CERTIFICATE OF LIABILITY INSURANCE (492)Client#: 1048507
INGENENT
ACORD. CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
5/23/2019
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(les) 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 any rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
USI Insurance Services, LLC
2502 N Rocky Point Drive
Suite 400
Tampa, FL 33607
CONTACT
NAME:
PHNE No, Exr): 813 321-7500 FAX No):
E-MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC A
INSURER A : Phoenix Insurance Company
25623
INSURED
Ingenium Enterprises, Inc.
14499 N. Dale Mabry Hwy. Suite 250
Tampa, FL 33618
INSURER B : Travelers Indemnity Company
25658
INSURER C: Beridey Insurance Company
32603
INSURER D : Travelers Properly Cu. Co. of America
25674
INSURER E :
INSURER F :
X
COVERAGES
CERTIFICATE 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.
INR
LTR
TYPE OF INSURANCE
ADDLSUBR
INSR
WVD
POLICY NUMBER
POLICY EFF
(MM/DD/YYYY)
POLICY EXP
(MM/DD/YYYY)
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
X
X
6803H433322
10/14/2018
10/14/2019
EACH OCCURRENCE
$2,000,000
$1,000,000
CLAIMS -MADE
X
OCCUR
DAMAGE TO RENTED
PREMISES aoccurrence)
MED EXP (Any one person)
$10,000
$2,000,000
PERSONAL & ADV INJURY
GEN'L
AGGREGATE
POLICY
OTHER:
X
LIMIT APPLIES
JECOT
PER:
LOC
GENERAL AGGREGATE
$4,000,000
PRODUCTS - COMP/OP AGG
$ 4,000,000
$
D
AUTOMOBILE
X
X
LIABILITY
ANY AUTO
OWNED
AUTOS ONLYAUTOS
AUTOS ONLY
X
SCHEDULED
NON -OWNED
AUTOS ONLY
X
X
BA220M6366
11/30/2018
10/14/2019
(EaacBedemSINGLELIMIT
$1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
B
X
UMBRELLA UAB
EXCESS LIAR
X
OCCUR
CLAIMS -MADE
X
X
CUP5K869570
10/14/2018
10/14/2019
EACH OCCURRENCE
$5,000,000
AGGREGATE
$5,000,000
$
DED
X
RETENT ON $10,000
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y / N
N / A
PER
STATUTE
OTH-
ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
C
Professional
Liability
AEC903136800
05/29/2019
05/29/2020
$2,000,000 per claim
$2,000,000 annl aggr.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached N more space Is required) RECEIVED
Professional Liability coverage is written on a claims -made basis.
RE: Engineer of Record RFQ34-15. The City of Clearwater is an Additional Insured as respects the Commercial
General Liability policy where required by a written contract prior to a loss per policy terms and MAY 2 8p�g
conditions.
OFFICIAL REC0FDSAND
IPaICi AT0dr rni,.-.
CERTIFICATE HOLDER
CANCELLATION
t
City of Clearwater
Attn: City Clerk
PO Box 4748
Clearwater, FL 33758-4748
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2016/03) 1 Of 1
#S25722163/M25718309
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