CERTIFICATE OF LIABILITY INSURANCE (992)A b® CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
11/15/2019
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
Lassiter -Ware Insurance of Maitland
2701 Maitland Center Parkway
Suite 125
Maitland FL 32751INSURERA:
CONTACT Anne Edwards
NAME:
PH(ONE
Ext): (800) 845-8437 FAX No): (888) 883-8680
n-DRLSS: AnneE@lassiterware.com
INSURER(S) AFFORDING COVERAGE
NAIC #
Gemini Insurance Company
10833
INSUREDINSURER
Prospect Construction et alINSURER
ZMG Construction Inc.INSURER
1930 North Donnelly StreetINSURER
Mt Dora FL 32757
B : Owners Insurance Company
32700
C : Liberty Surplus Insurance Corp
10725
D : Amerisure Mutual Insurance Company
23396
E : Travelers Property Casualty Company of America
25674
INSURER F :
PERSONALBADVINJURY
2019-20 Ren Mast
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 POLIC ES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADDL
INSD
SUBR
WVD
POLICY NUMBER
*" j'
{{`-� y
L. O.S
VGGP0000372 0't �j11;'11/16/2019
OFFICIAL RECORDS
F
51-500205-02
POLICY EFF
(MM/DD/YYYY)
^
[,
J
AND
et'--T
L'L
11/16/2019
POLICY EXP
(MM/DD/YYYY)
11/16/2020
11/16/2020
LIMITS
EACH OCCURRENCE
1,000,000
$
A
X
COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$ 50,000
CLAIMS -MADE X OCCUR
MED EXP (Any one person)
$EXCLUDED
PERSONALBADVINJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2.000,000
GEN'L
AGGREGATE
POLICY
OTHER:
X
LIMIT APPLIES PER:
JECOT LOC
PRODUCTS - COMP/OP AGG
$ 2,000,000
COMBINED SINGLE LIMIT
(Ea accident)
$ 1,000,000
B
AUTOMOBILE
X
LIABILITY
ANY AUTO
OWNED
AUTOS ONLY__
HIRED
AUTOS ONLY
SCHEDULED
AUTOS
NON -OWNED
AUTOS ONLY
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
PIP
$ 10,000
C
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS-MADEAGGREGATE
1000126060-06
11/16/2019
11/16/2020
EACH OCCURRENCE
$5,000,000
$ 5'000'000
$
DED X
RETENTION $ 0
D
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
YNN
N/A
WC20876980502
O6/Ol/2019
06!01(2020
X
STATUTE
ER
E.L. EACH ACCIDENT
$ 1,000, 000
E.L. DISEASE - EA EMPLOYEE
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
$
E
Inland Marine
QT -660 -9M193904 -TIL -19
11/16/2019
11/16/2020
Leased/Rented Equip
$250,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
I.GR I Ir'II.P.I G rnuLUGR
City of Clearwater
112 S. Osceola Ave
•
Clearwater
FL 33756
"^'•".-.--"-'-^
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
�_ -----,----
ACORD 25 (2016/03)
The ACORD name and logo are registered marks of ACORD