MS WRF BLEND TANK MIXER - 18-0057-UT - CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 11/13/2020
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 pollcy(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 1-813-229-8021 CONTACT
NAME: Diana Defreeuw
M. E. Wilson Company, LLC PHONE FAX
A/C No Ext: 813-984-3619 A/C,No: 813-434-2492
E-MAIL ddefreeuw@mewilson.com
300 W. Platt St. ADDRESS:
Ste 200 INSURER(S)AFFORDING COVERAGE NAIC#
Tampa, FL 33606 INSURERA: WESTFIELD INS CO 24112
INSURED INSURER B: BRIDGEFIELD EMPLOYERS INS CO 10701
TLC Diversified, Inc. INSURER G: TRAVELERS PROP CAS CO OF AMER 25674
2719 17th Street East INSURERD:
INSURER E
Palmetto, FL 34221 INSURERF:
COVERAGES CERTIFICATE NUMBER: 60729639 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 INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A X COMMERCIAL GENERAL LIABILITY TRA3972460 04/01/20 04/01/21 EACH OCCURRENCE $ 1,000,000
�
OCCUR DAMAGE TO RENTED
CLAIMS-MADE
PREMISES Ea occurrence $ 500,000
X Contractual Liability MED EXP(Any one person) $ 5,000
X $500 Prop Dmg Ded PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
POLICY PRO X❑ LOC PRODUCTS-COMP/OPAGG $ 2,000,000
JECT
OTHER: $
A AUTOMOBILE LIABILITY TRA3972460 04/01/20 04/01/21 COMBINED S INGLE LIMIT $ 1,000,000
Ea accident
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
X HIREDX NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
A X UMBRELLALIAB OCCUR TRA3972460 04/01/20 04/01/21 EACH OCCURRENCE $ 5,000,000
EXCESS LABX CLAIMS-MADE AGGREGATE $ 5,000,000
DED X RETENTION$ 0 $
B WORKERS COMPENSATION 83055326 04/01/20 04/01/21 X STATUTE ER
AND EMPLOYERS'LIABILITY
ANYPROPRIETOR/PARTNER/EXECUTIVE N/A E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED?
(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 $
C Installation Floater QT6605N309215TIL19 07/01/19 04/01/21 $5,000 Ded 1,000,000
Transit & Storage: 1,000,000
Deductible: 5,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
MS WRF Blend Tank Mixer/Contract No. 18-0057-UT/ TLC sob No. 2025
City of Clearwater and Certificate Holder are Additional Insured. Thirty (30 Days written notice of any cancellation,
non-renewal, termination, material change or reduction in coverage will be sent to Certificate Holder below.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Engineering Department ACCORDANCE WITH THE POLICY PROVISIONS.
Construction Office Specialist
P.O. Box 4748 AUTHORIZED REPRESENTATIVE
Clearwater, FL 33758-4748 v� >
USA
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
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60729639