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CERTIFICATE OF LIABILITY INSURANCE (1096)i 1 ® ACCORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/YYYY) DD/ 02/22/2022 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 NAME: WC./PHONE Ext): 713-877 8975 FAX No): 713-877 8974 E-MAIL manis-h attm riff.com ADDRESS: ry 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 INSURER D :Axis Surplus Insurance Company 26620 INSURER E :HDI Specialty Insurance Company 16131 INSURER F : COVERAGES CERTIFICATE NUMBER:YGCx96FU REVISION NUMBER: THIS 15 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 INSD SUBR wvD JJJ�� /// POLICY R E I\ /�(�i Y EFF /YYYY) POLICY EXP (MM/DD/YYYY) LIMITS C X COMMERCIAL GENERAL LIABILITY 61CSEQU3414 " r MAR0 2 2022 OFFICIA!- . rCORDS IEGISLA1;vE SRVCS 1Z7 /2022 AND DEPT. 02/28/2023 EACH OCCURRENCE $ 2,000,000 PREMISES (EaENTEoccu DAMAGE TO ence) $ 2,000,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 10,000 PERSONAL & ADV INJURY $ 2,000,000 GEN'LAGGREGATE POLICY OTHER: X LIMIT APPLIESPER: JET LOC GENERAL AGGREGATE $ 4,000,000 PRODUCTS - COMP/OP AGG $ 4,000,000 $ C AUTOMOBILE X LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY - _ SCHEDULED AUTOS NON -OWNED AUTOS ONLY '61CSEQU3415 02/28/2022 02/28/2023 COMBINED SINGLE LIMIT (Ea accident) 5,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ Physical Damage Ded. $ 250,000 D E X — UMBRELLA LIAB EXCESS LIAB X .— OCCUR CLAIMS -MADE P-001-000806562-01 CLXD57973005 02/28/2022 02/28/2023 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED X RETENTION $ $ A B WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? N (Mandatory in NH) If Yes. describe under DESCRIPTION OF OPERATIONS below N / A 61WNQU3411 61WBRQU3412 $500,000 Ded/SIR applies to all 02/28/2022 02/28/2023 X 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 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 }jk4414:5'14.4.414 � ACORD 25 (2016/03) Page 1 of 1 © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD