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CERTIFICATE OF LIABILITY INSURANCE (1074)ACORb® CERTIFICATE OF LIABILITY INSURANCE �../ DATE(MM/DD/YYYY) 02/23/2021 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 McGriff Insurance Services, Inc. 10100 Katy Freeway, #400 Houston, TX 77043 CONTACT Rachel Manis-Hyatt PHONE 713-877.8975 FAX 713-877-8974 (A/C. No, Ext)(A/C No): E-MAIL ADDRESS: fmanis-hyatt@mcgriff.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A :Property and Casualty Insurance Company of Hartford 34690 INSURED Primoris Distribution Services, Inc. including Florida Gas Contractors, Inc. and FGE Engineering, Inc. 10518 US Highway 301 Dade City, FL 33525 INSURER B :Twin City Fire Insurance Company 29459 INSURER C :Hartford Fire Insurance Company 19682 Lloyd's, INSURER D :Underwriters AtLondon 15792 INSURER E : INSURER F : DAMAGE TO RENTED PREMISES (Ea occurrence) COVERAGES CERTIFICATE NUMBER:CJWQUQVN 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 LTR TYPE OF INSURANCE ADDL-SUBR INSD WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP ) (02/28/2 LIMITS C X COMMERCIAL GENERAL LIABILITY 61CSEQU3414 ( �� t" i AAR. 0 y Iii2 r•,-.7rn 02/28/2021 o , /� I }'� AND EACH OCCURRENCE $ 2,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 2,000,000 MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'L AGGREGATE POLICY OTHER: X LIMIT APPLIES PER: JE T ❑LOC GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 $ C AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY HIREDNON-OWNED AUTOS ONLY — _ SCHEDULED AUTOS AUTOS ONLY 61CSEQU341 FFICIAI y l �^ ' j�( �rtv`‘,,, LEGISI-A r" Q2/28/2®2}r tI `CCrr,, {t 02/28/2022 COMBINED SINGLE LIMIT (Ea accident) 5,000,000 BODILY INJURY (Per person) $ BODILY INJURYPer accident ( ) $ PROPERTY DAMAGE (Per accident) $ Physical Damage Ded. $ 250,000 D X UMBRELLA LIAB EXCESS LIAB X — OCCUR CLAIMS -MADE AU2100190 AU2100390 02/28/2021 02/28/2022 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED X RETENTION $ $ A B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? /Mandatory in NH) Y yes, describe under DESCRIPTION OF OPERATIONS below Y / N N N / A 61WNQU3411 61WBRQU3412 $500,000 Ded/SIR applies to all 02/28/2021 02/28/2022X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 $ $ $ $ $ DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) The Certificate Holder is included as Additional Insured as respects the General Liability policy as required by written contract and subject to policy terms, conditions and exclusions. CERTIFICATE HOLDER CANCELLATION City of Clearwater Attn: City Clerk PO Box 4748 Clearwater, FL 34618-4748 ACORD 25 (2016/03) SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Page 1 of 1 © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD