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2019 CITYWIDE ROADWAY RESURFACING - 18-0054-EN - CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE OF LIABILITY INSURANCE FDATEIMMIDONYYYI 2115/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE BOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELYOR 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(les)must have ADDITIONAL INSURED provisions or be endorsed'. If SUBROGATION I5 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 j_iberty Mutual Insurance Co. National Insurance East-- NGUN AME;At;T Valerie Reece 2000 Vilestwood Cir. PHONE FAA - 513-867-3822 513-867-3822 AIC Wausau, WI 54401 EMAIL ADDRESS._.....__ CM9e prtProduction(cDlibertymutual.com ....... INSURER(S)AFFORDING COV€RAGE. NAIC# www.LibertyMutuat.com INSURER A: Liberty Mlutu@�Fire Insurance Company 23035 _ INSURED Preferred Materials, Inc. (216-TAM) 5701 INSURERS. Libert Insurance Corporation 42444 '..... C _ E. HillsboroughllsbHillsboroughAvenue, Suite 1122 INSURER Tampa FL 33610 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: 47084841 REVISION NUMBER: THIS IS T4 CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUER 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 AD SR POLICY EFf POLICY EXP LTR TYPE OF INSURANCE INSO I wVD POLICY NUMBER (MMIDDIYYYYI IMMIDOtYYYYILIMITS A ✓___ COMMERCIAL GENERAL LIABILITY l T82-C81-004095-118 911/2018 9/112019 EACH OCCURRENCE $2,000,000 CLAIMS-MADEOCCUR r9fi __ ' ® DAMAGE XCU Coverage Included PREMISES IEa occurrence) s250,000 ' ✓ Primary/Non-Contributory MED EXP tAny one person) $50,000 Separation gf_In urr d_ PERSONAL&ADV INJURY s2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL.AGGREGATE $2,000,000 POLICY l l JECOT- LOC PRODUCTS•COMPIOPAGG $2.000,000 OTHER: $ A AUTOMOBILE LIABILITY AS2-C81-004095-128 911/2018 9/1/2019 F ,teeDtSINGLELIMIT $2000000 ANY AUTO BODILY INJURY(Per person) S OWNED SCHEDULED AS2-C81-054502-528 91112018 911/2419 _. AUTOS ONLY AUTOS Physical_ Damage only: BODILY INJURY(Per accident) HIRED NON-OWNED s PROPERTY DAMAGE .�...__..__.... AUTOS ONLY AUTOS ONLY Comprehensive Ded$10,000 ,_Per accident $ Collision Ded$10,000 $ UMBRELLALIAB OCCUR EACHOCC_U_RR£NGE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED 1 -.- RETENTION$ - d $ 8 WORKERS COMPENSATION ✓ WA7-C8D-004095-028 9/1/2018 9/1/2019 / ST,4TUTE RH AND EMPLOYERS LIABILITY YIN All except OH,ND,WA.,WY. -.-__ ...ao.� ..,. ANYPROPRIETORrPARTNERrEXECUTIVE E.L.EACH ACCIDENT $1000 000 OFFICERIMEMBEREXCLUDED? NIA ._.e. .mom--_ � (Mandatory In NHI E.L DISEASE EA EMPLOYEE $i' mm yes,describe under WC7-C81-00409..:5-018 9/112018 9/1./2019 -. DESCRIPTION OF OPERATIONS below Wi MN E.L.DISEASE,POLICY LIM[T s 1 000 000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 2019 Citywide Roadway,Resurfacing Project 18-0054-EN City of Clearwater is listed as additional insured with regards to the general liability for ongoing and completed operations,and automobile liability policies,on a primary and non-contributory basis,where required by written contract. Waiver of subrogation Is included in favor of the additional insured,where required by written contract,and where applicable by law. CERTIFICATE HOLDER CANCELLATION City Of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE Y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED I Engineering Department ACCORDANCE WITH THE POLICY PROVISIONS. Attn: Construction Office Specialist P© BOX 4746 Clearwater FL_ 33758-4748 AuTHaRIEDREPR>REPRESENTATIVE X-11�41'e rr-�zz Valerie Reece 01988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD 47984641 I LM 44 1 -91189/19 - standard. 2/2,. Excess I Bao Lee 1 2f15/�919 4:04.96 PM f(-ST) I gage 1 of 1 is