CERTIFICATE OF LIABILITY INSURANCE (1030) _ Ben Brown Insurance Agency
AC R® CERTIFICATE OF LIABILITY INSURANCE °A `MIS°°'YYYY'
' 07/28/2020
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATF HOI DFR_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 NAME CT Jessica Beivitch-Certificates
Ben Brown Insurance Agency PHONE (941)487-3502 FAx (941)365-3143
AtC No Ext A1C,No:
3731 S Tuttle Ave E-MAIL certificates@benbrownins.com
ADDRESS
INSURERS)AFFORDING COVERAGE NAIC 0
Sarasota FL 34239-6410 INSURERA: GuideOne National Ins Co 14167
INSURED INSURER B: Auto-Owners Insurance Co 18988
J W Harris Contractors,Inc. INSURER C: Evanston Ins Co 35378
Zephryhills -FL 33540 INSURER F•
COVERAGES CERTIFICATE NUMBER: 19/BA,BAXS 20/GL,GLXS 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAYBE ISSUED OR MAY PERTAIN,THE INSURANCEAFFORDED 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 POLICY FF POLICY EXP
LTR INSD WVD POLICY NUMBER MMIDD MMIOD LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE �OCCUR DANAREMISEE S To
Ea occurrence) $
RFoo .O 50,000
P .
MED EXP(Any one person) $ 5,000
A Y 563000001-00 08/02/2020 08/02/2021 -PERSONAL&ADV INJURY $ 1,000,000
GEMLAGGREGATE LIMITAPPLIES PER. GENERALAGGREGATE Is 2,000,000
r•rcw
POLICY JECT r_1 LOC PRODUCTS-COMPlOPAGG $ L,vuv,uuu
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea acddent
X ANY AUTO BODILY INJURY(Per person) $
B OWNED SCHEDULED Y 5142469400 10101/2019 10/01/2020 BODILY INJURY(Per acc lent) S
AUTOS ONLY AUTOS
HIRED X NON-OWNED PROPERTY DAMAGE
x AUTOS ONLY AUTOS ONLY (Per.
Per acddent $
PIR 10,000 $
UMBRELLA LIAR X1 OCCUR EACH OCCURRENCE $ 4,000,000
C x EXCESSLUIB CLAIMS-MADE MKLV2EUL104140 08/02/2020 08/02/2021 AGGREGATE $ 4,000,000
DED RETENTION$ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY Y!N STATUTE ER
ANY PROPRIETOR/PARTNERIEXECUTIVE ❑ NIA E.L.EACH ACCIDENT $
OFFICERIMEMBER EXCLUDED?
(Mandatory in NH) E DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E:L.DISEASE-POLICY LIMIT $
Excess Auto -
Aggregate 11000,000
-u ._ LUt,1oiyt34oA19NF(Auto) Tuluir2tmf 1U1u1/2u2i7 OCcurrance 1,000,UUV
DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more,space is required)
Mobile Welding and Underground Installation.-Additional insured coverage provided for ongoing and completed operations(performs CG 201004/13&CG
2037 04/13)on a primary and non-contributory basis(per form CG 200104/13)with regard to the general liability policy as required by written contract.The
auto policy also provides additional insured coverage,on a primary and non-contributory basis,perform 58540 01115.Excess policies:One follows form
over the Gland the other over the auto liability.Copies of all endorsements are available upon request.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
City of Clearwater Administrative Offices and ACCORDANCE WITH THE POLICY PROVISIONS.
South Area Service Center
400 North Myrtle Ave AUTHORIZED REPRESENTATIVE
Clearwater FL 33755 &Mmw A"
fi1 dQttR_?A4A dRADrI 1"nDD!'fD XnAh1 A11«..Nle...e,,......i
Ben Brown Insurance Agency
Fax
v
To: City of Clearwater Administrative Offices and
Fax: 7275624902
T
From: Jessica
Phone: (941)487-3502
Email: Jessica@BenBrownins.com
Date: 7/28/2020 1:46 PM
Subject: JW Harris Contractors excess liability renewal certificate
Memo:
Good afternoon,
.
This is the excess liability policies renewal certificate of insurance
on behalf of JW Harris Contractors, Inc. for your records.
T
All policies managed by our agency are shown on this form.
.
If you have any questions, or need revisions, please respond directly
to Certifi4atgsfibenbrownins.com. our certificate danartmont_ and