CERTIFICATE OF LIABILITY INSURANCE (960) WILLIS TOWERS WATSON
26 CENTURY BLVD,
6TH FIL
NASHVILLE, TN 37214
FUR F C.F I F9
JN 2
2670 1 MB 0.425
CITY OF CLEARWATER 2670
PO BOX 4748
ENGINEERING, RFC #26-19
CLEARWATER, FL 33758-4748
****NU'O%TICE****
In order to expedite distribution of certificates to Certificate Holders, we would like to begin using electronic
distribution for future, issuances.Also, we would like to remove any certificates that are no longer needed.
If you would like to receive electronic copies in the future or no: longer require a certificate for this Insured,
please note as such below.
Please complete this form and submit with a copy of your current certificate to the contact
information below:
Do you wish to receive renewal certificates: Yes, No
Require a hard copy be mailed: Yes No
Email Address or Fax Number-
SR ID: 18099657
If you require additional information or have further questions, please feel free to contact:
Willis Towers Watson Global Certificate Center
Email: EDPCERTSOwillistowerswatson.com
Fax- 888-467-2378
Phone: 877-945-7378
Please note that it is your responsibility to provide up-to-date contact information;, to assure correct
distribution of any future renewal certificates.
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DATE(MWODiYYYYI
CERTIFICATE OF LIABILITY INSURANCE 06/13/2019
- - -
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: It the certificate holder is On 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;
Nill!$ of Massachusetts, Inc,
PHONiE 1-877-945-7378 FAX
A�CNct: 1-888-467-2378
c'/€r 26 Century Blvd .. t7.. .1...._ ._m_.....m._..._ _� ,�
P.O. Bax 305191 ADDRESS: cortificates@willis.com
Nashville, TN 3723051.91 USA INSURER(S)AFFORDING COVERAGE NAIL#
INSURER A: Allied world Assurance Company US Inc 19489
INSURER INSURER B,: Zurich American insurance Company 16535
GRD services Inc. . .. ... _. ..
2055 Niagara spalls Blvd., Suite 3 INSURER G,: Lexington Insurance Company 154311 7
Niagara Talls, NY 14304 USA INSURER D:
INSURER E.:
_
INSURER F
COVERAGES CERTIFICATE NUMBER:W11607983- - - 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. NCITWITHSTANDIN(3 ANY REQUIREMENT, TEAM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
GERTIFI ATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED h EHEIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAIL}CLAIMS.
INSFt. .._ _. AbbL'SUtta-..-. -.. .... POLICY EFF . POLICY E'}tP - ,.... .., ..
LTR .__. TYPE OF INSURANCE IVSD IV[1' POLIC,YNUMIDER _- y'.MIrA{DDiYYYY MKIDDiYYYY) _LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE, $
004AGE TO RENTED --
-.
CLAIMS MADE X OCCUR ' PPCMI E5(EA 9cwrCJme) $ 1,000,000.
A MED E.XP,Art one pwso a $ 25,000
Y 0310-4,497 ..1.2/01/201,8 32/01/2029 PERSONAL&ADV INJURY ..S -1,000,000,
CaLNL A.CiC AE(,-fA rIE LIMIT APPL.ItS F1 EA - GENERAL AC�.GREGATE 5._.. 2,000,000
POLICY ._. P80- .. LOC: PRODUCTS�C OMROP AGG 5;.-._ 2-,000,000''.
JECI -.
OTHER° 5
AUTOMOBILE LIABILITY mmCs aBIc4iN€rs JIklCLF LEMi"r $
1,000,000
E ll
X ANY AL IO BODILY AJUIRY(Per Ianrso,$) t
B OWNED SCHEDULED Y' BAF 3757423-04 07/03./2019 07101/2020 BODILY INJURY(per accidents SI
AUTOS ONLY AUTOS
x HIRED NUN OWNED PROPERTY DAMAGE
X X Hired Physical Damag If 100000
UMBRELLA LIAR
_.... . OCCUR j EACH OCCURRENCE $ ..
EXCESS CLAIMSMADEi AGGREGATE ti
DEQ_ RETENTION I---- -- -_--_ - - - $
..;aATUT 0TH=
WORKERS COMPENSATION E .�
AND EMPLOYERS'LIABILITY
Y t-1 1,000,000
B ANYPROPHI€IORB PARFN€Li EXEULJTIvk- E.L EACH ACCIDENT 9
OrFIGEi:'M`c,MBEREXGLJDE1 Na N/A IPC 0380936-04 07/01/2.014 07/01./2020' - 1.00�O.0t50..'I
iMsndatory In NH) E.L DISEASE-EA EMPLOYEE' t
It yes,describe under 1,000,000'
DESCRIPTION Or OPERATIONS kx law E d_ DSEAS€. PC,CIC;Y LIMIT i
C Profeamional Liabr 031710993... .12/03/2018 12/01/2019 Claim:$1,000,000/Agg $2,000,000
DESCRIPTION OF OPERATIONS,LOCATIONS t VEHICLES (ACORD 109,Additional Remarks Schedule,may be attached II more space is required)
C'HD Project no. : 11192847
Coverage for Contractual Liability is provided under General Liability policy.
City of Clearwater is included as an Additional insured as respects to General Liability and. Auto Liability where
required by contract or agreement,
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.
JUN 2 1 2019
City of Clearwater AUTHORIZED REPRESENTATIVE
Engineering, RFQ 26-19
PO Box 4748 d tr .f t'wf12Vt,
Clearwater, FL 33758-4748
019&16-2016 ACORN CORPORATION. All rights reserved,
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
su a®' IB099657 BATM 1239760
2 tae 4 2670
AGENCY CUSTOMER ID:
LOC#:
ADDITIONAL REMARKS SCHEDULE Page 2 Of 2
141�_
A13ENCY NAMED INSURED
Willis of Massachusetts, Inc. GXD Services Inc.
2055 Niagara Falls, Blvd., Suito 3
POUCY NUMBER Niagara Falls, NY 14304 USA
See Page I
CARRIER NAIC CODE
see Page 1 See P090 I EFFECTIVE DATE: See Page I
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACCIRD FORM,
FORM NUMBER: 25..._._..._ FORM TITLE. Certificate of Liability insurance
.. .
General Liability and Auto Liability policies shall be Primary and Non-contributory with any other insurance in force
for or which may be purchased by Additional Insured where required by contract or agreement.
ACORD 101 (2008/01) 0 2008 ACO'RD CORPORATION, All rights reserved.
The ACORD name and logo are registered marks of ACORD
SR ID: IB099657 SATCH: 1239760 CERT: W11607983
POLICY NUMBER: 0310-4497 COMMERCIAL GENERAL LIABILITY
CG 20 10 10 01
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or Organization:
Where required by written contract
(It no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
A. Section 11 — Who Is An Insured is amended to (1) All work, including materials, parts or
include as an insured the person or organization equipment furnished in connection with
shown in the Schedule, but only with respect to such work, on the project (other than
liability arising out of your ongoing operations per- service, maintenance or repairs) to be
formed for that insured. performed by or on behalf of the addi-
B. With respect to the insurance afforded to these tional insured(s) at the site of the cov-
additional insureds, the following exclusion is ered operations has been completed;
added: or,
2. Exclusions (2) Thai portion of "your work"' out of which
the injury or damage arises has been
This insurance does not apply to "bodily inju- put to its intended use by any person or
ry" or "property damage" occurring after: organization other than another con-
tractor or subcontractor engaged in
performing operations for a principal as
a part of the same project.
CG 20 10 10 01:1 @ ISO Properties, Inc., 2000 Page 1 of 1 0
3 of 4 2570
POLICY NUMBER: 0310-4497 COMMERCIAL GENERAL LIABILITY
CG 0371001
THIS ENDORSEMENT CHANGES TM LILY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name of Person or ation2.
Where required by written contract
Location And Description of Completed Operations:
Where required by written contract
Additional Premium:
N/A
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
Section 11 — Who Is An Insured is amended to include as an insured the person or organization shown in the
Schedule, but only with respect to liability arising out of "your work" at the location designated and described in the
schedule of this endorsement performed for that insured and included in the "products-completed operations haz-
ard",
CG 20 37 10 01 @ISO Properties, Inc., 2000 Page 1 of 1 13
POLICY NUMBER-. 0310-4497 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
PRIMARY A► NON-CONTRIBUTORY
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
Notwithstanding any other provision of this policy to the contrary, the insurance afforded to an additional
insured under this policy will be primary to, and non-contributory with, any other insurance available to
that person or organization in the event a contract or agreement you enter into requires you to furnish
insurance to that person or organization of the type provided by this policy.
GL 00021 00 (07/09)
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9
Coverage Extension Endorsement ZURICH
Policy No Eff. Date of Pot. Exp, Date of Pot. Eff. Dare of End. I Producer No, Adcrl,Prern Return Prem.
BAP 3757423-04 7/112019 7/1/2020 7,'1/X)'19 ---
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
This endorsement modifies insurance provided under the:
Business Auto Coverage Form
Motor Carrier Coverage Form
A. Amended Who Is An Insured
1. The following, is added to the Who Is An Insured Provision in Section 11 —Covered Autos Liability Coverage-,
The following are also "insureds":
a. Any "employee" of yours is an "insured" while using a covered "auto" you don't own, hire or borrow for acts
performed within the scope of employment by you. Any "employee" of yours is, also an "insured" while
operating an `auto" hired or rented under a contract or agreement in an "employee's" name, with your
permission, while performing duties related to the conduct of your business.
b. Anyone volunteering services to you is an "Insured" while using a covered "auto" you don't own, hire or
borrow to transport your clients or other persons in activities necessary to your business.
c. Anyone else who furnishes an "auto" referenced in Paragraphs A.l.a. and A.1 b. in this endorsement.
d. Where and to the extent permitted by law, any person(s) or organization(s) where required by written contract
or written agreement with you executed prior to any "accident", including those person(s) or organization(s)
directing your work pursuant to such written contract or written agreement with you, provided the "accident"
arises out of operations governed by such contract or agreement and only up to the limits required in the
written contract or written agreement, or the Limits of Insurance shown in the Declarations, whichever is less.
2. The following is added to the Other Insurance Condition in the Business Auto Coverage Form and the Other
Insurance— Primary and Excess Insurance Provisions Condition in the Motor Carrier Coverage Form:
Coverage for any person(s) or organization(s), where required by written contract or written agreement with you
executed prior to any "accident", will apply on a primary and non-contributory basis and any insurance maintained
by the additional "insured" will apply on an excess basis. However, in no event will this coverage extend beyond
the terms and conditions of the Coverage Form.
All other terms, conditions, provisions and exclusions of this policy remain the same.
U-CA-424-F C l(74/14)
Page 1 of 1
Includes copyrighted material of Insurance Services Office.Inc. with its permission