CERTIFICATE OF LIABILITY INSURANCE (925) ATE
A�® CERTIFICATE OF LIABILITY INSURANCE D09/10//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 USA Inc. NAME:
PHONE 500 Dallas Street,Suite 1500 (A/C,No Ext): FAX
No)7
Houston,TX 77002 E-MAIL
Attn:Hines.CertRequest@marsh.com ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA:Zurich American Insurance Company 16535
INSURED SR 54 Land Associates,LLC INSURER B:Allied World National Assurance Company 10690
c/o Hines Interests Limited Partnership INSURER C:American Zurich Insurance Company 40142
2800 Post Oak Blvd.
INSURER D
Houston,TX 77056
INSURER E
INSURER F:
COVERAGES CERTIFICATE NUMBER: HOU-003246325-06 REVISION NUMBER: 3
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 GL05087524-14 10/01/2018 10/01/2019 EACH OCCURRENCE $ 1,000,000
DA
CLAIMS-MADE 1XI OCCUR PREM SESOEa occurrDence $ 250,000
MED EXP(Any one person) $
PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 2,000,000
POLICY❑ PRO JECT [X] LOC PRODUCTS-COMP/OP AGG $ 2,000,000
OTHER: $
A AUTOMOBILE LIABILITY BAP5087526-14 10/01/2018 10/01/2019 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
X UMBRELLA LIAB X OCCUR 0306-9798 10/01/2018 10/01/2019 EACH OCCURRENCE $ 2,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 2,000,000
DED X RETENTION$10,000 $
C WORKERS COMPENSATION WC5087523-14(AOS) 10/01/2018 10/01/2019 X PER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
A Y/N WC0137026-04(WI) 10/01/2018 10/01/2019 1,000,000
ANYPROPRIETOR/PARTN ER/EXECUTIVE E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? F N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
RE: Development of natural gas distribution system in Asturia located in portions of Township 26,Ranges 17 and 17 East,Pasco County,FL,
CERTIFICATE HOLDER CANCELLATION
Clearwater Gas System SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Attn: Managing Director THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
400 N.Myrtle Ave ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater,FL 33755
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Christian Ryan 2
@ 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD