CERTIFICATE OF LIABILITY INSURANCE (1023) DATE(MM/DD/YYYY)
A�"® CERTIFICATE OF LIABILITY INSURANCE
07/17/2020
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 Certificate Department
NAME:
Single Source Insurance (APHExt): (727)298-0302 a/c,No): (727)298-0029
2189 Cleveland Street E-MAIL certificates@singlesourceins.com
ADDRESS:
Unit 235 INSURER(S)AFFORDING COVERAGE NAIC#
Clearwater FL 33765 INSURERA: Blackboard Insurance Company 26611
INSURED INSURER B: Ascendant Insurance Solutions
Tampa Bay Plumbing, LLC INSURER C: New Hampshire Insurance Company 23841
613 S Missouri Ave. INSURER D: Technology Insurance Cc 42376
INSURER E: GreatAmerican Insurance Company 16691
Clearwater FL 33756 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL2071711247 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 ADDLSUBR TYPE OF INSURANCE POLICY EFF POLICY EXP
LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000
DAMAGE TO
CLAIMS-MADE ❑OCCUR _PREMISES
Ea oRENTED
""ence $ 100,000
MED EXP(Any one person) $ 5,000
A Y Y SINGLES100001HIBP-47257 07/19/2020 07/19/2021 PERSONAL&ADV INJURY $ Included
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000
POLICY ❑ PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000
PRO-
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANYAUTO BODILY INJURY(Per person) $
B OWNED SCHEDULED Y Y CA-52995-0 07/19/2020 07/19/2021 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNEDPROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
Uninsured motorist $ 100,000
UMBRELLA LIAB XiZ'" 'Vu_R"'y'V" 1,000,000
OCCUR EACH OCCURRENCE $
C EXCESS LIAB CLAIMS-MADE 043749347 07/19/2020 07/19/2021 AGGREGATE $ 1'000'000
DED I I RETENTION $ $
WORKERS COMPENSATION X1 PER OTH-
AND EMPLOYERS'LIABILITY v/N STATUTE ER
1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
D OFFICER/MEMBER EXCLUDED? ❑ N/A Y TWC3886470 07/19/2020 07/19/2021
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
Inland Marine Scheduled Equipment $42,158
E TBA 07/19/2020 07/19/2021 Miscellaneous Tools $112,000
Deductible $2,500
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Coverages continued:(D)Insurer: Lloyd's of London-Policy#AN E4333017//Eff-Exp: 11/20/2019-11/20/2020 Professional Liability: Each Claim$1,000,000
Total Policy Aggregate$1,000,000
Certificate Holder included as Additional Insured by written contract with regards to General Liability&Automobile Liability. Primary&Non-Contributory
Wording Included.Certificate Holder listed in favor of Waiver of Subrogation by written contract with regards to General Liability,Automobile Liability&
Workers Compensation.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Clearwater Gas System ACCORDANCE WITH THE POLICY PROVISIONS.
400 N Myrtle Ave
AUTHORIZED REPRESENTATIVE
Clearwater FL 33755 �)C � (y
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