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CERTIFICATE OF LIABILITY INSURANCE (1103) A�" CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIWYY) 08/01/2022 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 CONTACT Jessica Belvitch-Certificates NAME: Ben Brown Insurance Agency AHONEICC' Ext): (941)487-3502 plc,No): (941)365-3143 3731 S Tuttle Ave E-MAIL certificates@benbrownins.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Sarasota FL 34239-6410 INSURERA: Upland Specialty Insurance Company 16988 INSURED INSURER B: National Indemnity Co of the South 42137 J W Harris Contractors,Inc. INSURER C: Underwriters at Lloyds,London 3448 Crystal Springs Rd. INSURER D: Ascot Specialty Insurance Company 23752 INSURER E: Upland Specialty Insurance Company 16988 Zephryhills FL 33540 INSURER F: COVERAGES CERTIFICATE NUMBER: 21/22-GL renw 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. ILTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF EXP MMIDD ( IYYW) (MM DDIYYW) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE X OCCUR PREMISES Ea occurrence $ 50,000 MED EXP(Any one person) $ Excluded A Y USPCL0005622 08/02/2022 08/02/2023 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑X PRO El LOC PRODUCTS-COMP/OPAGG $ 2,000,000 JECT OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident ANY AUTO BODILY INJURY(Per person) $ B OWNED �/ SCHEDULED Y 74APBOO4982 10/01/2021 10/01/2022 BODILY INJURY(Per accident) $ AUTOS ONLY /� AUTOS X HIRED �/ NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY /� AUTOS ONLY Per accident Hired/borrowed $ UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 5,000,000 A X EXCESS LIAB CLAIMS-MADE USXCL0001622 08/02/2022 08/02/2023 AGGREGATE $ 5,000,000 nDED RETENTION $ $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY YIN STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEElNIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Excess Auto Liability Aggregate $2,000,000 C SCT1134921 10/01/2021 10/01/2022 Occurrence $2,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Mobile Welding and Underground Installation. - General liability endorsements: CG 2010 04/13-Additional insured for ongoing operations as required by contract CG 2037 04/13-Additional insured for products&completed operations as required by contract CG 2001 04/13-Primary and non-contributory as required by contract Auto liability endorsements: M-5409 07/09—Scheduled additional insured CERTIFICATE HOLDER CANCELLATION 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 AGENCY CUSTOMER ID: 00021338 LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Ben Brown Insurance Agency J W Harris Contractors,Inc. POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance Excess policies:One follows form over the GL and the other over the auto liability Copies of all endorsements are available upon request ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER ID: LOC#: ADDITIONAL REMARKS SCHEDULE Page of AGENCY NAMED INSURED Ben Brown Insurance Agency J W Harris Contractors,Inc. POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance:Notes D-Excess GL only-$4M over$5M-Pol#ESXS221000044502-8/2/2022-8/2/2023 Limits Occ$4,000,000/Agg$4,000,000 E-Excess Auto Liability-Pal#USXTLO169922-7/13/2022-10/1/2022-Limits Occ$2,000,000/Aggregate$2,000,000 ACORD 101 (2008101) © 2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD