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CLEARWATER POLICE DEPARTMENT DISTRICT 3 SUBSTATION - PROPOSAL FOR CONSTRUCTION DEMOLITION - 18-0004-PD - CERTIFICATE OF LIABILITY INSURANCESHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES 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). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION $ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2016 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY B SEE ACORD 101 FOR LIMITS 2,250,000 01/01/2022 11PKG8914312 Susan C. Ricciardi X NYC-010931214-03 1,000,000 25,000,000 14WCI8925112 (CA,IL,MD,NY,PA,TX) X 37885 25,000,000 DED : $1M EA CLAIM / $3M AGG(Claims Made) of Marsh USA Inc. N 01/01/2021 X 01/01/2021 01/01/2021 Arch Indemnity Insurance Company 5 01/01/2022 01/01/2021 A C 36940 01/01/2022 11PKG8914312 (AOS) Professional Liability A 4,500,000 SIR: $750,000 - NEW YORK ONLY 2,250,000 X 20699 XL Specialty Insurance Company 1,000,000 X D 12/30/2020 202026 01/01/2021 25,000,000 Re: 18-0004-PD Police Department District 3 Substation; 202026 - Clearwater Police Dept District 3 Substation The City of Clearwater is included as an Additional Insured (except for Workers Compensation and Professional / Pollution) as required by written contract. This insurance is primary and non-contributory with X 01/01/2021 PO Box 4748 Clearwater, FL 33758 City of Clearwater Indian Harbor Insurance Co. 10,000 respects to General Liability. A Waiver of Subrogation applies as required by written contract. 01/01/2022 A ACE Property and Casualty Insurance Company CN101636071-AJAX-GAWUP-21-22 SIR: $500,000 - ALL OTHER STATES EACH CLAIM / AGGREGATE 10,000 01/01/2022 2,000,000 TBD ($10,000,000) 01/01/2022 TBD ($15,000,000) and Pollution E 11CAB8914412 (MA) 4,500,000 11150 300,000 1,000,000 01/01/2022 11WCI8914212 (AOS) 1166 Avenue of the Americas Marsh USA, Inc. X New York, NY 10036 X Global Infrastructure Solutions, Inc. Ajax Building Company, LLC Midway, FL 32343 1080 Commerce Blvd. X X CEO742018006 01/01/2021 Engineering Department 01/01/2021 A 01/01/2022 30830 Arch Insurance Company ACORD 101 (2008/01) The ACORD name and logo are registered marks of ACORD © 2008 ACORD CORPORATION. All rights reserved. THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER:FORM TITLE: ADDITIONAL REMARKS ADDITIONAL REMARKS SCHEDULE Page of AGENCY CUSTOMER ID: LOC #: AGENCY CARRIER NAIC CODE POLICY NUMBER NAMED INSURED EFFECTIVE DATE: 22 PRODUCTS - COMP/OPS AGG - $5,000,000�� GENERAL AGGREGATE - $5,000,000� New York DAMAGE TO RENTED PREMISIS (EA OCC) - $300,000� EACH OCCURRENCE - $2,500,000� PERSONAL & ADV INJURY - $2,500,000� MED EXP (ANY ONE PERSON) - $10,000� �� GENERAL LIABLITY - ALL OTHER STATES (EXCLUDES NEW YORK) LIMITS: � Certificate of Liability Insurance CN101636071 Marsh USA, Inc.� Global Infrastructure Solutions, Inc.� Ajax Building Company, LLC� Midway, FL 32343 1080 Commerce Blvd.� 25