CERTIFICATE OF LIABILITY INSURANCE ACO CERTIFICATE OF LIABILITY INSURANCE DATEIMI� I
S�M . 130/201 s
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 he endorsed.
If SUBROGATION is WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsemenL A statement on
this certificate does not confer ri hts to the certificate holder in lieu of such endorsements.
PRODUCER � T Michele Hennesse _
Diversified Insurance Industries, Inc. PHONE
3(17 International Circle, Suite 110 IC No_ExQl 410.433-3440
410-319.0622 c n1, _ .
Hunt Valley MD 21030 a®DnIEss: rnichele.hennesse dii ins.cOrra
INSURERt,31 AI`FqROING COVERAGE _.NAIC#
tNSURERA:Arch Insurance Co' _-_.. 11150
INSURED ULTIAII-4 INSURER B:AMER INTERSTATE INS- 31.895
Ultimate CNG,LLC INSURER c:Admiral Insurance Co" 24856
3185 Wheatland Farms Drive -- - �
Oakton VA 22124 INSURER D:
IN$URER E: m,,,.,_...
INSURER F:
COVERAGES CERTIFICATE NUMBER:812895384 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 NTH 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 Ate.SUI3R POLICY EFF POLICY EXP+ 1 LIMITS
TR TYPE.OF INSURANCE INsn wvD POLICY NUMBER MMID 9MRJLN3'YYY
C X COMMERCIAL GENERAL LIABILITY FEIPPL2433801 1112912018 1112912019 EACH OCCURRENCE $1,000,000
E TO RENTED
CLAIMS-MADE E__1 OCCUR PPR IV S o $519,000
MED EXP(Any an person) $5,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE S2,000,000
POLICY I—J JECT 0 LOC PRODUCTS-COMPPCP AGG 1 $2,000,000
OTHER:
DeduclsbleWS$5,000
A AUTOMOBILE.LIABILITY FSCAT0220006 782312.018 712312019 COMBINED SINGLE LIMIT $1,0 ,000
Fa accdertt9
X ANY AUTO BODILY INJURY(Per persona) _.S
OWNED SCHEDULED ®...r..W^
AUTOS ONLY AUTOS I30t7@LY INJURY(Per accident)
X HIRED NON-OVVNED PROPERTY DAMAGE
T S
._...,,., AUTOS ONLY AUTOS ONLY ;LPer acckbent)
$
C UMBRELLA LiABX OCCUR FEIEXS2433901 1112912018 1182912019 EACH OCCURRENCE $6,000,000
.Y, EXCESS UAB CLAIMS-MADE AGGREGATE $6,000,000
__J
DEI] FT RETENTION
B
WORKERS COMPENSATION AVVVCNC262819201'77 892612018 812512019 X TAT TE ERH
AND EMPLOYERS'LIABILITY YIN �� ...,�....�.n..
ANYPROPRIETORIPARTNERE7tECUTIVE E.L.EACH ACCIDENT $1,000,000
OFFICERNEMBER EXCLUDED? NIA
(Mandatm In NH) El.[NSEASE-EA EMPLOYEE',S 1,000,000
If yelp describe r
D , IPTI OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101.,Additional Remarks Sehedute;may be attached if more she is ragwred)
City of Clearwater is included as additional insured when required by Written.
RECEIVED
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
G A ADMIN ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater
400 N Myrtle Ave A UTHORAZED REPRESENTATIVE
Clearwater FL 33755
p 1988-2015 ACORD CORPORATION, All rights reserved.
ACORD 26(2016/03) The ACORD name and logo are registered marks of ACORD