CERTIFICATE OF LIABILITY INSURANCE (546) DATE(MM/DD/YYYY)
AO e, CERTIFICATE OF LIABILITY INSURANCE 1/2/2020
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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)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 CONTACT BRENDA M CORDER
Town &Country Insurance Agency NAME:
PHONE
1525 Herbert St. Ste 106 A/CNo Ext:386 767 0147 FAX No): 386 767 5075
Port Orange FL 32129
E-MAIL DD SS: BRENDA@TOWNCO1.COM
INSURER(S)AFFORDING COVERAGE NAIC#
Phone: 386-767-0147 Fax: 386-767-5075 INSURERA: HARTFORD INSURANCE COMPANY 11185
INSURED Williamson Dacar Associates Inc INSURERB: HARTFORD INSURANCE COMPANY 10700
15500 Lightwave Dr Suite 106 INSURERC:ADMIRAL INSURANCE COMPANY 24856
Clearwater,FI 33760 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MWDD/YYY MWDD/YYY
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 2,000,000
CLAIMS-MADE MAEOCCUR PREM SES Ea occurrence) $ 1,000,000
MED EXP(Any one person) $ 10,000
A
X 21 SBTY4564 09/24/2019 09/24/2020 PERSONAL&ADV INJURY $ 2,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ 4,000,000
POLICY -PRO ❑ LOC PRODUCTS-COMP/OPAGG $ 4,000,000
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANY AUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
�( HIREDXNON-OWNED 21 SBTY4564 09/24/2019 09/24/2020 PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
UMBRELLA LAB X OCCUR EACH OCCURRENCE $ 2,000,000
A EXCESS LAB CLAIMS-MADE 21 SBTY4564 09/24/2019 09/24/2020 AGGREGATE $ 2,000,000
DED RETENTION$ $
WORKERS COMPENSATION XPER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
Y/N
BANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? N/A 21WECAC1LPE 01/01/2020 01/01/2021
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000
PROFESSIONAL LIABILITY E0000030428-05 09/14/2019 09/14/2020 occurrence 5,000,000
Cclaims made retro date $25,000 deductible aggregate 5,000,000
9/14/1996
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required)
INSURED'S LOCATIONS: 15500 Lightwave Dr. Suite 106, Clearwater,Fl 33760
851 Broken Sound Parkway, Suite 133 Boca Raton, FI 33487
CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED WITH A WAIVER OF SUBROGATION IN THE FAVOR OF CITY OF
CLEARWATER WITH RESPECTS TO PROFESSIONAL SERVICES CONTRACT FOR MISC. CITY FACILITIES IMPROVEMENT
PROJECTS ARCHITECT OF RECORD RFQ 11-14
30 DAYS NOTICE OF CANCELLATION 10 DAYS NOTICE FOR NON PAYMENT OF PREMUM
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
ACCORDANCE WITH THE POLICY PROVISIONS.
C/O ENGINEERING DEPARTMENT
PO BOX 4748 AUTHORIZED REPRESENTATIVE
CLEARWATER,FL 33758-4748
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