CERTIFICATE OF LIABILITY INSURANCE - RFQ 26-19 (17) DATE(MM/DD/YYYY)
A�"® CERTIFICATE OF LIABILITY INSURANCE
10/05/2020
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 Vicky Van Wormer
NAME:
Brown&Brown of Florida,Inc. (APHExt): (727)461-6044 a/c,No): (727)442-4695
Pinellas Division E-MAIL vvanwormer@bbpinellas.com
ADDRESS:
83 Park Place Blvd,Suite 101 INSURER(S)AFFORDING COVERAGE NAIC#
Clearwater FL 33759 INSURERA: The Charter Oak Fire Insurance Company 25615
INSURED INSURER B: The Travelers Indemnity Company ofAmerica 25666
Kisinger Campo&Assoc.Corp. KCCS,Inc. INSURER C: Travelers Property Casualty Company of America 25674
Campo&Associates,PLLC INSURER D: Travelers Casualty and Surety Company 19038
201 N Franklin St,Suite 400 INSURER E: Admiral Insurance Company 24856
Tampa FL 33602 INSURER F:
COVERAGES CERTIFICATE NUMBER: X20-21 Standard 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
N"" ence $ 300,000
Contractual MED EXP(Any one person) $ 10,000
A X XCU Included Y 6308254A604 10/01/2020 10/01/2021 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 X OWNED SCHEDULED Y 8105N338364 10/01/2020 10/01/2021 BODI LY I NJ U RY(Pe r accide nt) $
AUTOS ONLY AUTOS
HIRED NON-OWNEDPROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
UMBRELLA LIAB XOCCUR EACH OCCURRENCE $ 4'000'000
C EXCESS LIAB CLAIMS-MADE CUP7J748484 10/01/2020 10/01/2021 AGGREGATE $ 4'000'000
DED I X1 RETENTION $ 10'000 $
WORKERS COMPENSATIONP
v/N ER OTH-
AND EMPLOYERS'LIABILITY STATUTE ER
500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
D OFFICER/MEMBER EXCLUDED? N/A UB7J070308 10/03/2020 10/03/2021
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under 500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
Professional Liability Claims Made Per Claim 5,000,000
E Retro Date 11/02/2014 E000002720507 10/01/2020 10/01/2021 Aggregate 5,000,000
Deductible 250,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Certificate holder is an additional insured with respect to general liability,auto liability and umbrella liability. Endorsements available upon request.Waiver of
Subrogation applies to general liability and workers compensation&employers liability.Explosion,Collapse&Underground hazard included in CGL.
Project: Professional services under Engineer of Record Agreement RFQ#26-19 and all Task Work Orders issued thereunder.A thirty-day written notice of
cancellation shall be provided,with the exception of ten-day notice for non-payment of premium.(KCA Project#6201908.00)
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 Engineering, RFQ#26-19 ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 4748
AUTHORIZED REPRESENTATIVE
Clearwater FL 33758-4748
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