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CERTIFICATE OF LIABILITY INSURANCE (473)
A�® CERTIFICATE OF LIABILITY INSURANCE D04/E9/2018D/YYYY) 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 CONTACT Marsh Risk&Insurance Services NAME: PHONE CA License#0437153 (A/C,No Ext): FAX No)7 633 W.Fifth Street,Suite 1200 E-MAIL Los Angeles,CA 90071 ADDRESS: Attn:LosAngeles.CertRequest@Marsh.Com INSURER(S)AFFORDING COVERAGE NAIC# CN 101 348564-STND-GAU E-1 8-19 08 2020 INSURER A:ACE American Insurance Company 22667 INSUREDAECOM INSURER B:N/A N/A AECOM Technical Services,Inc. INSURER C:Illinois Union Insurance Cc 27960 URS Corporation Southern INSURER D:SEE ACORD 101 7650 W.Courtney Campbell Causeway Tampa,FL 33607-1462 INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: LOS-002150592-18 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICYNUMBER MM/DD MM/DD A X COMMERCIAL GENERAL LIABILITY HDOG71093669 04/01/2018 04/01/2019 EACH OCCURRENCE $ 1,000,000 DA CLAIMS-MADE 1XI OCCUR PREM SESOEa occurrDence $ 1,000,000 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000 X POLICY❑ PRO JECT ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ A AUTOMOBILE LIABILITY ISA H25157229 04/01/2018 04/01/2019 COEaMaccidccidennt SINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ D WORKERS COMPENSATION SEE ACORD 101 04/01/2018 04/01/2019 X PER OTH- AND EMPLOYERS'LIABILITY STATUTEER Y/N 2,000,000 ANYPROPRIETOR/PARTN ER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? � N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 2,000,000 If yes,describe under 2,000,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ C ARCHITECTS&ENG. EON 621654693 04/01/2018 04/01/2019 Per Claim/Agg $1,000,000 PROFESSIONAL LIAB. "CLAIMS MADE" Defense Included DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Re:Contract No.RFQ#34-15 Engineer of Record Agreement RETROACTIVE DATE:3/23/1990—Illinois Union Insurance company. City of Clearwater is named as additional insured for GL&AL coverages,but only as respects work performed by or on behalf of the named insured. This insurance is primary and non-contributory over any existing insurance and limited to liability arising out of the operations of the named insured and where required by written contract with respect to the GL&AL coverages. Severability Of Interest/Cross Liability is included for General Liability coverage. CERTIFICATE HOLDER CANCELLATION City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Attention:D.Scott Rice,PE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Assistant Engineering Director ACCORDANCE WITH THE POLICY PROVISIONS. Engineering,RFQ#34-15 P.O.Box 4748 Clearwater,FL 33758-4748 AUTHORIZED REPRESENTATIVE of Marsh Risk&Insurance Services James L.Vogel @ 1988-2016 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: CN101348564 LOC#: Los Angeles AC"J?o ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY NAMED INSURED Marsh Risk&Insurance Services AECOM AECOM Technical Services,Inc. POLICY NUMBER URS Corporation Southern 7650 W.Courtney Campbell Causeway Tampa,FL 33607-1462 CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation/Employer Liability cont. Policy Number Insurer States Covered WLR C64788759 Indemnity Insurance Company of North America-NAIC#43575 AOS WLR C64788723 ACE American Insurance Company-NAIC#22667 CA and MA SCF C64788747 ACE American Insurance Company-NAIC#22667 WI Retro WCU C64788802 ACE American Insurance Company-NAIC#22667 OH,Ohio Qualified Self Insured(QSI)-SIR:$500,000,Only applicable to specific qualified entities self-insured in the state of Ohio Waiver of Subrogation is applicable where required by written contractwith respect to WC. If the insurerfor the Workers Compensation policy cancels its policy for any reason other than for non-payment of premium,the insurer will provide 30 days notice of cancellation to those Certificate Holders that require it by written contract. ACORD 101 (2008101) ©2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AC Ij D® CERTIFICATE OF LIABILITY INSURANCE DATE/DO/MY) 03/21/20 TT-IIS 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 Marsh Risk & Insurance Services CA License #0437153 777 South Figueroa Street Los Angeles, CA 90017 Attn: LosAngeles.CertRequest@Marsh.Com CN101348564-STND-GAUE-18-19 Added 127 04 2019 CONTACT NAME: PHONE FAX (ac, No. Ext): (A/C, No): ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : ACE American Insurance Company 22667 INSURED AECOM URS Corporation Southern 7650 West Courtney Campbell Causeway Tampa, FL 33607 INSURER B : N/A N/A INSURER C : Illinois Union Insurance Co 27960 INSURER D : SEE ACORD 101 $ 2,000,000 INSURER E : INSURER F : X CERTIFICATE NUMBER: LOS -00215241 • 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 INSD SUBR WVD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MM/DDIYYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY HDO G71093669 IVE D RECEIVE APR 1 0 2018 /�y+µ� �r/�/�i 04/01/2018 �{ 04/01/2019 EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1 MED EXP (Any one person) $ 5,000 PERSONAL & ADV INJURY $ 2,000,000 GE X 'L AGGREGATE POLICY OTHER: LIMIT APPLIES PRO- JECT PER: LOCPRODUCTS GENERAL AGGREGATE $ 2,000,000 - COMP/OP AGG $ 2,000,000 $ A AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY ISA H2$1�S/r'"d�-L1r1:A''T. I.P. ECOf`./LIS r/ LEGISLATIVE SRVCS DEPT. U4 /2018 04/01/2019 COMBINED SINGLE LIMIT cident) $ 2000 000 BODILY INJURY (Per person) $ BODILY INJURY(Per accident ) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA UAB EXCESS LUIS OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENT ON $ $ 0 WORKERS COMPENSATION AND EMPLOYERS LIABILITY ANYPROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS belowE.L. Y/N N NIA SEE ACORD 101 04101/2018 04/01/2019 x PER STATUTE 0TH - ER E.L. EACH ACCIDENT $ 2,000,000 E.L. DISEASE - EA EMPLOYEE $ 2,000,000 DISEASE - POLICY LIMIT $ 2,000,000 C ARCHITECTS & ENG. PROFESSIONAL LIAB. EON G21654693 "CLAIMS MADE" 04/01/2018 04/01/2019 Per Clain Agg Defense Included $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached It more space Is required) Re: Engineer of Record Agreement. RFQ 16-12. The General Liability policy includes a Severability of Interest clause where required by written contract. City of Clearwater is included as Additional Insured as respects the General Liability and Automobile Liability policies, where required by written contract. Such insurance shall be primary insurance with respect to the interest of the additional insureds and any other insurance maintained by the additional insured shall be excess and not contributing with the insurance required hereunder. Waiver of Subrogation applies in favor of the Additional Insured as respects General Liabllit) and Automobile Liability, where required by written contract. OLDER CANCELLATION City of Clearwater Attn: City Clerk PO Box 4748 Clearwater, FL 33758-4748 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 of Marsh Risk & Insurance Services James L. Vogel ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Aco v® AGENCY CUSTOMER ID: CN101348564 LOC #: Los Angeles ADDITIONAL REMARKS SCHEDULE Page 2 of 2 AGENCY Marsh Risk & Insurance Services NAMED INSURED AECOM URS Corporation Southern 7650 West Courtney Campbell Causeway Tampa, FL 33607 POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER* 25 FORM TITLE: Certificate of Liability Insurance Workers Compensation/Employer Liability cont. Policy Number Insurer States Covered WLR C64788759 Indemnity Insurance Company of North America - NAIC # 43575 AOS WLR C64788723 ACE American Insurance Company - NAIC # 22667 CA and MA SCF C64788747 ACE American Insurance Company - NAIC # 22667 WI Retro WCU C64788802 ACE American Insurance Company - NAIC # 22667 OH, Ohio Qualified Self Insured (QSI) - SIR: $500,000; Only applicable to specific qualified entities self-insured in the state of Ohio Waiver of Subrogation is applicable where required by written contract with respect to WC. If the insurer for the Workers Compensation policy cancels its policy for any reason other than for non-payment of premium, the insurer will provide 30 days notice of cancellation to those Certificate Holders that require it by written contract. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 3 POLICY NUMBER: ISA H25157229 Endorsement Number: 8 COMMERCIAL AUTO CA 20 48 10 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. DESIGNATED INSURED FOR COVERED AUTOS LIABILITY COVERAGE This endorsement modifies insurance provided under the following: AUTO DEALERS COVERAGE FORM BUSINESS AUTO COVERAGE FORM MOTOR CARRIER COVERAGE FORM With respect to coverage provided by this endorsement, the provisions of the Coverage Form apply unless modified by this endorsement. This endorsement identifies person(s) or organization(s) who are "insureds" for Covered Autos Liability Coverage under the Who Is An Insured provision of the Coverage Form. This endorsement does not alter coverage provided in the Coverage Form. This endorsement changes the policy effective on the inception date of the policy unless another date is indicated below. Named Insured: AECOM Endorsement Effective Date: SCHEDULE Name Of Person(s) Or Organization(s): Any person or organization whom you have agreed to include as an additional insured under a written contract or provided such contract was executed prior to the date of loss. nformation required to complete this Schedule, if not shown above, will be shown in the Declarations. Each person or organization shown in the Schedule is an "insured" for Covered Autos Liability Coverage, but only to the extent that person or organization qualifies as an "insured" under the Who Is An Insured provision. contained in Paragraph A.1. of Section Ii -Covered Autos Liability Coverage in the Business Auto and Motor Carrier Coverage Forms and Paragraph 0.2. of Section I — Covered Autos Coverages of the Auto Dealers Coverage Form. CA 20 48 10 13 Insurance Services Office, Inc., 2011 Page 1 of 1 POLICY NUMBER. HDO ("71053559 1 Endorsamert Number. 1 COMMERCIAL GENERAL LIAB4LUTT CG 20 10 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - SCHEDULED PERSON OR ORGANIZATION This endorsement modRies insurance provided under the following COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE N me Of Additional insured Peraoa(s) Or Organtration(s) Any Owner, Lessee or Contractor whom you have agreed to include as an additional insured under e MOten contract: provided such contract was executed prior to the date of loss LocatIonp) Of Covered Operations All locations entero you are Performing aegoing operations for such additional insured pursuant to any such written uonirect. Information required to complete thus Schedule lf not s A. Section It -- Who la An Insured is amended to include as an additional insured the persons} or organicatien(s) shown in the Schedule, but only with respect to liability for `bodily injury". 'property damage" or "personal and advertisaig injury,' caused. in whole or in part, by 1. Your acts or omissions; or 2. The acts or omissions of those acing on your behalf: in the performance of your ongoing opera&uns for the additions! insured(*) et the to et+oris) designated above. However: 1. The insurance afforded to such addbone6 insured er y applies to the extent perrniied by lee end 2. If coverage proutded 10the additional insured is required by a contract or agreement, the insurance afforded to such additional insured wt/ not be broad than that Attich you are required by that contract or agreement to provide for such additional insured. hewn above, wit be mown in the Dederakon s. B. Mlh reaped to the insurance afforded to these additional insureds. the following additional exclusions apply This Insurance does not apply CO "bodily injury" or "property damage" occurring after: 1. All work, including materials. parts or fin ement furnished In connec0ont with such woiic, on the project (other than service. meititenence or repass) to be performed by or on behalf of the additional insured(s) at the Iocabon of the covered operations has been completed: or 2. That portion of "your work" out of which the Injury or damage arisen nee been put to its intended use by any person or organization other then another Contractor or subcontractor engaged In preforming operations kir a pfsncipal as a pert of One same project C. IMSI respect to the insurance afforded to these additional insureds. the 1Mtowing is added to Section III — Limits Of insurance: if coverage provided to the additional insured is required by a contract or agreement, the most we C0 20 1004 13 Insurant* Services Office. Inc., 2012 Page 1 off: veil pay on behalf of the additionalinsuredis the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the aoplicabte Limits of Insurance Shown in the Declarations; Page 2of2 whichever is less. This endorsement shall not increase the applicable Limns Of Insurance -shown In the Decturetiona re Insurance Services Other, Inc., 2012 GG 20100413 1 POLICY NUMBER: HBO G71093669 Endorsement Number: 5 COMMERCIAL GENERAL LIABILITY CG 20 37 0413 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS _ COMPLETED OPERATIONS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLt t tD OPERATIONS LIABILITY COVERAGE PART Name Of Additional Insured Person{s) Or Organization(s) Any person or organization whom you have agreed to include as an additional insured under a written contract, provided such contract was executed prior to the date of loss. SCHEDULE Location And Description Of Conn toted 0. rations All locations where you are performing work for such additional insured pursuant to any such written contract. Information r wired to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section 1I — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for 'bodily injury" or "property damage" caused, in whole or in part, by "your work* at the location designated and descried in the Schedule of this endorsement performed for that additional insured and included in the "products -completed operations hazard". However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured.; B. Wth respect to the insurance afforded to these additional insureds, the following is added to Section ill — Limits Of insurance: If coverage provided to the additional insured Is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Lints of Insurance shown in the Declarations, CO 20 37 0413 0 Insurance Services Office, Inc., 2012 Page 1 of 1 0002145 SP 0206 -C01 -P02146 -I City of Clearwater Attn: City Clerk PO Box 4748 Clearwater, FL 33758-4748