CERTIFICATE OF LIABILITY INSURANCE - MOC11343 - RFQ 34-15 (3) HWLOCHN-01 JPASKA
TE(MMIDOff"Y)
CERTIFICATE OF LIABILITY INSURANCE F
II'ATE
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 be endorsed. If SUBROGATION IS WAIVED,—SU61act—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 CNT T
NAME,;_DdJennifer Paska
Mesirow Insurance Services,Inc. PHONE
353 N.Clark St 11th R CNPi_Ex0!(3-11-2)6-95-4-0-6 0
— FAX
IAJ_ -
Chicago,IL 60654 E-MAIL ss,Jennifer.Paska alliant.com
.................. .........................
INSURERS}------- AFFORDING COVERAGE.......... 1AIC...... 0
.....
.... ....... INSURER A:Charter Oak Fire Insurance Company25615
INSURED
INSURER B:Travelers Property Casualty Company of America
25674
H.W.Lochner,Inc. lNsuRFR c.
225 West Washington,12th Floor INSURER D;
Chicago,IL 60606
INSURER E:
................
INSURER F:
' 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 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 TER
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. MS,
LTR TYPE OF INSURANCE
So WVD POLICY NUMBER D=L LIMITS
A X COMMERCIAL GENERAL LIABILITY j_&MM_ ___
EACH OCCURRENCE $ 11 000 06
CLAIMS-MADE X- OCCUR P630845IS877COF18 0510112018 0510112019 DAMAGE-Ta'RENTEU — ---- -- _11 6
P_REMISESjI1s_q nqs)___$ s :o
MED EXP(Any one person) $ 6,000
PERSONAL&ADV INJURY $ 1,000,000
..............
GEN'L AGGREGATE Li M I T APP LJ E S PER:
_-GENERAL AGGREGATE 2,000,00
POLICY X PRO- X C�C
JECT
............... PRODUCTS-COM WOP AGG 2,000,000
OTHER $
AUTOMOBILE LIABILITY i5OMB.,NEd'-�INGLE L[I�ff—
ganq_ 1,000,000
B _k ANY AUTO P81108451121877TIL18 05,101/2018 0510112019 BODILY INJURY(Per person) $
ALL OWNED SCHEDULED
AUTOS AU7jOS BODILY INJURY(Per accidant) $
NON-OwNEF,) FROV - _E�_ ..........
HIRED AUTOS X AUICS PERTYDAG
/Par accident' $
Drive Mar Car
X UMBRELLA LLAB XOCCUR EACH OCCURRENCE 5,_006*0_0
B EXCESS LIAB CLAIMS MADE. ZUPlOP6386418NF 05101/2018 0610112D19-
......... ...........- AGGREGATE $ 5,000,000'
DIED X RETENT'ON$ 10,000 .......... —-----
WORKERS COMPENSATION PER OTH.
AND EMPLOYERS'LIABILITY YIN XS7& ER
B ANY PROPRIE70FUPARTNER/EXECUTIVE F-- UB4K20461718 0510112018 0610112019'
OFFICERNIEMBER EXCLUDED? N NIA E.L.EACH ACCIDENT 1,000,000;
(Mandatory In N4)
If is s,describe under E.L.DISEASE•-EA EMPLOYEE $ 1,000,000
...........
PES01 PTI 0 N OF CLP E RATiONS be-Tow
L DISEASE-POLICY LIMIT $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES tACORD 101,Additional Roma;;.Schac[.I.,may be attached it more space is required)
iHWL#MOC1 1343 Re:Engineer of Record,RFQ#34.15 The following is included as additional insured an a primary,non-contributory basis with respect to
general liability and automobile liability coverages as required by written contract:*City of Clearwater Waiver of subrogation applies in favor of additional
insureds as required by written contract.
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
Engineering ACCORDANCE WITH THE POLICY PROVISIONS.
RFQ#34-15
Clearwater,FL 33768-4748 AUTHORIZED REPRESENTATIVE
C 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD