CERTIFICATE OF LIABILITY INSURANCE (1094) DATE(MM/DD/YYYY)
A�"® CERTIFICATE OF LIABILITY INSURANCE
10/01/2020
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 Jessica Belvitch-Certificates
NAME:
Ben Brown Insurance Agency A CONE,N Ext): (941)487-3502 A C,No): (941)365-3143
3731 S Tuttle Ave E-MAIL certificates@benbrownins.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Sarasota FL 34239-6410 INSURERA: Guide One National Ins Cc 14167
INSURED INSURER B: National Indemnity Company of the South 42137
J W Harris Contractors,Inc. INSURER C: Evanston Ins Cc 35378
3448 Crystal Springs Rd. INSURER D: Underwriters at Lloyds, London
INSURER E:
Zephryhills FL 33540 INSURER F:
COVERAGES CERTIFICATE NUMBER: 20/All 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 oTED
Ncurrrence $ 50,000
MED EXP(Any one person) $ 5,000
A Y 563000001-00 08/02/2020 08/02/2021 PERSONAL&ADV INJURY $ 1'000'000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2'000'000
POLICY ❑ PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANYAUTO BODILY INJURY(Per person) $
B OWNED SCHEDULED Y 74APBOO4195(GL) 10/01/2020 10/01/2021 BODILY INJURY(Peraccident) $
AUTOS ONLY AUTOS
HIRED NON-OWNEDPROPERTY DAMAGE $
AUTOS ONLY NX AUTOS ONLY Per accident
PIP 10,000 $
UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4'000'000
C EXCESS LIAB CLAIMS-MADE MKLV2EUL104140 08/02/2020 08/02/2021 AGGREGATE $ 4'000'000
DED I I RETENTION $ $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVEF-1N IA E.L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
Excess Auto Liability
D SCT1134920 10/01/2020 10/01/2021 Aggregate 1,000,000
Per Occurrence 1,000,000
DESCRIPTION OF OPERATIONS/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(per forms CG 2010 04/13&CG
2037 04/13)on a primary and non-contributory basis(perform CG 2001 04/13)with regard to the general liability policy as required by written contract.The
auto policy also provides additional insured coverage per form M-3745 07/86.Excess policies:One follows form over the GL and 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
AUTHORIZED REPRESENTATIVE
400 North Myrtle Ave
Clearwater FL 33755
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