MARSHALL STREET WRF MOTOR CONTROL CENTER NO. 9 ELECTRICAL SYSTEMS UPGRADES - 16-0033-UT - CERTIFICATE OF LIABILITY INSURANCE - 16-0033-UT (3) DATE(MM/DD/YYYY)
A�" CERTIFICATE OF LIABILITY INSURANCE 3/29/2019
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
NAME:
Sihle Insurance Group, Inc. PHONE FAX
1021 Douglas Ave. A/C No Ext): 407-869-0962 A/C,No:407-774-0936
Altamonte Springs FL 32714 ADDE-MRESS: info@sihle.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: Bridgefield Casualty Ins. Co. 10335
INSURED BLSMITH-01
INSURER B
BL Smith Electric, Inc.
29252 US Highway 27 INSURERC:
Dundee FL 33838-4264 INSURERD:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:958617648 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
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
1:1 OCCUR
DAMAGE S( RENTED
CLAIMS-MADE
PREMISES Ea occurrence)
ccurrence) $
MED EXP(Any one person) $
PERSONAL&ADV INJURY $
GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $
POLICY❑ PRO-
[:]JECT LOC PRODUCTS-COMP/OP AGG $
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
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 LAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
A WORKERS COMPENSATION Y 0196-45702 4/1/2019 4/1/2020 X PERX OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? ❑ N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
RE: Marshall St.WRF MCC9 Electrical Systems Upgrade Project#16-0033-UT. Blanket Waiver of Subrogation applies as respects workers compensation
when required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater
100 S. Myrtle Avenue, Suite 200 AUTHORIZED REPRESENTATIVE
Clearwater FL 33756
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will
not enforce our right against the person or organization named in the Schedule. (This agreement applies only
to the extent that you perform work under a written contract that requires you to obtain this agreement from
us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
*Blanket Waiver of Subrogation Applies*
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Date Prepared: March 28, 2018
Carrier: Bridgefield Casualty Insurance Company
Effective Date of Endorsement: April 1, 2018
Policy Number: 196-45702 Countersigned by:
Insured: B L Smith Electric Inc.
WC 00 03 13 (Ed. 4-84)
"Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. Copyright 1984 NCCI"