CERTIFICATE OF LIABILITY INSURANCE (1006) '4CC>'R CERTIFICATE F LIABILITY 1NSt1RANCE EDATEtM"QD1[YYM1 )
THIS12J2g12019
CER IFIRATE ATE IS ISSUrzD.AS A MATTER OF I€VFORMATION 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 TOES.NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURERS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
If SU R SUBP.ROGATION
I The certificate WAIED hofde ct t ADDITIONAL INSURED,the policy(€es)must have ADDITIONAL INSURED.pravisions or he endorser#;
If SUBROGATION IS WAIVED,subject to the terms and conditions of the pofiry,.certaln.polloPes may require an endorsement.A statement on
this certificate does not confer rights to the Certificate.hnrder in lied of such endorsement(s).
PRODUCER. CONTAC .
MCGRiFF,.SE#BELS&WILLIAMS,INC. NAME:
3400 Overton Park Drive SE PHONE. rlg4 4.97:7500 F
Suite 300 AIC Na Ext' AIC No:.
E.MA L
Atlanta,GA 30339 ADDRESS:
INSURERS AFFORDING COVERAGE NAIC9'
INSURED
INSURER A:ACE American Insurance Corn an 22567
Kelly SeMoes Inc.and lt's,Subsldiades INSURER B:ACE Fire Underwriters Insurance Com an 20762
Troy.West Big Beaver Road INSURER c;lndemnl Insurance Cam an of Norih America
Tray,MI 415084 43575
9ranctllDept INSURER D,Federel Insurance Corn an
20289
INSURER6 ACB Pro and Casual lnsurence Corn 20698
INSURER F:
COVERAGES. CERTIFICATE.NUMI3ER:L5NX8QCrT RE11I5IDfJ NUMBER:
THIS IS TO.CERTIEY THAT THE ppLlCIES OF INSURANCE LISTS[].BELOW HAVE BEEWISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT CONTRACT OR.OTHER OOCUMFNT Wi7H RESPECT TO WHICH THIS
CE2TIRCATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEP0N.iS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS S1iOWN Iulgy i IAVir B[ct H REpUGED BY Pgla.CLAIMS,
INSR
LTR. TYPE OF INSURANCOL
E
Ns YYv POLICY NUMaER P POLICY EFF POLIO. P.
A LIMITS
X COMMERCIAL GENERAL LIABILITY HDO 67156629.8 � � `61!0112020 01/61/2621
$ 2,1100,000
CLAIM&MADE F OCCUR EACH OCCURRENCE
X Contractual LlablCty PREMISES @s occuRer Ge 5 2,DDD,060
MED EXP.(Any one poison) §: 5,000
PE1`ISONAL,%ADV INJURY g 2,000,000
GENT AGGREGATE L1MIF APPLIES PER:
X POLICY 1_1:JECT E LOC GENERALAGGREGArr .g. .2,000,000
OTHER:.
PRODUCTS.-roMP1OP AGG $: 2,0011.000
'A AUMMOA14ELIABILITY ISA 252 X143. S
01/01/2020 0910111021 COM81 ED SI GLE LIMIT
X ANY AUTO Ea accidan! 2;0(10,000
OWNED SCHEDULED BODILY INJURY(Parpersan) s
AUTOS ONLY
HIRED NO AUTOS
ZNEI] BODILY INJURY(Per Boddeni) S
AA ITOS.ONLY X AUT0S ONLY PROPERTY DAMAGE $
E )( UMBRELLA LIAB X OL�tlR U G2782413.Fi 0115 411D11262t7 01/01/2621 S
i-3rMS LIAR. CLAIMS-MADE EACH OCCURRENCE .g 15,000,060
AGGREGATE S 15,0.00,000
DELT. RETENTION$�.
13 A AN ID eERSyeRS,.COMPENSATION LR GG6922T49[[AZ;CA;MA] 0110112020. 01101126x3 PER arH- 5
AN ID ErrrPLaIERS'.L.lABIL1FY YIN CF C6682a189(WI X. T T R
arty PItaPRMTOwaARTNER LCUTNF WLR 066922820(AOS)
�FICERIMEMBER EXCLUDED? �N NIA, CU 066822868 E.L.EACH ACCIDENT g 1;00.6.000
(Mandatory In NH).
IF s,doscrl6e under. E,L.pISEA3E-EA EMPLOYEp 5 1,000,000
D SCRIPTION OF OPERATIONS vaim
D. CRIME 68018 744 E.L.DISEASE-POLICY LIMIT S 11000,00.0
Covers Employee Dishonesty(Theft) 01I611202D 61/01/2629 Each Loss 3,000,00
&Customer Protection ($USD} s
S
DESCRIPTION OF OPERATIONS 1.LOCATIONS IVEHICLES(ACORO ID1,AddltlorlatRam8ft Schadtk may be attanhed If more space Is.requirsd) §
Any provisions referenced on this Certlflcate of Insurance apply only as required by written contract; In.the.event of cancellation by insurance.Com an
Liability,Workers Compensation and Automobile Llabll R y{ies]the Genera!
Sty policy(ies}have been endo provide 36 days Natice of Cancellatlpn to the cerllficate holder shown below.
Evidence of Coverage
CERTIFICATE HOLDER CANCELLATION'
N
am. CLEARWATER GAS. SHOULD ANY OFTHEABOVE DESCRIBED POLICIES BE CANCELLED.SirFt]RE
Address THE EXPIRATION DATE THtEREOF, NOTICE WILL. BE .DELIVERED IN
777 MAPLE STREET ACCORDANCE WITH THE POLICY PROVISIONS,
ess 2:
AUTHORIZE]REPRESENFATi YE.
city.
Clearwater State: FC zlp.Code'33755
Page 1 of 2 ®1988-2(x155 ACORt CORPORATION. All.rights reserved.
,.0 Ke,^t]h gAlR Q1 1,)n
AGENCY CUSTOMER[Dt'
LDC#:
ACorte® ADDITIONAL REMARKS SCHEDULE. Page2of2
PR CEP .
MCGRIFF;SEEBELS&WII LIANAS,INC, NSU elly SREeOrvices Inc.and.It's Subsidiafts
PoucY NUMSER
CARRIER MAIC COW .
ISSUE DATE- 12r2W019
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORINT IS.A SCHEDULE TO ACORD FORM,
FORM NUMBER: FORM TITLE:
Coverage - Excess. workers compensation
Carrier - ACE Ameri:can. insurance.Compariy (NAIL Code 22667.).
P011:Cy # - WCU. C6G922858
Term = '1/1/x(324 - 1/1/2021
Limits. -
Each Accident $1,000,D00
Disease Policy Limit $1.000 coo
Disease Each.Employee $1,000,000
Coverage - Retro Workers Comnensatio-n
Carrier - ACE Fire Underwriters Insurance Company ("fd Code 20702)
Policy # - SCF C66922789
Term - 1/1/2020 - 1/1/2021
Limits -
Each Accident t1,000,000
Bisease Policy Limit $1,000;0.00
Disease. Each Employee $l;DoD,000
ACORD 101 t20081a I} 0 2008 ACORD CORPORATION. All rights reserved.
The:ACORD Warne and.logo are registered nnar.Ecs of ACORD CERTIFICATE NUMBER:L5NXBQQT