CERTIFICATE OF LIABILITY INSURANCE (2) DATE(MM/DD/YYYY)
A�" CERTIFICATE OF LIABILITY INSURANCE 7/22/2019
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: Melissa Burk
Diversified Insurance Industries, Inc. a/CONN Ext: 410-319-0622 p/c,No:410-433-3440
307 International Circle, Suite 610 E-MAIL
Hunt Valley MD 21030 ADDRESS: melissa.burk@dii-ins.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA:Arch Insurance Co' 11150
INSURED ULTIM-4 INSURERB:AMER INTERSTATE INS- 31895
Ultimate CNG, LLC
3185 Wheatland Farms Drive INsuRERc:Admiral Insurance Co' 24856
Oakton VA 22124 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:295776123 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 MWDD/YYY MWDD/YYY
C X COMMERCIAL GENERAL LIABILITY FEIPPL2433801 11/29/2018 11/29/2019 EACH OCCURRENCE $1,000,000
CLAIMS-MADE OCCUR PREMISES(E.o. rr
PREMISES Ea occurrence) $50,000
MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY jECT RO-
LOC PRODUCTS-COMP/OP AGG $2,000,000
OTHER: Deductible $$5,000
A AUTOMOBILE LIABILITY FBCAT0220007 7/23/2019 7/23/2020 COMBINED SINGLE LIMIT $1,000,000
Ea accident
ANY AUTO BODILY INJURY(Per person) $
OWNED X SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
X HIREDX NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
C UMBRELLA LAB X OCCUR FEIEXS2433901 11/29/2018 11/29/2019 EACH OCCURRENCE $6,000,000
X EXCESS LAB CLAIMS-MADE AGGREGATE $6,000,000
DED RETENTION$ $
B WORKERS COMPENSATION AVWCNC2628192017 8/25/2018 8/25/2019 X PER 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)
City of Clearwater is included as additional insured 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
400 N Myrtle Ave AUTHORIZED REPRESENTATIVE
Clearwater FL 33755
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