CERTIFICATE OF LIABILITY INSURANCE (1057) . � DATE(MMIDD?YYYY)
CERTIFICATE OF LIABILITY INSURANCE 11125/2020
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 N.OT CONSTITUTE A.CONTRACT BETWEEN THE ISSUING INSURERS),.AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT:It the:certificate holder is an ADDITIONAL INSURED,the policy(les)most have ADDITIONAL INSURED provisions or be endorsed.If L
SUBROGATION IS WANED,subject to the terms and conditions of the policy,Certain policies may requ€re an endorsement,A statement on this
certificate does not confer rights t4 the certificate holder In lieu of such endorsement(s).
PRODUCER CONTACT m
AonNAME:
Houston
Services Southwest, Inc. (866) 283-7122 PAX {800) .363-0105 �
IlOustoTXOffice (A1C.No.Ext): A1C. ,a
5.555 San Felipe E-MAIL 0
suite 1500 ADDRESS: �
Houston ix 7.7056 USA
INSURER(S)AFFORDING COVERAGE NAIC'#
INSURED INSURER A: Ironshore Specialty Tnsurance Company 25445
Trillium Transportation Fuels, LLC INSURER 3, ACE American 1psurancO company 22667
Pb Sox 26210
Oklahoma City 69.73126 USA INSURER C: Indemnity insurance'Ca. of North America. 43575
INSURER p, ACE Fire Underwriters Insurance Co. 20702
INSLIREREs Texas Insprance Company 16543
INSUIIERr: Westchester Fire Insurance Company 110030.
COVERAGES CERTIFICATE NUMBER:570085015633 REVISION NUMBER:
THIS.IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO.THE.INSURED NAMEDABOVE FOR THE POLICY PERIOD
INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CQNDITION 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 8HOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. Limits shown are as requested
NSFI AQDL!5UtIKj POLICY L1161' POLICY EXP
LTR TYPE OF INSURANCE INSD'NNP PDLICY NUTADERMUIDDIYYYYI MIODIYYY LIMITS
X COMMERCIAL GENERAL LIABILITY xSLG EACH OCCURRENCE 51,000,0oo
SIR applies per policy terris A conditions
CLAA45.MADE OCCUR PREMISES Ea occurcancel $1,:000,000
MED,EXP{Any ane para rjT
PERSONAL&ACV INSUSY $7.,060,000 m
0EN'LAGGREGATELIMITAPP_IE S.PER, GENERALAGGREGATE $8,000,000 1z
X POLICI ❑JECT LOC PROIDLTCTS=COMPiOP AGG S8,000,000 m
OTHER; o
r.
B. AUTOMOBILE LIABILITY Y 'Y ISA H?5313719 12/01/.202012/01/2021 COMB INEDSINGLE.LIMIT $5.;.000,000 �
'E21a 0 i enl)
X ANYAU`TQ 800ILYINJURY{Per prson)
OWNED SCHEDULED 9WILYINJURYweraccldeni) y
AUTOS ONLY AUTOS.
HIRF.DA11TOS NON-OWNED PROPERTYDAMAGE.
ONLY AUTOS ONLY
Pcraccidenil v
C1
E X LIMBRELLALIAa x I OCCUR TCOK20347a 12/01/2020 12 01/2023 EACHOCCURRENCE $117,000.00 U
EXCESS LAB rl CLAIMS-MADS 51R applies.per polity terns 6.condiiOnS AGGREGATE $15;OQQ,060
DEO I X I RETENTION
C WOR KE HIS COMPENSATION AND Y WLRC 7906487 12/01/2020 12/01/2021 2021 � PER STATUTE
H EMPLOYERS'LiAeILTrY Yi N Y WLRc.6780Wq 12/01/2020 12/01/2021 n
B
ANY.ICERWEMaF.RETOR I ECLIJOE I EXEC UTAl1E F Y SCFC67806566 12/01/2020 12/01/2021 E.L.EACH ACMDENT 51,000,000
OFFICER�hIEMSER�EXCLODE6? Hi A
(Mandnidry la NH) E.L.DISEASE-EA EMPLOYEE 51,006,.040
If'y ri.decribb undo'
.
0 SCRIPTIONOr 0PERATiONS be€dw E.L,DISEASE-POLICY LIMIT 51,000,000
A EhV Site Dab 042.568601 12/01/Z01S 12/01/2021 Aggregate $10,000,000--
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(AC ORO 161,Additional Remarks Scliodule.,may be mWrhed If mare space is required)
MC590 and. CA9948.are included on t.he.above. rEferenced..Automob-ile Liability ppolicy. Certificate Holder.is included as . .
Additional Insured in ac�ardance with.the policy rovisions of the Autn LTahility.and General Liability policies. k Waiver.af
subrogation is granted in favor of certificate Holder in accordance with the policy prpvisi.ons. of the workers Compensation,
auto Liability and General Liability .policies;
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCAIBED POLICIES BE .CANCELLED BEFORE THE.
EXPIRATION DATE THEREOF,NOTICE WALL BE DELIVEREO IN ACCORDANCE WITH THE s.
POLICY PROVAS10NS.
Clearwater Gas CNG Site AUT HPRtZEDREPRESENTATIVE
1020 N. Hercules AVerlue an
Clearwater FL 33755 USAi
01988-2015 ACORD CORPORATION-All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
0 DATE (MM/DD/YYYY)
CERTIFICATE OF PROPERTY INSURANCE LIT!/6/2D)2 YO
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.
PRODUCER GONTACT
NAME'
Ann Risk services southwest, Inc, PHONE
Houston TX Office .i(A�C. NO Ext): (866) 283--7122 (Zr.NOD (900) 363-0105
55155 San Felipe &MAIL
suite 1500 ADDRES1,;
PRODUCER
Houston Tx 77056 USA CUSTOMERW570000058326,
s,
INSUIREA(S)AFFORDING COVERAGE NAfC,#
INSURED INSURIERA: colony insurance company 39993
Trillium Transportation Fuels, LLC INSURER B.
INSURER C:
PO Box 10
klaboma City OK 73126 USA INSIMER D:
aNSURER E�
I INSuREn F;
CL)VERAGES 570085091518 R--VISION NUMBER:
LOCATION OF PREMMSt DESCRIPTION,OF PROPERTY(A"ach ACORD 101,Addifional Remarks Schedude,if mom Spam Is mquIrad)
BE' Clearwater Gas CNG Site, 1020 N. Hercules Ave., Clearwater, FL 33755.
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 00
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CD
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. 1-1
0)
INSA POLICY EFFECTIVE POLICY EXPIRATION a
LTR DATEiMM)DD
TYPE OF INSURANCE POLICY NUMBER /YYYY) DATE (MMiDDrfYYY) COVERED PROPERTY LIMIT$ Ln
BUILDING 0
A X pRopj�WIN BPRTZU=.
CAUSES OFLOSS DEDUCTIBLE$ PERSONAL PROPERTY LM
SASr, BUILDING 7BUSINESS INCOME id
BROAD
EXTRA EXPENSE LIJ
to
CONTENTS RENTAL VALUE
X SPECIAL
BLANKET BULDING z
EARTHOIJAKE ULI
BLANKET PERS PROP
WIND IR
X BLANKET SLOG PP v5=0.000 2
FLOOD U.
SIM B&PP Cad
X Loss bmk $,5,000,000
UJ
INLAND MARINE TYPE OF POLICY
CAUSES OF LOSS POUCY NUMBER
NAMED PERILS
CRIME
TYPE OF POLICY
BOILER&MACHINERY
EQUIPMENT BREAKDOWN
SPECIAL CONDITIONS I OTHER COVERAGES(ACORD 101,Addiflonel Rernaft Schedule,may be attached if moro space Is required)
CERTIFICATE HOLDER CANCELLATION
L.
7FITIV 1 M- SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY
PROVISIONS, R
Clearwater Gas CNG Site I I I�
1020 . Hecues AvenuDEC Zai�',"o
ClearwNaterrFLl33755 USAe AUTHORIZED REPRESENTATIVE
GAS AWN
0 1995-20,15 ACORD CORPORATION. All rights reserved,
ACORIA 24(201,6103) The ACORD name and logo are registered marks of ACORD