2018 SEWER POINT REPAIRS AND IMPROVEMENTS PROJECT - 17-0060-UT - CERTIFICATE OF LIABILITY INSURANCE (8) Client#: 23703 ENGISPR
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ACORD,. CERTIFICATE OF LIABILITY INSURANCE 08DATE/(MMIDDI29/2019
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.
IP/IPORTANT: If the certificate hoider Is anADDITIONAL INSURED,thee-pofil ie's-i-must 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 Renee Payne
Lanier Upshaw, Inc. FilmFAX
, 863 284-3177 Aic,No): 863 682-6292
1115 US Hwy 98 South E-MAIL
ADDRESS: Renee.Payne@lanierupsh,aw.com
P.O. Box 468 INSURERS)AFFORDING COVERAGE NAIL Is
Lakeland, FL 33802 INSURER A:C-1-11Y'-s"r-mc-CO 39993
................ . ..... _
INSURED Engineered Spray Solutions, LLC INSURER B N.fir,rral lm.na Coparty T2 8496
W-tftid I.—s-*C.-pa.y
130INSURER C 6 Banana Road 1.,INSURER,,- , D; _124112
Lakeland, EL 33810 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TOCERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED
CATED NOTWTHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACTOR 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.
ADDL�SUB ...... POLICY-, _ EFE_ PO'LiCYFXP
INSR TYPE OF INSURANCE POLICY NUMBER (MWDDNYYY) LIMITS
LTR INSR iWVD
A X 1 COMMERCIAL GENERAL LIABILITY 103GL001102004 09102/201909102/202 EACH OCCURRENCE s2,000,000
DAMAGE TO RENTED
CLAIMS-MADE X�OCCUR
'PREMISES&a occurrence-L,_—,$100,000
I
X BI/PD Ded:1,000 MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE s2,000,000
POLICY PRO-
Xi JECT i LOC PRODUCTS-COMPIOP AGO $2,000,000
OTHER: $
_TCOMBINED SINGLE_WIT
C AUTOMOBILE LIABILITY CII M4813093 0910212019 09102/2021(E. md.M) ,
$1,000,000
ANY AUTO
X BODILY INJURY(Per person) $
ALL OWNED SCHEDULED $
AUTOS i AUTOS BODILY INJURY(Per acrident)
,7v_1 NON-OWNED -PROPERTY DAMAGE
X� HIRED AUTOS AUTOS
XPIP PIP $
$10,000
B UMBRELLA LIAB 72275U1 93ALI 09/02/2019 09102/2020 EACH OCCURRENCE
i X OCCUR s2000000
...............
X
EXCESS LIAR AGGREGATE 000 CLAIMS-MADE
DRETENTION$0
............
WORKERS,COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE IER
ANY PROPRIETORIPARTNEPJFXECUTIVE E L EACH ACCIDENT $
OFFICER/MEMSER EXM.UDEDNIAi
(Mandatory in NH) E L DISEASE-EA EMPLOYEE $
11 yes,describe under
DESCRIPTION OF OPERATIONS below DISEASE-POLICY LIMIT $
C RentediLeased CMM4813093 0910212019;09102/2020 $100,000 Max Per Item
!Equipment I I
$250,000 Catastrophe
1 $1,000 Deductible
DESCRIPTION OF OPERATIONS!'LOCATIONS t VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space$a required)
Project Name: 2018 Sewer Point Repair& improvements Project(Section D4-Manhole Surfacing-Polyur4thane)
Project#17-0060-UT
The City of Clearwater is included as additional insured with waiver of subrogation in regards to the
general liability and automobile liability as required by written contract. General liability coverage is SE 3 TDI
primary/non-contributory as required by written contract. Umbrella liability follows form.A 30 day notice
of cancellation applies in favor of the certificate holder,except 10 days for non-payment of premium.
J
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Engineering Department ACCORDANCE WITH THE POLICY PROVISIONS.
Attn: Construction Office Specialist
P.O. Box 4748 AUTHORIZED REPRESENTATIVE
Clearwater, FL 33758-4748
C.
1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) 1 of I The ACORD name and logo are registered marks of ACORD
#S455400IM455388 JRW