CERTIFICATE OF LIABILITY INSURANCE (568) E!E(MM/DD/YYYY)
ACORU®
2/2/2021
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
NAME: Tina Cardinale
Adcock-Adcock Insurance Agency PHONEFAX
315 W. Fletcher Ave. A/c No,
Ext): 813.933.6691 A/C,No):
Tampa FL 33612-3414
E-MAIL
tinar@adcock-insurance.com
INSURER(S)AFFORDING COVERAGE NAIL#
INSURERA: Southern-Owners Insurance Co. 10190
INSURED 37861 INSURER B: Bridgefield Employers Ins Co 10701
KPI Engineering Inc.
3203 Queen Palm Drive INSURER C: National Casualty Company 11991
Tampa FL 33619 INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:681809209 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 INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A X COMMERCIAL GENERAL LIABILITY 20693312 2/1/2021 2/1/2022 EACH OCCURRENCE $1,000,000
CLAIMS-MADE OCCUR DAMAGE TO RENTED
PREMISES Ea occurrence $300,000
MED EXP(Any one person) $10,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
PRO-
POLICY ❑ LOC PRODUCTS-COMP/OP AGG $2,000,000
X JECT
OTHER: $
A AUTOMOBILE LIABILITY 20693312 2/1/2021 2/1/2022 COMBINED SINGLE LIMIT $1,000,000
Ea accident
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 UMBRELLA LAB X OCCUR 4711820001 2/1/2021 2/1/2022 EACH OCCURRENCE $4,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $4,000,000
DED X RETENTION$ $
B WORKERS COMPENSATION 83052197 1/15/2021 1/15/2022 X PERUTE OTH-
AND EMPLOYERS'LIABILITY Y/N STATER
ANYPROPRIETOR/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
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
C Professional Liability JE00000108 10/25/2020 10/25/2021 Aggregate Limit 3,000,000
Each Claim 3,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
City of Clearwater is named as Additional Insured under General Liability per Additional Insured form#55202,attached, if terms/requirements are met and
subject to all policy conditions,wording,terms,etc. General Liability policy includes a Blanket Wavier of Subrogation, per form#55091,attached, if
terms/requirements are met and subject to all policy conditions,wording,terms,etc.Workers Compensation policy includes Blanket Waiver of Subrogation, per
form WC000313,attached, if terms/requirements are met and subject to all policy conditions,wording,terms,etc.
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
P.O Box 4748
Clearwater FL 33758 AUTHORIZED REPRESENTATIVE
O 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
Agency Code 12-0004-00 Policy Number 072312-20693312
COMMERCIAL GENERAL LIABILITY
55091 (1 - )
CAREFULLY.THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT
COMMERCIAL GENERAL LIABILITY PLUS
ENDORSEMENT
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
1. EXTENDED WATERCRAFT LIABILITY Exclusions
Under SECTION I-COVERAGES, COVERAGE A. With respect to only HIRED AUT
NON-
BODILY INJURY P AUTO LIABILITY, the exclusions which
LIABILITY,2. Exclusions, g., exclusion ( ) is apply to SECTION I-COVERAGES, COVERAGE
deleted and is replaced by the following: A. BODILY INJURY
LIABILITY, other than the Nuclear Energy Liability
( ) A watercraft you do not own that is: Exclusion Endorsement, do not apply. The following
exclusions apply to this coverage:
( ) Less than 50 feet long; and
( ) Not being used to carry persons or This coverage does not apply to:
property for a charge;
. "Bodily injury' or"property damage" expected or
. HIRED AUT AUTO intended from the standpoint of the insured.
LIABILITY This exclusion does not apply to "bodily injury"
resulting from the use of reasonable force to
Coverage for"bodily injury" and "property damage" protect persons or property.
liability provided under SECTION I COVERAGES,
COVERAGE A. BODILY INJURY . Any obligation of the insured under a workers
DAMAGE LIABILITY, is extended as follows under compensation, disability benefits or unemploy-
this item, but only if you do not have any other ment compensation law or any similar law.
insurance available to you which affords the same or
similar coverage. c. (1) "Bodily injury" or"property damage" arising
out of the actual, alleged or threatened
Coverage discharge, dispersal, seepage, migration,
release or escape of"pollutants":
We will pay those sums the insured becomes legally
obligated to pay as damages because of"bodily (a) That are, or are contained in any
injury" or"property damage" arising out of the main- property that is:
tenance or use of an "auto":
1) Being transported or towed by,
a. You do not own; handled or prepared for placement
. Which is not registered in your name; or into or upon, or taken from the
c. Which is not leased or rented to you for more °'auto";
than ninety consecutive days
) Otherwise in the course of transit by
and which is used in your business. you or on your behalf; or
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55091 (10-08) Copyright Insurance Services Office, Inc., 1982, 1988, 2002, 2004 Page 1 of 7
Agency Code 12-0004-00 Policy Number 072312a0583312
3) Being disposed of, stored, treated or (1) War, including undeclared orcivil war:
processed into orupon the ''auho^;
(2) Warlike action byamilitary force, including
(b) Before such "poUutants" orproperty con- action inhindering ordefending against an
taining "pollutants" are moved from the actual or expected attack byany govern-
place they are accepted by you or ment' sovereign orother authority using
anyone acting onyour behalf for military personnel orother agents; or
placement into or onto the "auto"; or
(3) Insurrection, rebellion, revolution, usurped
(o) After such "pollutants" or property power, or action taken by governmental
containing ^poUutan1s'' are removed authority inhindering ordefending against
from the "auto" tuwhere they are any ofthese.
delivered, disposed oforabandoned by
you oranyone acting inyour behalf. e. "Bodily injury' or"property damage"for which
the insured isobligated topay damages by
c. (1) (a)above does not apply to"poUu- reason ofthe assumption ofliability inacontract
tants"that are needed orresult from the or agreement. This exclusion does not apply to
normal mechanical, electrical orhydraulic liability for damages:
functioning of the "auto" or its parts, if the
discharge, release, escape, seepage, (1) Assumed inacontract oragreement that is
migration ordispersal ofsuch "pollutants" is an "insured contnac1^, provided the "bodily
directly from apart ofthe "auto" designed\o injury" or"property damage" occurs subse-
hold, store, receive or dispose of such quent10the execution ofthe contract or
"pollutants" by the "auto" manufacturer. agreement. However, if the insurance under
this policy does not apply tothe liability of
c' (1) (6) and c. (1) (c) above donot apply, the insured, italso does not apply tmsuch
ifasadirect result ofmaintenance oruse of liability assumed bythe insured under an
the "auto". "poUutants" orproperty contain- "insured contract".
ing "poUutan1s"which are not inorupon the
^auto''' are upset, overturned ordamaged a1 (2) That the insured would have inthe absence
any premises not owned byorleased\o of the contract or agreement.
you. The discharge, release, escape,
seepage, migration or dispersal of the f. "Property damage" to:
^poUutants^ must bedirectly caused bysuch
upset, overturn ordamage. (1) Property owned orbeing transported by, or
rented orloaned\many insuned� or
(2) Any loss, cost orexpense arising out ofany:
(2) Property inthe care, custody orcontrol mf
(a) Request, demand ororder that any any insured other than "property damage"to
insured orothers test for, monitor, clean aresidence oraprivate garage byaprivate
up, remove, contain, treat, detoxify or passenger"auto" covered by this coverage.
neutralize, mrinany way respond to, or
assess the effects of°poUutants°; or g. "Bodily injury" to:
(b) Claim or"suit' byoronbehalf ofagov- (1) Ao "empkoyee" ofthe insured arising out of
emmenta|authority for damages be- and inthe course ofemployment bythe
cause oftesting for, monitohng, cleaning insured; or
up' removing, containing, treating,
detoxifying or neutralizing, or in anyway (2) The spouse, chi|d, panent, brother orsister
responding ho. orassessing the effects ofthat"emp|oyee"as a consequence of
of"pollutants". Paragraph (1) above.
d. "Bodily injury' or"property damage" however This exclusion applies:
caused, arising directly orindirectly, out of:
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Agency Code 12-0004-00 Policy Number 072312a0583312
(1) Whether the insured may be liable as an b. Any person using the "auto" and any person
employer orinany other capacity; and other than you, legally responsible for its use
with respect to an ''auto" owned or registered in
(2) Toany obligation toshare damages with or the name of:
repay someone else who must pay dam-
ages because ofthe injury. (1) Such person; or
This exclusion does not apply to: (2) Any partner or"executive officer" ofyours or
amember ofhis orher household; or
(1) Liability assumed bythe insured under an
"insured contrac1" (3) Any''emp|oyee^ oragent ofyours who is
granted anoperating allowance ofany sort
(2) "Bodily injury" 0oany''emp|oyee^ ofthe in- for the use ofsuch ^auto^
suredarising out ofand inthe course ofhis
domestic employment bythe insured unless c. Any person while employed inorotherwise
benefits for such injury are inwhole orin engaged induties inconnection with an "auto
part either payable orrequired tobepro- buoiness". other than an "auto business"you
videdunder any workers compensation law. operate.
Who 8sAnInsured d. The owner or lessee (of whom you are a sub-
lessee) of a hired "auto" or the owner of an
With respect to only this coverage, SECTION UU - "auto"you do not own or which is not registered
WHO ISANINSURED, isdeleted and replaced by inyour name which isused inyour business or
the following: any agent oremployee ofany such owner or
lessee.
SECTUONNU-VVHO IS AN INSURED
e. Any person ororganization with respect tothe
Each ofthe following isaninsured with respect to conduct of any current or past partnership or
this coverage: joint venture that is not shown as a Named
Insured inthe Declarations.
a' You.
Additional Definitions
b. Your partners ifyou are designated inthe
Declarations asapartnership orajoint venture. The following definition applies 1monly this coverage:
c' Your members if you are designated in the "Auto business" means the business or occupation
Declarations asalimited liability company. ofselling, repairing, servicing, storing orparking
"autos".
d. Your"executive officers" if you are designated in
the Declarations asenorganization other than a Limits mfInsurance
partnership,joint venture orlimited liability
company. With respect to only this coverage' SECTION I88-
LIMITS OF 8NSURANCE, is deleted and replaced
e' Any person using the "auto" and any person or by the following:
organization legally responsible for the use ofon
"auto" not owned by such person ororganiza- SECTION I88~ LIMITS OF INSURANCE
tion, provided the actual use iswith your permia-
sion. a. The Limits of Insurance shown in the Declara-
tions and the rules below fix the most we will
None mfthe following isaninsured: pay regardless ofthe number of:
a' Any person engaged inthe business mfhis or (1) Insureds;
her employer with respect 10 "bodily injury"to
any co-"emp|oyee" ofsuch person injured inthe (2) Claims made or"sui<s" brought; ur
course ofemployment.
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Agency Code 12-0004-00 Policy Number 072312a0583312
(3) Persons ororganizations making claims or isnot attached tothis policy, then the following is
bringing ^suks" added 0oSECTION III ~LIMITS OF INSURANCE:
6. VVewill pay damages for"bodily injury" or Commencing with the effective date ofthis policy,
"property damage" upbothe limits ofliability wewill provide one additional Products-Completed
stated inthe Declarations for this coverage. Operations Aggregate Limit,for each annual period,
Such damages shall bepaid zsfollows: equal tothe amount ofthe Products-Completed
Operations Aggregate Limit shown inthe Dedana-
(1) When Hired Auto and Non-Owned Auto duns. The maximum Products-Completed Opera-
Each Occurrence Limit isshown inthe tions Aggregate Limit for any annual period will be
Declarations, such limit isthe total amount nomore than two times the original Products-
of coverageandthemostwewiUpayforaU Completed Operations Aggregate Limit.
damages because oforarising out cfall
"bodily injury" and "property damage" inany 5. PERSONAL INJURY EXTENSION
one "occurrence".
a. |fthe endorsement EXCLUSION - PERSONAL
(2) When Bodily Injury Hired Auto and Non- INJURY AND ADVERTISING INJURY, 5535U.
Owned Auto Each Occurrence Limit and isattached tothis policy, then this provision, 5.
Property Damage Hired Auto and Non- PERSONAL INJURY EXTENSION, does not
Owned Auto Each Occurrence Limit are apply.
shown inthe Declarations:
6. |fthe endorsement EXCLUSION - PERSONAL
(a) The limit shown for Bodily Injury Hired INJURY AND ADVERTISING INJURY, 5S35O.
Auto and Non-Owned Auto Each Occur- isnot attached tmthis policy, then under SEC-
rence is the total amount ofcoverage TION V-DEFINITIONS, 15' "Personal injury" is
and the most wewill pay for all dam- deleted and replaced bythe following:
ages because mfmrarising out ofall
"bodily injury" inany one "occunence" 15. "Personal injury" means, other than "bodily
injur/', arising out ofone ormore ofthe
(b) The limit shown for Property Damage following offenses:
Hired Auto and Non-Owned Auto Each
Occurrence isthe total amount ofcover- a. False arrest, detention orimprisonment;
age and the most wewill pay for all
damages because ofmrarising out ofall b. Malicious prosecution;
"property damage" inany one "occur-
rence".
occur-vence" c. The wrongful eviction from, wrongful
entry into, orinvasion mfthe right of
3. BROADENED SUPPLEMENTARY PAYMENTS private occupancy ofaroom, dwelling or
premises that a person occupies by or
Under SECTION 8 ~COVERAGES, COVERAGE A. onbehalf ofits owner, landlord or
BODILY INJURY AND PROPERTY DAMAGE lessor-,
LIABILITY, COVERAGE B. PERSONAL INJURY
AND ADVERTISING INJURY LIABILITY and d. oral orwritten publication ofmaterial
SUPPLEMENTARY PAYMENTS~COVERAGES A that slanders orlibels aperson oror-
AND B: ganizationordisparages aperson's mr
organization's goods, products mr
Paragraph 4.. the amount vvewill pay for the actual sen/ices;
loss ofearnings isincreased from $250per day to
$400 per day. e. Oral or written publication of material
thatvio|atesa person's right ofprivacy;
4. ADDITIONAL PRODUCTS-COMPLETED or
OPERATIONS AGGREGATE LIMIT
f. Discrimination, humiliation, sexual
If the endorsement. EXCLUSION - PRODUCTS harassment and any violation of civil
COMPLETED OPERATIONS HAZARD, CG21 04. rights caused bysuch discrimination,
humiliation orsexual harassment.
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55091 (10-08) Copyright Insurance Services Office, |nc' 1y82. 1g88. 2OO2. 2OO4 Page 4of7
Agency Code 12-0004-00 Policy Number 872312-20693312
G. BROADENED KNOWLEDGE OF OCCURRENCE (2) "Property damage"caused byorresulting
from any ofthe following:
Under SECTION IV~COMMERCIAL GENERAL
LIABILITY CONDITIONS, 2. Duties 8nThe Event (a) Mechanical breakdown, including
OfOccurrence, Offense,Claim OrSuit,the follow- bursting orrupture caused bycen-
ingparagraph isadded: trifuga|fonce;
Paragraphs a. and b.of this condition will not serve (b) Cnadking, settling, expansion or
todeny any claim for failure toprovide uowith notice shrinking;
assoon aspracticable after on "occurrcncc" oran
offense which may result in o claim: (c) Smoke orsmog:
a' |fthe notice ofanew claim isgiven toyour (d) Birds, insects, rodents orother ani-
^emp|oyee''; and mals:
6. That"emp|uyee"fails 0oprovide uswith notice (e) Wear and tear;
as soon as practicable.
(f) Corrosion, rust, decay, fungus, dete-
Thisexception shall not apply: nouation. hidden orlatent defect orany
quality inproperty that causes such
a' Toyou; or property todestroy ordamage itself; or
b. To any officer, dinector, partner, risk manager or (g) Water that flows or leaks from any
insurance manager ofyours. heating, air conditioning, plumbing mrfire
protection system caused byorresulting
7. DAMAGE TOPREMISES RENTED TO YOU from freezing, unless:
Under SECTION 8 ~COVERAGES, COVERAGE A. 1) You make areasonable effort to
BODILY INJURY AND PROPERTY DAyNAGEL8A- maintain heat inthe building or
B8LQTY. the last paragraph is deleted and replaced stnucture� or
bythe following:
2) You drain the equipment and shut
Exclusions c.through n. do not apply to damage by off the water supply if the heat is not
fire, lightning, explosion, smoke orwater damage to maintained.
premises rented toyou ortemporarily occupied by
you with permission ofthe owner. Aseparate limit (3) "Property damage" caused directly or
ofinsurance applies tothis coverage asdescribed in indirectly byany ofthe following:
7. DAMAGE TO PREMISES RENTED TO YOU, a.
Limits of Insurance. (a) Water that backs up from a drain or
sewer;
The following additional exclusions apply to "pro-
perty damage" arising out of Water Damage to (b) Mud flow ormudslide;
premises rented toyou mrtemporarily occupied by
you with permission ofthe owner: (c) Volcanic eruption, explosion mreffusion�
(1) "Property damage"to: (6) Any earth movement, such asearth-
quake. landslide, mine subsidence,
(a) The interior ofthe premises caused by earth sinking, earth rising orearth
orresulting from rain mrsnow, whether shifting;
driven by wind or not; or
(e) Regardless mfthe cause, flood, surface
(b) Heahng, air conditioning, plumbing or water, vvaves, tidcs, tidal waves, storm
fire protection systems, orother equip- surge, overflow ofany body ofwater, or
men1orappliances. their spray, all whether wind driven or
not;
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55091 (10-08) Copyright Insurance Services Office, |nc.' 1982. 1988. 28O2. 20U4 Page 5of7
Agency Code 12-0004-00 Policy Number 072312a0583312
ND Water under the ground surface insured only ifaCertificate ofInsurance was
pressing on, or seeping or flowing issued prior to loss indicating that the
through: person ororganization was anadditional
insured
1) Walls, foundations, floors orpaved
surfaces; but only with respect toliability for:
2) Basements, whether paved or not;
or (1) "Bodily injury";
3) Doors,windows orother openings. (2) "Property damage";
(3) "Personal injury"; or
(4) "Property damage" for which the insured is (4) "Advertising injury"
obligated topay asdamages byreason of
the assumption ofliability inacontract or caused inwhole orinpart, byyour maintenance,
agreement. This exclusion does not apply operation oruse ofequipment leased tuyou by
toliability for damages that the insured such person ororganization.
would have in the absence of this contract
or agreement. b. With respect 0othe insurance afforded toam
additional insured, this insurance does not apply
a' Limits of Insurance tmany"occurrenoe"which takes place after the
equipment lease expires.
With respect tothis coverage only, under
SECTION INN ~LIMITS 0FINSURANCE, c. The following is added to SECTION 88I~ LIMITS
paragraph 6. isdeleted and replaced bythe OF INSURANCE:
following:
The Limits ofInsurance for the additional in-
6. The most wewill pay under Coverage Afor sunedare those specified inthe written contract
damages because nf"property damage"to oragreement between the insured and the
premises rented to you or temporarily |essor, not to exceed the limits provided in this
occupied byyou with permission ofthe policy. These limits are inclusive ofand not in
owner arising out mforcaused byfire, addition tothe Limits ofInsurance shown inthe
lightning, explosion, smoke and water Declarations.
damage isthe amount shown inthe
Declarations under Damage 1oPremises 9. BLANKET ADDITIONAL INSURED - MANAGERS
Rented toYou. OR LESSORS OF PREMISES
b. Under SECTION IV-COMMERCIAL GEN- a. SECTION III-WHO ISAN INSURED is
ERALLIABILITY CONDITIONS, 4' Other amended toinclude asanadditional insured any
8nsunance, paragraph b., the word fire is person or organization with whom you have
amended toinclude fire, lightning, explosion, agreed:
smoke or water damage.
(1) |nawritten contract oragreement, executed
8. BLANKET ADDITIONAL INSURED~LESSOR OF prior 10loss,toname asanadditional
LEASED EQUIPMENT insured; or
a' SECTION III-WHO IS AN INSURED is (2) |nanoral contract oragreement, executed
amended toinclude asanadditional insured any prior toloss,toname asanadditional
person ororganization with whom you have insured only ifaCertificate ofInsurance was
agreed: issued prior to loss indicating that the
person ororganization was anadditional
(1) |nowritten contract oragreement, executed insured
prior toloss, toname asonadditional
insuned� or but only with respect 10liability arising out ofthe
ownership, maintenance oruse ofthat part of
(2) |nonoral contract oragreement, executed the premises leased toyou.
prior toloss, toname asanadditional
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Agency Code 12-0004-00 Policy Number 072312a0583312
b. This provision issubject bzthe following addi- form the organization orthe end ofthe
dona|exclusions, applicable tothis provision policy period, whichever isearlier;
only:
b. Coverage Adoes not apply bo "bodily injury"
(1) Any"occurrence"which takes place after or"property damage" that occurred before
you cease tobeotenant inthat premises. you acquired orformed the organization;
and
(2) Structural alterations, new constructions or
demolition operations performed bymron c. Coverage Bdoes not apply to "personal
behalf ofthe additional insured. injury" or"advertising injury" arising out of
anoffense committed before you acquired
c' The following isadded toSECTION III~ LIMITS orformed the organization.
OF INSURANCE:
No person or organization is an insured with
The Limits ofInsurance for the additional in- respect 10the conduct ofany current orpast
sured are those specified in the written contract partnership,joint venture or limited liability
oragreement between the insured and the company that isnot shown asaNamed Insured
manager orlessor ofthe premises, not<o inthe Declarations.
exceed the limits provided in this policy. These
limits are inclusive ofand not inaddition tothe 11. BLANKET WAIVER OF SUBROGATION
Limits mfInsurance shown inthe Declarations.
The following isadded toSECTION 8V~COyNK0ER-
10. NEWLY FORMED OR ACQUIREQORGANIZA- CIALGENERAL LIABILITY CONDITIONS, 8.
TIONS Transfer Of Rights of Recovery Against Others
To Us.
Under SECTION 11-VVHO IS AN UNSURE0, Para-
graph 4. isdeleted and replaced bythe following: When you have agreed to waive your right of subro-
gation in a written contract, executed prior to loss,
4. Any organization you newly acquire orform, with any person ororganization, wewaive any right
other than apartnership,joint venture orlimited torecovery wemay have against such person mr
liability company, and over which you maintain organization because ofpayments wemake for
ownership ormajority interest, will qualify asa injury ordamage arising out ofyour ongoing opera
Named Insured ifthere isnoother similar tions or"your work" done under acontract with that
insurance available tothat organization. person ororganization and included inthe
However "products-comp|e1edoperations hazand"
a- Coverage under this provision isafforded All other policy terms and conditions apply.
only until the 18Othday after you acquire or
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55091 (10-08) Copyright Insurance Services Office, |nc' 1y82. 1g88. 2OO2. 2OO4 Page 7of7
Southern-Owners Ins.Co. Issued 12-02-2020
AGENcv ADCOCK-ADCOCK PROP&CAS AGENCY INC Company POLICY NUMBER 072312-20693312-21
12-0004-00 MKT TERR 052 Bill 20-23-FL-0702
INSURED KPI ENGINEERING INC Term 02-01-2021 to 02-01-2022
55056(07-87)
SUPPLEMENTAL
CG 2010 ADDITIONAL INSURED - EXCLUSION PRODUCTS COMPLETED OPERATIONS
NAME OF PERSON OR ORGANIZATION:
- THE SCHOOL DISTRICT OF OSCEOLA COUNTY
- DR GILLS
- THE SCHOOL DISTRICT OF HILLSBOROUGH
- CORPORATION OF THE PRESIDING BISHOP OF THE CHURCH OF JESUS CHRIST
OF LATTER-DAY SAINTS, A UTAH CORPORATION SOLD
- HILLSBOROUGH CO A POLITICAL SUBDIVISION OF THE
STATE OF FLORIDA, HILLSBOROUGH COUNTY BOCC
- LAKE COUNTY A POLITICAL SUBDIVISION OF THE STATE OF FLORIDA &
THE BOARD OF COUNTY COMMISSIONERS
- HART
- SCHOOL BOARD OF PINELLAS COUNTY
- Q & Q INC AND AM KING CONSTRUCTION CO LLC
- TAMPA ELECTRIC COMPANY
- CITY OF CLEARWATER
- DIX HITE & PARTNERS
- SOCIETY OF ST VINCENT DEPAUL SOUTH PINELLAS INC
- CITY OF WINTER PARK
- MINIMISE USA
- SAPUTO DAIRY FOODS USA LLC
- BDG ARCHITECTS
- EMPAD ARCHITECTURE
- MANATEE COUNTY BOARD OF COMMISSIONERS A POLITICAL SUBDIVISION
OF THE STATE OF FLORIDA
- OSCEOLA COUNTY BOARD OF COUNTY COMMISSIONERS C/O DIRECTOR OF HUMAN
RESOURCES
- THE CITY OF MARCO ISLAND
- CITY OF SEBASTIAN
- THE SCHOOL BOARD OF DUVAL COUNTY, FLORIDA AND ITS MEMBERS,
OFFICIALS, OFFICERS AND EMPLOYEES
- SPRINGER CONSTRUCTION
- ORANGE COUNTY BOARD OF COMMISSIONERS
- PINELLAS COUNTY A POLITICAL SUBDIVISION OF THE STATE OF FLORIDA
Agency Code 12-0004-00 AGENCY COPY Policy Number 072312-20693312
COMMERCIAL GENERAL LIABILITY
CG 20 10 04 13
THIS ENDORSEMENTLI . PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS, LESSEES OR
CONTRACTORS - SCHEDULED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
Name Of Additional Insured Person(s)
Or Organization(s) Location(s)Of Covered Operations
SEE SUPPLEMENTAL DECLARATIONS ALL JOBSITES FOR THIS ENTITY
Information required to complete this Schedule, if not shown above, will be shown in the Declarations.
A. Section 11 -Who Is An Insured is amended to in- in the performance of your ongoing operations for
clude as an additional insured the person(s) or or- the additional insured(s) at the location(s) desig-
ganization(s) shown in the Schedule, but only with nated above.
respect to liability for"bodily injury", "property dam- However:
age"or"personal and advertising injury" caused, in 1. The insurance afforded to such additional in-
whole or in part, by: sured only applies to the extent permitted by
1. Your acts or omissions; or law; and
2. The acts or omissions of those acting on your 2. If coverage provided to the additional insured is
behalf; required by a contract or agreement, the
CG 20 10 04 13 O Insurance Services Office, Inc., 2012 Page 1 of 2
..........
Agency Code 12-0004-00 AGENCY COPY Policy Number 072312-20693312
insurance afforded to such additional insured will intended use by any person or organization
not be broader than that which you are required other than another contractor or subcontractor
by the contract or agreement to provide for such engaged in performing operations for a principal
additional insured. as a part of the same project.
B. With respect to the insurance afforded to these addi- C. With respect to the insurance afforded to these
tional insureds, the following additional exclusions additional insureds,the following is added to
apply: Section III-Limits Of Insurance:
This insurance does not apply to "bodily injury" or If coverage provided to the additional insured is
"property damage"occurring after: required by a contract or agreement, the most we
1. All work, including materials, parts or equipment will pay on behalf of the additional insured is the
furnished in connection with such work, on the amount of insurance:
project(other than service, maintenance or re- 1. Required by the contract or agreement; or
pairs)to be performed by or on behalf of the 2. Available under the applicable Limits of
additional insured(s) at the location of the cov- insurance shown in the Declarations;
ered operations has been completed; or whichever is less,
2. That portion of"your work"out of which the in- This endorsement shall not increase the applicable
jury or damage arises has been put to its Limits of Insurance shown in the Declarations.
CG 20 10 04 13 0 Insurance Services Office, Inc., 2012 Page 2 of 2
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY VVC ¢¢ ¢313
(Ed. 4-84)
WAIVER OFOUR RIGHT TDRECOVER FROM OTHERS ENDORSEMENT
We have the right to recover our payments from anyone liable for an injury covered by this policy. We will
not enforce our right against the person or organization named in the Schedule. (This agreement applies only
to the extent that you perform work under mwritten contract that n*quin*e you to obtain this agreement from
us.)
This agreement shall not operate directly or indirectly to benefit anyone not named in the Schedule.
Schedule
*Blanket Waiver ofSubrogation Applies*
This endorsement changes the policy to which it is attached and is effective on the date issued unless otherwise stated.
Date Prepared:
Cmrher: Bridgefie|d Employers Insurance Company
Effective Date ofEndorsement: January 15. 2021
Policy Number: 830-52197 Countersigned by:
Insured: Kenyon & Partners, Inc.
VVC ¢¢ ¢313 (Ed 4-84)
"Includes copyright material of the National Council on Compensation Insurance, Inc.used with its permission.Copyright 1eo4woor