CERTIFICATE OF LIABILITY INSURANCE (976) WILLIS TOWERS WATSON
26 CENTURY BLVD.
6TH FL
NASHVILLE,TN 37214
RECEIVE0
3006 1 MB 0,425
111111111111111 1 11 1 111111111,1--I I I I I I-I I I I I I I I-I I-I I I I I I I I I I-I-I
CLEARWATER GAS SYSTEM
400 N MYRTLE AVE 3006
CLEARWATER, FL 33755-4433
N ON 1(30 E
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 for 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: 18459554
If you require additional information or have further questions, please feel free to contact-,
Willis Towers Watson Global Certificate Center
Email: EDPCERTSOwillistowersli atson.corn
Fax: 888-467-2378
Phone: 877945-7378
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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=08132/2019
DDIYYYY)CERTIFI LIABILITY I
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 BOLDER.
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 endorsemengs).
PRODUCER NA RAE:CT
Willis of Pennsylvania, Inc. JPIILIFIE - FAX
c/o 26 Century Blvd 1-877-945-7378 AIC No. 1-880-467-2378
P.O. Box 305191 E-MAiL� certificateaQ+Rillia.ccltl
Neahville, TN 372.345191 USA €NSURERjsI AFFOR01W.COVERAGE NAIL p
INSURER A: Liberty Mutual. Fire insurance Comany 23035
INSURED INSURERS, Associated Electric A Gas Insurance Servici B1164
Mxrrlin Gas services, LLC Liberty insurance Corporation 42404
909 Silver Lake Boulevard INSURER C: rp ._..a...y,. 1e..a..,
[lover, DE 19904 INSURER
INSURED E
INSURER F
COVERAGES CERTIFICATE NUMBER:W12460663 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED Tp 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 AI26L SIiBR' POLICY EFF I I ICY EXP i
PDIICYNUMBER MMJDMYYYY Rd QDfYYYY LIMITS
X.COMMERCIALGENERAL LIABILITY EACHOCCURRENCE $ 11000,000
CLA11R5-MAOI X OCCUR PRE a,9RSES_{Ee eFG t-11r) a7 100,000
R ! MED EXP{AU one person) $ 10,000
Y TB2--641--444639-039 09/01/2019 09/01/2020 PERSONAL&ADV ItIJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER• GENERAL AGGREGATE $ 2 000,000
X.POLICY PECTDC LOC PRODUCTS-COMPfOP AGO .$' 2,000,000
PRO. — v
OTHER, :$
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1 000,000
_ a acsJd�rsll-. 0, 00
X ANY AUTO
BODILY INJURY(Per person)
A OWNED �j SCHIe[y9JLEla A82^641^444639^013 '09/01/2019 x 09./01/2020, BODILY INJURY(Per accident) $
AUTOS ONLY I AUTOS
HIRED NOR-OWNED I PROPERTY C7AMAGI $
AUTOS ONLY � AUTOS ONLY Per accidBsei/
i. Florida PIP Coverage;$ 10000
B UMBRELLA LIAB X OCCUR _ _ I EACH OCCCUPPENCE �.$ 5,000,000
X EXCESS LIARCLAIMS MACE X1158178011? 09/Ol/2019 09/01/2020:AGGREGATE $, 5,000,000
DED RETENTIONS
WOR IfERSCOMPENSATION X PER 4TH
AND EMPLOYERS'LIABILITY YIN I PIAL_- _ I I
C ANYPROPRIETCRIPARTNER.IEXECUTIVE E.L.EACH ACCIDENT $ 1,000,000.
CI`FICERrMEMBeREXCL10ECd1 No NIA RC2-641-4,44639-059 09/01/2019 09/01/2020'. 11000,000.
(Mandatory In NH) E.L.0ISEASE EA EMwPLOYEE
tl es,descr pee usede 1,000,000
Sl SCFEIPTIt71S SIF OPERATIONS Ire!ety E.L.DISEASE•POLICY LIM€T;$
a
I
i
DESCRIPTION OF OPERATIONS 1 LOCATIONS t VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached II melte space 1s required)
Clearwater Gas System is included as Additional Insured with respects to General Liability.
CERTIFICATE HOLDER CANCELLATION
RFC )^ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION IRATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
4 ,.. 2 0�
Clearwater Goa System AUTHORrZED REPRESENTATIVE
400 N. Myrtle Ave ��t °�•�nsaCt�
Clearwater, FL 3.3755 GAS
0198'8-2018 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
$n ID. 18459554 SArcH: 1350507
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