CERTIFICATE OF LIABILITY INSURANCE (49)
Client#: 32207
RROE
ACORDTM
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYYY)
12/12/07
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER
Saginaw Bay Underwriters
Commercial Lines
1258 S. Washington P.O. Box 1928
Saginaw , MI 48605
R. Roese Contracting Inc.
P.O. Box 158
KaWkawlin, MI 48631
INSURERS AFFORDING COVERAGE
INSURER A: Zurich North America
INSURER B: Cincinnati Ins. CO.
INSURER C: Hanover Ins. CO.
INSURER D:
INSURER E:
NAIC#
INSURED
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
~iRR ~~~~ TYPE OF INSURANCE POLICY NUMBER PJ>1-~1:~f~8,wr Pg~.w (~~~~.gN LIMITS
A GENERAL LIABILITY G L0914088700 01/01/08 01101/09 EACH OCCURRENCE $1 000,000
- DAMAGE T9E~Eo~J~.'?ence\
X COMMERCIAL GENERAL LIABILITY $300,000
I CLAIMS MADE [X] OCCUR MED EXP (Anyone person) $10000
X PD Ded:5,000 PERSONAL & ADV INJURY $1 000.000
GENERAL AGGREGATE $2000.000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2000.000
I nPRO- n
POLICY JECT LOC
A ~TOMOBILE LIABILITY BAP914088800 01101108 01/01/09 COMBINED SINGLE LIMIT
lL ANY AUTO (Ea accident) $1,000,000
- ALL OWNED AUTOS R'FCEIVF ~ BODILY INJURY ....
$
SCHEDULED.AlIIOS " ~,),,1 (Per person)
- .
X HIRED AUTOS .'.
- .... 200 ". BODILY INJURY $
lL NON-OWNEDAUTOS ".,''4 _I'. ,', (Per accident)
.. X Drive Other Car PROPERTY DAMAGE
. .. r . . '?EC0Pr;~ (Per accident) $
,1\ ~ ~"'..
~ ,.. r r ,
GARAGE LIABILITY ....", .:J!( vi.,;:, 'Ed AUTO ONLY - EA ACCIDENT $
~ ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY XS1160390 01/01/08 01101/09 EACH OCCURRENCE $5000.000
:=J OCCUR [X] CLAIMS MADE AGGREGATE $5 000.000
$
~ DEDUCTIBLE $
RETENTION $ $
-A- WORKERS-COMPENSATION -AND WC914988900 01101108 - 01/0-1169 - .1 WC SJATU- I IOJ~-
EMPLOYERS' LIABILITY $100,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? EL. DISEASE - EA EMPLOYEE $100,000
If yes, describe under $500,000
SPECIAL PROVISIONS below EL DISEASE - POLICY LIMIT
C OTHER Leased or IHH793266202 01101108 01101109 $200,000 Limit
Rented Equipment $5,000 Deductible
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES J EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Certificate Holder and any other persons or entities identified in the
Supplementary Conditions are named Additional Insured with respects to the
General
Liability. Owner and Contractor waive all rights against each other and
(See Attached Descriptions)
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater, City Manager
100 S. Myrtle Ave., 3rd Floor
Clearwater, FL 33756-5520
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ----3.0..- DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
ACORD 25 (2001/08) 1 of 3
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ESL
@ ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-5 (2001/08)
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#M123913
DESCRIPTIONS (Continued from Page 1)
their respective officer, directors, employees and agents for all losses
and damages caused by, arising out of or resulting from any of the perils
covered by such policies and any other property insurance applicable to
the
work; and, in addition, waive all such rights against Sub-contractors,
Engineer, Engineer's Consultants and all other persons or entities
identified in the Supplementary Conditions to be listed as insured or
additional insured under such policies for losses and damages so caused.
AMS 25.3 (2001/08)
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#M123913