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CERTIFICATE OF LIABILITY INSURANCE (893)ACORD � CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY) 02/19/2018 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 MCGRIFF, SEIBELS & WILLIAMS OF TEXAS, INC. 818 Town & Country Blvd, Suite 500 Houston, TX 77024-4549 CONTACT NAME: PHONE (A/C. No, Eat): 713-877-8975 FAX No): 713-877-8974 E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Liberty Mutual Fire Insurance Company 23035 INSURED Primoris Distribution Services, Inc. including Florida Gas Contractors, Inc. and FGE Engineering, Inc. 10518 US Highway 301 Dade City, FL 33525 INSURER B :LM Insurance Corporation 33600 INSURER C :Liberty Insurance Corporation 42404 INSURER D :Underwriters At Lloyd's, London 15792 INSURER E : INSURER F : DAMAGE TO RENTED PREMISES (Ea occurrence) COVERAGES CERTIFICATE NUMBER:BPMXJVGW 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 LTR TYPE OF INSURANCE ADDL INSO SUBR WVD POLICY NUMBER (IPO COY ) POLICY EXP M/ (MDD/YYYY) LIMITS C X COMMERCIAL GENERAL LIABILITY TB7-C91-463703-068 ° F \/E � 1 F ... i_.. ?i '. r� r / /� 02/28/2018 `� `; 4 i 1 I 02/28/2019 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 2000 000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE POLICY OTHER: X LIMIT APPLIES PER: 78-r- LOC GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 $ C AUTOMOBILE X — LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY _ _ SCHEDULED AUTOS NON -OWNED AUTOS ONLY AS7-C91-463703-0791' `�- ,EI.lJI�1,RX/A'$I LEGISLATIVE .SRVCS DEPT. 02/28/2019 COMBINED SINGLE LIMIT(Ea YN $ 2,000,000 BODILac BODILYINJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ Physical Damage Ded. $ 250,000 D X UMBRELLA LIAB EXCESS UAB X OCCUR CLAIMS -MADE A17EL00500 02/28/2017 02/28/2018 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED X RETENTION $ $ A B C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/ N N N / A WC2-691-463703-038 WA5-C9D-463703-048 WC5-C91-463703-058 EW5-69N-463703-028 TX/LA SIR: $250,000 EW7-69N-463703-018 CA SIR: $250,000 02/28/2018 02/28/2019 X PER STATUTE 0TH - ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 $ $ $ $ $ DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is included as Additional Insured as respects the General Liability policy as required by written contract and subject to policy terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION City of Clearwater Attn:x Clerk POOBox 4748 Clearwater, FL 34618-4748 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE x ACORD 25 (2016/03) Page 1 of 1 © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ACORO® CERTIFICATE OF LIABILITY INSURANCE �. -- DATE(MM/DD/YYYY) 02/20/2019 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 MCGRIFF, SEIBELS & WILLIAMS OF TEXAS, INC. 818 Town & CountryBlvd, Suite 500 Houston, TX 77024-4549 CONTACT PHON PHONE 713 877-8975 FAX No): 713-877-8974 (NC. No. Ertl: E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Liberty Mutual Fire Insurance Company 23035 INSURED Primoris Distribution Services, Inc. including Florida Gas Contractors, Inc. and FGE Engineering, Inc. 6101 S Broadway, Suite 200 Tyler, TX 75703. INSURER 8 :LM Insurance Corporation 33600 INSURER C :Liberty Insurance Corporation 42404 INSURER D :Underwriters At Lloyd'sLondon 15792 INSURER E : PREM SES (Ea occurrence) INSURER F : COVERAGES CERTIFICATE NUMBER:UC2BUM2P 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 :Y PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMB r TB7-C91 463703-069 �E�./ FEB5 O RECORDS IEGISIATIVE _ i . I 0 : 2019 2019 AND SIMS DEPT. POLICY EXP (MMIDD/YYYY) 02/28/2020 LIMITS EACH OCCURRENCE $ 2,000,000 C X COMMERCIAL GENERAL LIABILITY CLAIMS -MADE X OCCUR PREM SES (Ea occurrence) $ 2,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GE 'L AGGREGATE POLICY OTHER: X LIMIT APPLIES 78,-. PER:FFICIAI LOC GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 $ C AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY _ SCHEDULED AUTOS NON -OWNED AUTOS ONLY AS7-C91-463703-079 02/28/2019 02/28/2020 COMBINED SINGLE LIMIT (Ea accident) $ 2,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ Physical Damage Ded. $ 250,000 D X UMBRELLA UAB EXCESS LIAB X OCCUR CLAIMS -MADE AU1900190 02/28/2019 02/28/2020 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED X RETENT ON $ $ A B C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If Yes, describe under DESCRIPTION OF OPERATIONS below Y / N N N /A WC2-691-463703-039 WA5-C9D-463703-049 WC5-C91-463703-059 EW5-69N-463703-029 TX/LA WA7-C9D-468237189 EW7-69N-463703-019 CA All Policies Subject to SIR: $250,000 02/28/2019 02/28/2020X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 $ $ $ $ $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is included as Additional Insured as respects the General Liability policy as required by written contract and subject to policy terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION City of Clearwater Attn: City Clerk PO Box 4748 Clearwater, FL 34618-4748 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE C17f ACORD 25 (2015!03) Page 1 of 1 © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD