CERTIFICATE OF LIABILITY INSURANCE - RFQ 24-16 (12) Client#:26140 WHARTONS F-IRATE(MM1DDNYYY)
ACORD,. CERTIFICATE OF LIABILITY INSURANCE 1 312912018
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY ANDCONFERS 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 hc�idcCis an ADDITIONAL INSURED,theiiorIcyCes)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 any rights to the certificate holder In lieu of such endorsement(s).
PRODUCER 0R?X7
NAME:
Bouchard Insurance Inc. -1267 Noy:
101 N Starcrest Dr. '-,MAR"
�rtificates@bouchardinsurance.com
Clearwater, FL 33765 INSURER(S)AFFORDING COVERAGE NAIL
727 447.6481 INSURER A:Amerisure Insurance Company 119488
.............
INSURED INSURER B:Liberty Insurance Underwriters 19917
Wharton-Smith, Inc.
INSURER C Starr indemnity&Liability Co ---—------ ..........38318-------------
PO Box 471028 INSURER 0 XL Specialty insurance Co 37885
Lake Monroe, FL 32747 ---_.........
I INSURER E: Berkley Assurance Company 39462
1 INSURER F: I
COVERAGES CERTIFICATE 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 CONTRACTOR OTHER DOCUMENT V%-ITH 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,
.....----------------------
ADDLSUBR POLICY r=Fr POLICY FXP
TYPE OF INSURANCE LIN11TS
LTR INSR WVD NUMBER Mm Y-�Yy
COMMERCIAL.GENERAL LIABILITY Y Y GL 0361081301 13410112018 04101/2019 EACH OCCURRENCE 151,000,000
PA"I E T C RENTED S1 000 000
CLAMS MADE X' OCCUR S
MIR E 3
X Contractual Liab MED EXP(Ary one person) s10 000
X XCU Included 8 A DV I N J U RY $1,000,00.10
GEN'_AG G REG ATE L1107 APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY X _ERCT LOG PRODUCTS-CONIR'OP AGG $2,000,000___,__,
! $
(OTHER:
................. ............ —---------- ..................
COMBINED SINGLE LIMIT
A AU"
UTOMOBILE LIABILITY Y Y 'CA20361071301 0410112018 0410112019 1 000,000
_(zLac_C1de_r1t_.LL......................-111 ,
X ANY AUTO BODILY INJURY(Per person) S
---------------
OWNED SCHEDULED BODILY 1 NJURY(Per accic�em) S
AUTOS ON-_Y AUTOS
x H RED x NON-OWNED PROPERTY OIAMAGE S
AUTOS ON-Y AUTOS ONLY Per a LQi d er_,L.....
B UMBRELLA LIAR X OCCUR y Y 100008433604 04/01/201B 04/0112019 EACH OCCURRENCE X2.0 000 000
CCCU
X
C X EXCESS LIAB CLAIMS-MADE Y Y 1000023609 04/0112018 04/0112019 AGGREGATE 99a_0001_000_
I DE D RETENTION$ S ...............
WORKERS COMPENSATION
A Y WC203610912 04/01/2018 0410112019 X__,p
I AND EMPLOYERS'LIABILITY Y;N 5TATUTE_______ER__I
I ANY PROPRIETOR,-PARTNER.'EXECUT.%,'E- E .EACH ACCIDENT � $1, 00 00
1 OFFICERIMENIBER EXC-UDED? N NIA ........... WL-0 -------
(Mandatory In NH)
E DISEASE-EA EMP:_OYEE, $1,000 000
It yes,describe under 0,000,000
D'ESC4 PTION OF OPERATIONS below E-L.DISEASE-POLICY 1 Nirr
D Rented Equipment UM00024961MA18A 4!01/2018;04101/201 2,000,000
E Pollution Llab PCADB50038590418 4101/2018'04/011201 5,000,000
E Professional Liab IPCADB50038590418 4101/201B 04/01/201 5,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space is required)
Certificate holder is additional insured as respects General Liability,Automobile Liability and
ExcesslUmbrella Liability only if required by written contract,and subject to the terms,conditions and
exclusions as specified in the policy.
Coverage is primary as respects to General Liability Automobile Liability and non-contributory as subject
(See Attached Descriptions)
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
100 SOUTH MYRTLE AVENUE ACCORDANCE WITH THE POLICY PROVISIONS.
#220
CLEARWATER, FL 33756-5520 AUTHORIZED REPRESENTATIVE
1988-2015 ACORD CORPORATION.All rights reserved.
ACORD 25(2016103) 1 of The ACORD name and logo are registered marks of ACORD
#S841494IM838371 GINDE
i
TI (Continued from e 1
to the terms, conditions and exclusions of your policy.
Waiver of subrogation applies in favor of certificate holder as respects General Liability,Automobile
Liability and Workers Compensation only if required by written contract,and subject to the terms,
conditions and exclusions as specified in the policy.
It is agreed by endorsement to the General Liability,Automobile Liability and Workers Compensation
policies that these policies shall not be cancelled by the insurance carrier without first giving thirty
(30)days prior written notice except for nonpayment of premium or if the first named insured elects to non
renew.
Blanket Loss Payee applies for Rented and Leased Equipment.
Ranted and Leased EgUipm nt deductible:
$2,500 standard deductible,.
2%subject to$10K minimum deductible applies to all rented cranes, directional boring equipment and items
valued over$750,000
PROJECT: CONCRETE CRACK REPAIR FOR CITY OF CLEARWATER NEWRF
SAGITTA 25.3(2016103) 2 of
SB41494fM838371