LIFT STATION 45 FORCE MAIN REPLACEMENT - 17-0016-UT - CERTIFICATE OF LIABILITY INSURANCE ' CERTIFICATE OF LIABILITY INSURANCE 09/2/2019"'
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(les)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 1-813-229-8021 C NTACT Diana Defreeuw
NAME:
M. E. Wilson Company, LLC PHONE 813-984-3619 FAx 813 434-2492
(A/C.its_E> A1C Nom.._— ......--- _.-.._......._
E-MAIL ddefreeuw@mewilson.com
300 W. Platt St. .._ADDRESS;-__
Ste 200 INSURERS AFFORDING_COVERAGE NAIC#____
Tampa, FL 33606 INSURERA: WESTFIELD INS CO 24112
INSURED INSURERS: BRIDGEFIELD EMPLOYERS INS CO 10701
TLC Diversified, Inc. _._.._._ CO
INSURERC; TRAVELERS PROP CAS CO OF AMER 25674
2719 17th Street East lrisugERu:
INSURER E;
Palmetto, FL 34221 INSURERF:
COVERAGES CERTIFICATE NUMBER:57327820 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 --..._.—_ Abb sU -----`------ ----------POLICY EFF--- P6LIGY EXP LIMITS
TR TYPE OF INSURANCE POLICY NUMBER D D
A X COMMERCIAL GENERAL LIABILITY ITRA3972460 04/01/19 04/01/20 EACH OCCURRENCE $ 1,000,000
`--— i TSAA E OO�N
CLAIMS-MADE X j OCCUR PREMISES(Ea occurrence) $ 500,000
X Contractual Liability5 000
MED EXP(Any ono person) $ _
$500 Prop Ding Ded PERSONAL&ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
E
POLICY CjC LOC ...-PRODUCTS--C--O--
MP/OPAGG $ 2,000,000
HOTHER:
$
A AUTOMOBILE LIABILITY TRA3972460 04/01/19 04/01/20COMBINEDSINGLELIMI $ 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
$
A X UMBRELLA UAB X OCCUR TRA3972460 104/01/19 04/01/20 EACHOCCURRENCE Is 51000,000
EXCESS UAB _ CLAIMS-MADE AGGREGATE 1$ 510001000
DED X RETENTION$ 0 $
WORKERS COMPENSATION X PER 1 O H
B 83055326 04/01/19 04/01/20 STATUTE, ER
AND EMPLOYERS'LIABILn'Y Y/N � �— --- --
ANYPROPRIETOR/PARTNER/EXECUTIVE — N/A E.L.EACH ACCIDENT $ 1 000 000
'OFFICER/MEMBEREXCLUDED9 --"— ---" ---
�(Mandatory lnNH) E.L.DISEASE EA EMPLOYEE $ 1,000,000
_.—---...
If yes,describe under — _ _..- ._---
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
C ,Installation Floater QT660SK309215TIL19 07/01/19 04/01/21 Per job 1,000,000
Transit & Storage: 1,000,000
Deductible: 5,000
DESCRIPTION OF OPERATIONS I LOCATIONS t VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space Is required)
Project: City of Clearwater: 17-0016-UT/Lift Station 45 Force Main Replacement / TLC Job No. 1907
City of Clearwater and Certificate Holder are Addtional Insured. Thirty (30) days written notice of any cancellation,
non-renewal, termination, material change or reduction in coverage will be sent to Certificate Holder below.
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.
Construction Office Specialist
P.O. Box 4748 AUTHORIZED REPRESENTATIVE
Clearwater, FL 33758-4748 wv-t (
USA '�J"
Q 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
JL002
57327520
r
ot Wk]kKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC 00 03 13
(Ed. 4-84)
WAIVER OF OUR RIGHT TORECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for on injury covered by this policy. We will �
not enforce our right against the person or organization named in the Schedule. (This agreement applies only
to the extent that you perform work under a written contract that requires you to obtain this agreement from
un.)
This agreement shall not operate directly orindirectly to benefit anyone not named in the Schedule.
Schedule
*Blanket Waiver ofSubrogation Applies*
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated,
Date Prepared: February 13, 2010
Carrier: Bridgefie|d Employers Insurance Company
Effective Date ofEndorsement: April 1. 2O1Q
Policy Number: 83O-55326 Countersigned by:
Insured: TLC Diversified, Inc.
WCq0M3 13 (Ed, 4-84)
"Includes copyright material of the National Council on Compensation Insurance, Inc. used with its permission. Copyright leo4wCCr
POLICY NUMBER: TRA 3972460 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANCES THE POUCY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED ® OWNERS,
LESSEES OR
CON71RACTORS - SCHEDULED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured P n(s)
Or O s) Location(s)Of Covered Operations
All persons or organizations when you have All Locations
agreed in writing in a contract or agreement
that such persons or organizations be added
as an additional insured.
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section II - Who Is An Insured Is amended to I. All work, Including materials, parts or
Include as an additional Insured the person(s) equipment famished In connection with
or organization(s) shown In the Schedule, but such work, on the project (other than
only with respect to liability for"bodily Injury", service, maintenance or repairs) to be
"property damage" or "personal and adver- performed by or on behalf of the addi-
tising injury" caused, in whole or in part, by: tional insured(s) at the location of the
covered operations has been completed;
1. Your acts or omissions; or or
2. The acts or omissions of those acting on 2. That portion of "your work" out of which
your behalf„ the Injury or damage atises has been put
to its Intended use by any person or or-
In the performance of your ongoing r- ganization other than another contractor
ations for the additional Insured(s) at the or subcontractor engaged in performing
location(s) designated above. operations for a principal as a part of the
However same project.
1. The Insurance afforded to such additional C. With respect to the insurance afforded to
insured only applies to the extent per- these additional insureds, the following is
miffed by law; and added to Section III -Limits Of Insurance:
If coverage provided to the additional Insured
2. If coverage provided to the additional in- Is required by a contract or agreement, the
sured is required by a contract or agree- most we will pay on behalf of the additional
ment, the insurance afforded to such insured is the amount of insurance:
additional insured will not be broader
than that which you are required by the 1. Required by the contract or agreement;
contract or agreement to provide for or
such additional insured, . Available under the applicable Limits of
B. With respect to the Insurance afforded to Insurance shown in the Declarations;
these additional Insureds, the following addi- whichever is less.
tional exclusions apply: This endorsement shall not increase the ap-
This insurance does not apply to "bodily in- plicable Limits of Insurance shown In the
jury" or"property damage" occurring after: Declarations.
0 Ins ice,Inc,2012 CG 20 10 04 1
4aR
POLICY NUMBER.; TRA 3972480 COMMERCIAL GENERAL LIABILPfY°
POLICY.THIS ENDORSEMENT CHANGES THE .
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies Insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPU=TED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of AddlillionalI Person(s)
Or Organi (s) Location(s)And Desedpoon Of Covered Operations
All persons or organizations when you have All Locations
agreed In writing in a contract or agreement
that such persons or organizations be added
as an additional insured.
Information required to complete this Schedule, if not shown above,will be shown in the Declarations.
A. Section 11 -Who Is An Insured is amended to contract or agreement to provide for
include as an additional Insured the n(s) such additional Insured.
or organization(s) shown in the Schedule, but
only with respect to liability for'bodily injury" B. With respect to the Insurance afforded to
or"property damage" caused, in whole or In these additional insureds, the fallowing is
part, by "your work" at the location desig- added to Section III -Llmfts Of Insurance:
nated and described In the schedule of this If coverage provided to the additional Insured
endorsement performed for that additional Is required by a contract or agreement, the
insured and included in the "products- most we will pay on behalf of the additional
completed operations hazard". insured Is the amount of Insurance;
However: 1. Required by the contract or agreement;
1. The insurance afforded to such additional or
Insured only applies to the extent per- 2, Available under the applicable Limits of
milted by law; and Insurance shown in the Declarations;
2. If coverage provided to the additional in-
sured is required by a contract or agree-
ment, the insurance afforded to such This endorsement shall not increase the ap-
additional insured will not be broader plicable Limits of Insurance shown in the
than that which you are required by the Declarations.
0 Insurance Services Offm Inc,2012 CO 20 37 04 13
POLICY NUMBER: TRA3972460 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
RIGHTSWAIVER OF TRANSFER OF
AGAINST OTHERS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Person OrOrganization:
Any person or organization for whom you are required In a written contract or agreement to include
a waiver of transfer of rights of recovery against ethers to us, provided the "bodily Injury" or"property
damage" occurs subsequent to the execution of the written agreement.
Information required to complete this Schedule, If not shown above, will be shown in the Declarations.
The following is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section
IV- Conditions:
We waive any right of recovery we may have against the person or organization shown in the Schedule
above because of payments we make for injury or damage arising out of your ongoing operations or
"your work" done under a contract with that person or organization and Included In the "products-
completed operations hazard"_ This waiver applies only to the person or organization shown in the
Schedule above.
C insurance Services Office,Inc.,2008 CG 24 04A 05 00
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY WC@0 $3 13
(Ed. 4-84)
WAIVER OF OUR RIGHT TO RECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will
not enforce our right against the person or organization named in the Schedule. (This agreement applies only �
to the extent that you perform work under awritten contract that requires you to obtain this agreement from
us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
*Blanket Waiver ofSubrogation Applies*
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Date Prepared: February 13. 2O19
Carrier: Bridgofie|dEmployers Insurance Company
Effective Date ofEndorsement: April 1. 2O19
Policy Number: 83O-55328 Countersigned by:
Insured: TLC Diversified, Inc.
WC 00 03 13 (Ed. 4-84)
"Includes copyright material ofthe National Council nnCompensation Insurance, Inc. used with its permission. Copyright 1g84wCC|"
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POLICY NUMBER: TRA 3972460 COMMERCIAL GENERAL LIABILFTY
POLICY.THIS ENDORSEMENT CHANGES THE PLEASE READ IT CAREFULLY.
ADDITIONAL I - OWNERS, LESSEES OR
CONTRACTORS - COMPLETED OPERATIONS
This endorsement modifies Insurance provided under the fb4 ing:
COMMERCIAL GENERAL LIABILITY COVERAGE DART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Name Of Addlitilonall1 Pe (s)
Or Organization(*) on(s)And Description Of Covered Operations
All persons or organizations when you have All Locations
agreed in writing In a contract or agreement
that such persons or organizations be added
as an additional Insured.
Information required to complete this Schedule, if not shown above,will be shown in the Deciaratlons.
A. Section 11 - 'ilttho Is An Insured is amended to contract or agreement to provide for
Include as an additional Insured the person(s) such additional Insured.
or organization(s) shown in the Schedule, but
only with respect to liability for'bodily injury" S. With respect to the Insurance afforded to
or"property damage" caused, in whole or In these additional insureds, the following is
part, by "your work" at the location desig- added to Secdon III -Limilts Of In
nated and described In the schedule of this If coverage provided to the additional Insured
endorsement performed for that additional Is required by a contract or agreement, the
Insured and included In the "products- most we will pay on behalf of the additional
completed operations hazard". insured Is the amount of insurance:
However.- 1. Required by the contract or agreement;
1. The insurance afforded to such additional or
Insured only applies to the extent per- 2. Available under the applicable Limits of
mitt by law; and Insurance shown in the Declarations;
2, If coverage provided to the additional in-
sured is required by a contract or agree-
ment, less.the Insurance afforded to such This endorsement shall not increase the ap-
additionat insured will not be broader plicable Limits of Insurance shown in the
than that which you are required by the Declarations.
Insure ces Office, Inc,2012 CC 20 37 04 1
POLICY NUMBER: TRA3972460 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. IT CAREFULLY.
WAIVER OF TRANSFER OF RIGHTS OF RECOVERY
AGAINST OTHERS TO US
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART
SCHEDULE
Nan* Person Or O an on:
Any person or organization for whom you are required in a written contract or agreement to Include
a waiver of transfer of rights of recovery against others to us, provided the "bodily injury" or"property
damage" occurs subsequent to the execution of the written agreement.
Information required to complete this Schedule, if not shown above, will be shown In the Declarations.
The following Is added to Paragraph 8. Transfer Of Rights Of Recovery Against Others To Us of Section
IV - Conditions:
We waive any right of recovery we may have against the person or organization shown In the Schedule
above because of payments we make for Injury or damage arising out of your ongoing operations or
"your work" done under a contract with that person or organization and included In the "products-
completed operations hazard". This waiver applies only to the person or organization shown in the
Schedule above.
0 Insurance Servl4as Office,inc.,20M CG 24 04A 05 09