CERTIFICATE OF LIABILITY INSURANCE - RFQ 26-19 DATE(MM/DDYYY)
A�" /YCERTIFICATE OF LIABILITY INSURANCE 6/19/2019
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: Vicky Van Wormer
Brown &Brown Insurance-Clearwater PHONE FAX
83 Park Place Blvd., Suite 101 A/C No Ext): 727 450-7018 AIC,Noy 727-450-7083
E-MClearwater FL 33757-2456 ADDRESS: vvanwormer@bbpinellas.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA:Admiral Insurance Company 24856
INSURED INSURER B:The Travelers Indemnity Company of America 25666
Kisinger Campo&Assoc. Corp. INSURER C:The Charter Oak Fire Insurance Company 25615
KCCS, Inc.
Campo&Associates, PLLC INSURER D:Travelers Casualty and Surety Company 19038
201 N. Franklin Street, Ste. 400 INSURER E:
Tampa FL 33602
INSURER F
COVERAGES CERTIFICATE NUMBER:719864668 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 POLICY NUMBER MM/DD MM/DD
C X COMMERCIAL GENERAL LIABILITY Y 6308254A604 9/1/2018 9/1/2019 EACH OCCURRENCE $1,000,000
DAMAGE S( RENTED
CLAIMS-MADE OCCUR
PREMISES Ea occurrence)
ccurrence) $300,000
X Contractual Liab MED EXP(Any one person) $10,000
X XCU Included PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
� PRO-
POLICY 1:1 LOC PRODUCTS-COMP/OP AGG $2,000,000
OTHER: $
B AUTOMOBILE LIABILITY Y 8102G365561 9/1/2018 9/1/2019 COMBINED SINGLE LIMIT $1,000,000
Ea accident
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
X HIREDX NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
X PIP$10,000 $
B X UMBRELLA LAB X OCCUR Y CUP7J748484 9/1/2018 9/1/2019 EACH OCCURRENCE $4,000,000
EXCESS LAB CLAIMS-MADE AGGREGATE $4,000,000
DED X RETENTION$1 n nnn $
D WORKERS COMPENSATION UB7J070308 10/3/2018 10/3/2019 X PERX OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTEI ER U.S.L.H.
ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $500,000
OFFICE R/M EMBER EXCLUDED? FN] N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $500,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $500,000
A Professional Liability E000002720505 11/2/2018 11/2/2019 Per Claim 5,000,000
Claims Made Aggregate 5,000,000
Retro Date 11/2/2014 Deductible 250,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Certificate holder is an additional insured with respect to general liability,auto liability and umbrella liability. Endorsements available upon request.Waiver of
Subrogation applies to general liability and workers compensation&employers liability. Explosion,Collapse& Underground hazard included in CGL.
Project: Professional services under Engineer of Record Agreement RFQ#26-19 and all Task Work Orders issued thereunder. A thirty-day written notice of
cancellation shall be provided,with the exception of ten-day notice for non-payment. (KCA Project#6201908.00)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF CLEARWATER ACCORDANCE WITH THE POLICY PROVISIONS.
ENGINEERING, RFQ#26-19
P.O. Box 4748 AUTHORIZED REPRESENTATIVE
Clearwater FL 33758-4748
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD