CERTIFICATE OF LIABILITY INSURANCE (993) WILLIS TOWERS WATSON
26 CENTURY BLVD,
6TH FL R E C E I V F.13
NASHVILLE,TN 37214
G MS A D N1 1,N
3014 1 MB 0A25
1111111111111 NJ
CLEARWATER GAS SYSTEM 3014
400 N MYRTLE AVE
CLEARWATER, FL 33755-4433
****NOTIU#'%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 I i ke to receive electronic copies in the future or no longer require a certificate for this Insured,
please note as such below,
Please complete this form 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: 18731845
If you require additional information or have further questions, please feel free to contact:
Willis Towers Watson Global Certificate Center
Email: EDPCERTSOwillistowerswatson.com
Fax: 888-467-2378
Phone: 877-945-7378
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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LIABILITY DATE(MWDDIYYYY)
CERTIFICATE OF 10/28/2019
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)mast 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 ri hts to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT -
-..
Willis Towers Watson Yssuranes, Services Wast, Inc. Pka Willis NAME:
PHONE 1-877-945-737$ FAX
I-BBB-467-2338
insurance Services of California, Inc. E-MAIL
c/o 26 Century Blvd ADDRESS,
certificatesBwillis.com
P.O. Box 3053.91
INSURE R(S)AFFORDING COVERAGE N AIC#
Nashville, TR 372305191 USA """`""°nd
INSURER A; endurance Assurance CorTaoratican 11551
INSURED INSURERB. Sompo America Eire i Marine Insurance Comp; 38997
WS-TSR., LLC — ,�.�...�.�.—_ -.........._...
c/o Robert as, curray & Associates, Inc. INSURERC. Allied World National Assurance Company 1.0690
One Beacon Street, 22nd Floor INSURER D
Roston, NA 02108 ... .
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER;W13563899 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TQ THE INSURED NAMED ABOVE.FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIREMENT,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 AODL SUBR` POLICY NUMBER I5v D Y YYY MP IiC7VYYYY LIMITS
CTRR159 MIKQ
X COMMERCIAL GENERAL LIABILITY
CURRENCE $
EACH OC1:0017,000
CLAIMS•MADE X OCCUR I a �� I - 500,000
_ . F'F�EMISES IEa occurrence} ..�.._
AI MED EXP¢Any one pet son) $ 1,000
x GGRIO011997502 10127/2019;10/27/2020;
PERSONAL$ADV INJURY $ 1.000,000.
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY jECT X LOG PRODUCTS•GOMIPtOP AGCY $ 2,000,000
EC7
OTHER- r Liquor Liability $ 11000,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT � 1,000.000
X ANY AUTO ' $C7DiCY INJURY(Per{x:rscrrl) ,.$, _.. ....._-.
S -OWNED SCHEDULED ICVS1022WO 10/27/201.9 10/27/2020 BODILYINJURY(Per aCCKlentl $
AUTOS ONLY AUTOS _
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY �AUTOS ONLY .gF'sa aco�derrP).
$
C X UM13RELLAUAB X OCCUR (EACHOCCUJRRENCE $ 5,000,000
— nre.m
EXCESS LIAR CLAIMS MADE 0309-2216 10/27/2019 10/27/2020
AGGREGATE $ 51000,000
DED X RETENTION$ 10,000 $
WORKERS C O®APENSATION
PtA
AND EMPLOYERS*LIABILITY Y t N STATUTE ER
AOFFICE II ME MSE REXCLUDED? LJ
N r A E,I,EACH ACCIDENT $
(Mandatory In NttD I E.L.DISEASE-EA EMPLOYEE,S
[lies,describe uotder _
DESCRIPTION OF OPERATIONS hebw E.L.DISEASE•POLICY LIMIT $
DESCRIPTION OF OPERATIONS)LOCATIONS I VEHICLES(ACORD 101 Additional Remarks SctuMdutea,may tae attached It more apace Is required)
Starkey Ranch, 2500 Heart Pine Ave., Odessa, FL
Certificate Holder is included as an Additional Insured with regards to General Liatailityr coverage,
CERTIFICATE HOLDER R c F I v T,1,1� CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
dt,. cr J'`
THE EXPIRATION DATE THEREOF, NOTICE WILL BE [DELIVERED IN
ACCORDANCE WITH THI_POLICY PROVISIONS.
Clearwater Gas System GAS ADMIN AUTHORIZED REPRESENTATIVE
400 North Myrtle Avenue �/�,,�
Clearwater, FL 33755
0 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
SR TD. 18731845 14,29779
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