CERTIFICATE OF LIABILITY INSURANCE (1076)/
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
07/30/2021
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 Jessica Belvitch - Certificates
NAME:
Ben Brown Insurance Agency
A/CONNo Ext): (941) 487-3502 A/c, No): (941) 365-3143
E-MAIL Certificates@benbrownins.com
ADDRESS:
3731 S Tuttle Ave
INSURER(S) AFFORDING COVERAGE NAIC #
INSURERA: Gemini Insurance Company 10833
Sarasota FL 34239-6410
INSURED
INSURER B: National Indemnity Company of the South 42137
INSURER C : Underwriters at Lloyds, London
J W Harris Contractors, Inc.
INSURER D:
3448 Crystal Springs Rd.
INSURER E:
INSURER F:
Zephryhills FL 33540
COVERAGES CERTIFICATE NUMBER: 20/BA, BARS 21/GL, GLXS 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 CONTRACTOR 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.
INSIR
LTR
TYPE OF INSURANCE
ADDLSUBR
INSD
WVD
POLICY NUMBER
POLICY EFF
MM/DD/YYYY
POLICY EXP
MM/DD/YYYY
LIMITS
Clearwater FL 33755
X
COMMERCIAL GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000
CLAIMS -MADE FX OCCUR
DA AG To E
PREM SES Ea oNTEDence $ 50,000
MED EXP (Any one person) $ Excluded
PERSONAL&ADV INJURY $ 1,000,000
A
Y
VGGPOO6091
08/02/2021
08/02/2022
GEN'L AGGREGATE LIMIT APPLIES PER:
GENERAL AGGREGATE $ 2,000,000
POLICY PES F] LOC
PRODUCTS - COMP/OP AGG $ 2,000,000
$
OTHER:
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
BODILY INJURY (Per person) $
ANYAUTO
B
OWNED�/ SCHEDULED
AUTOS ONLY /� AUTOS
Y
74APBOO4195
10/01/2020
10/01/2021
BODILY INJURY (Per accident) $
PROPERTY DAMAGE $
Per accident
X
HIRED �/ NON -OWNED
AUTOS ONLY /� AUTOS ONLY
UMBRELLALIAB
X
OCCUR
EACH OCCURRENCE $ 5,000,000
AGGREGATE $ 5,000,000
A
X
EXCESS LIAB
CLAIMS -MADE
VGFX001377
08/02/2021
08/02/2022
DED I I RETENTION $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
PER OTH-
STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑
OFFICER/MEMBER EXCLUDED?
N / A
E.L. EACH ACCIDENT $
(Mandatory in NH)
E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT $
C
Excess Auto Liability
SCT1134920
10/01/2020
10/01/2021
Aggregate $1,000,000
Occurrence $1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Mobile Welding and Underground Installation. - Additional insured coverage provided for ongoing and completed operations (per forms CG 2010 04/13 & CG
2037 04/13) on a primary and non-contributory basis (per form CG 2001 04/13) with regard to the general liability policy as required by written contract. The
auto policy also provides additional insured coverage per form M-3745 07/86. Excess policies: One follows form over the GL and the other over the auto
liability. Copies of all endorsements are available upon request.
CERTIFICATE HOLDER CANCELLATION
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Clearwater Administrative Offices and
ACCORDANCE WITH THE POLICY PROVISIONS.
South Area Service Center
AUTHORIZED REPRESENTATIVE
400 North Myrtle Ave
Clearwater FL 33755
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD