CERTIFICATE OF LIABILITY INSURANCE (1056) DATE(MM/DD/YYYY)
A�QCERTIFICATE OF LIABILITY INSURANCE® 01/04/2021
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
MCGRIFF,SEIBELS&WILLIAMS,INC. NAME:
P.O.Box 10265 A//®NN ExtJ7 800-476-2211 q/c N017
Birmingham,AL 35202 E-MAIL
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIL#
INSURER A:Associated Electric&Gas Insurance Services Limited
INSURED INSURER B:Liberty Mutual Fire Insurance Company 23035
Chesapeake Utilities Corporation including Marlin Gas Services
909 Silver Lake Blvd INSURER C:Liberty Insurance Cor oration 42404
Dover,DE 19904-2409
INSURER D
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:58VK86PW 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 TYPE OF INSURANCEADDLSUBR POLICY EFF POLICY EXP LIMITS
LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
B X COMMERCIAL GENERAL LIABILITY TB2-641-444639-030 09/01/2020 09/01/2021 EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ 100,000
MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X POLICY PRO LOC PRODUCTS-COMP/OP AGG $ 2,000,000
PRO-
OTHER: Time Element Pollution $ 1,000,000
B AUTOMOBILE LIABILITY S2-641-444639-010 09/01/2020 09/01/2021 COMBINEDSINGLELIMIT 1,000,000
Ea accident $
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNEDPROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
A UMBRELLA LAB OCCUR L5817802P 09/01/2020 09/01/2021 EACH OCCURRENCE $ 5,000,000
X EXCESS LIAB X CLAIMS-MADE AGGREGATE $ 5,000,000
DED RETENTION$ $
C WORKERS COMPENSATION A7-64D-444639-050 09/01/2020 09/01/2021 X PER OTH-
AND EMPLOYERS'LIABILITYY/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? N/A
(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 $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater AUTHORIZED REPRESENTATIVE
P.O. Box 4748 Clearwater,FL 33758d(d�
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