-572-2412 Ext): tv ,Noll..
USI Insurance Services National, Inc. E-MAIL
ADDRESS. certs@trinet.com
2601 South Bayshore Drive, Suite 1600 INS U R ERIS)AFFORDING COVERAG E NAIC4
Coconut Grove, FL 33133 INSURERA Indemnity Insurance Company of North America i 43575
INSURED INSURER B
Strategic Outsourcing, Inc
INSURER C
FM//L Heath Consultants Incorporated INSURER D:
PO Box 241448 INSURER E: -----
Charlotte, NC 28224 INSURER F;
COVERAGES CERTIFICATE NUMBER: 12713494 REVISION NUMBER See below
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE ENSURED 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,
IN R ADOLIS111 UBR_ POLICY EFF PO11 LICY E-XP ..
LFR TYPE OF INSURANCE INSD WVD POLICY NUMBER MMDDNYYY MMIDDIYYYY LIMITS
COMMERCIAL GENERAL LIABILITY 'EACH OCCURRENCE S
-'
OCCUR DREGDAMAGE-TO RENTED
CLAIMS-MADE
....._.. PREMISES crr<c.urrens;e) `�
MED EXP(Any one person) S
(� PERSONAL$ADV INJURY 5 -
GENL AGGREGATE LIMIT APPLIES PER-- ,_GENERAL.AGGREGAI E S
1 POLICY jRo LOC PRODUCTS COMPtOP AGG S
07HER: $'
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S.
Ea audderrt)
ANY AUTO BODILY INJURY(Per person) ($..
�'-- — ......... ...... .
.....
OWNED SCHEDULED
BODILY INJURY(Per ar..rident) $
AUTOS ONLY _._,AUTOS _ (
------
FIRED NON OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY Per accgoerl€ (S
Is
UMBRELLA LIAR _ OCCUR - - EACH OCCURRENCE 15
EXCESS LIAB CLAIMS-MADE: AGGREGATE
DED ....RETENTIONS _ S.
WORKERS COMPENSATION 03/01/2018 03/01/2019 PER
A AND EMPLOYERS'LIABILITY YIN _ X WLR_C64970033 _.X �STATUTE ERF
ANYPROPR&ETOR.MAR THE R,ExECLfTN E �^ E L EACH ACCIDENT (§ 1 000 000
OFFICERIMEMBEREXCLUDED, N �N I A
_(Mandatory in NH) E L DISEASE-EA EMPLOY EEI S 1,000,000
If yes.describe undar 1,000,000 -.
DESCRIPTION OF OPERATIONS Lrekow E L DISEASE-POLICY LIMIT S
I
DESCRIPTION OF OPERATIONS f LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached II more space is required)
RE:: RE: ITB#15-16.
Workers'Compensation coverage is limited to employees leased to Heath Consultants, Inc by Strategic Outsourcing, Inc.A Waiver of Subrogation applies
in favor of City of Clearwater Gas Department as required by written contract.A 30 day notice of cancellation is endorsed to the policy for City of
Clearwater Gas Department(Except for 10 days for non-payment of premium).
CERTIFICATE HOLDER CANCELLATION
City of Clearwater SHOULD ANY OF TETE ABOVE[DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Attn.: Clearwater Gas Systems ACCORDANCE WITH THE POLICY PROVISIONS.
P.O. Box 4748
Clearwater FL 33758-4748 AUTHORIZEDREFIR ESENTATIVE
i
e
The ACORD name and logo are registered marks of ACORD 01988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 2016103)
Worker Compensation and Employers"Liability Pot icy
Named Insured En dors erne nt Nurnber
Strategic Outsourcing, Inc
FM//L Heath Consultants Incorporated Policy Number
Syrnbol: Nuniaer: WLR_C64970033
Policy Period Effective[date of Endorserrent
03/01/2018 TO 03/01/2019 03101/2018
-& -sued By(Nacre of insurance Con-parry)
Indemnity Insurance Co.of North America
Insert the Policy numbaer.Trine remainder of the iinformation is to be corn pleredonly whenthisendor went Islssued subsequentto the preparation of the policy.
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will not
enforce our right against the person or organization named in the Schedule. This agreement applies only to the
extent that you perform work under a written contract that requires you to obtain this agreement from us,.
This agreement shall not operate directly or indirectly to benefit any one not named in the Schedule.
Schedule
City of Clearwater
Attn.:Clearwater Gas Systems
P.O. Box 4748
Clearwater FL 33758-4748
: RE: ITB#15-16
For the states of CA, TX,refer to state specific endorsements.
This endorsement is not applicable in KY, NH, and NJ.
Authorized Agent
WG 000313 11/05 Ptd U.S.A Copyright 1982-83, National Council on Compensation Insurance
U E3 E3�
NOTICE TO OTHERS - SPECIFIC PARTIES
A. If we cancel this Policy prior to its expiration date by notice,to you or the first Named insured for any reason other
than nonpayment of premium, we will endeavor, as set out below, to send written notice of cancellation, via such
electronic or other form of notification as we determine,to the persons or organizations listed in the schedule set
out below(the"Schedule"). You or your representative must provide us with both the physical and e-mail address
of such persons or organizations, and we will utilize such e-mail address or physical address that you or your
representative provided to us on such Schedule.
B. We will endeavor to send or deliver such notice to the e-mail address or physical address corresponding to each
person or organization indicated in the Schedule at least 30 days prior to the cancellation date applicable to the
Policy.
C. The notice of cancellation is intended only to be a courtesy notification to the person(s)or organization(s) named
in the Schedule in the event of a pending cancellation of coverage.We have no legal obligation of any kind to any
such person(s) or organization(s). Our failure to provide advance notification of cancellation to the person(s) or
organization(s) shown in the Schedule shall impose no obligation or liability of any kind upon us, our agents or
representatives, will not extend any Policy cancellation date and will not negate any cancellation of the Policy.
D. We are not responsible for verifying any information provided to us in any Schedule, nor are we responsible for
any incorrect information that you or your representative provide to us- If you or your representative does not
provide us with the information necessary to complete the Schedule, we have no responsibility for taking any
action. In addition, if neither you nor your representative provides us with e-mail and physical address information
with respect to a particular person or organization,then we shall have no responsibility for taking action with regard
to such person or entity.
E. We may arrange with your representative to send such notice in the event of any such cancellation.
F. You will cooperate with us in providing, or in causing your representative to provide, the e-mail address and
physical address of the persons or organizations list(WLR-C64970033 03/01/2018 03/01/2019
G. The provisions of this notice do not apply in the event that you cancel the Policy-
SCHEDULE
Name of Certificate Holder E-Mail Address Physical Address
City of Clearwater Attn.: Clearwater Gas Systems
P.O. Box 4748
Clearwater FL 33758-4748
WC 99 03 86(`t 0111) Page 1 of 1