Okaloosa County BOCC — December 4, 2012 — ERMC Amendment & Coordination Sheet — reading text

424-3188 CERTIFICATE OF LIABILITY INSURANCE FAX: (423)424-4699 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION I 1/10/2013 I n s u r i t y Group ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ~E:R THE COVERAGE AFFORDED BY THE POLICIES BELOW. 6148 Lee Highway Suite 206 Chattanooga TN -- 37421 - -- INSURERS AFFORDING COVERAGE NAIC# ~ .. -- ---- ---­ INSURED INSURER A: The Ins. Co. State o f PA 19429 ........_­ ERMC IV, L.P. i INSURER _ B: St. ...... _ - - - - - - - - Paul -~~ FIre & Marine Ins Co .. .--~~- .........- ­ 24767 ­ 6148 Lee Highway, Suite 300 : INSURER coNational Union F i r e Ins. Co. ! 19445 ---" ... .._­ - i INSURE~~ Chattanqoga TN 37421 INSURER E: COVERAGES 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 OFSUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. GENERAL LIABILITY ~.._ _1_, 000, 000 X : COMMERCIAL GENERAL LIABILITY : . L$~_ 1QO I OO() A :~ CLAIMS MADE l X-. OCCUR L1929589 10/1/2012 10/1/2013 o :$ ......bjlOO,OOO x J $500, 000 SIR . !i.L.90 0,.0 0 0 : GEN'LAGGREGATE LIMIT APPLIES PER: 2, oQO-,-O 00 1---+-, Xl POLIcy-l PRO- i LOC , AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 1-: (Ea accident) 1,000,000 I X: ANY AUTO A ALL OWNED AUTOS A0939768 lO/1/2012 i 10/1/2013 BODilY INJURY (Per person) SCHEDULED AUTOS I . HIRED AUTOS BODILY INJURY (Per accident) NON·OWNED AUTOS PROPERTY DAMAGE (Per accident) AUTOONLY~C9()E:NT_' $ EAACC; $ ... OTHER THAN i AUTO ONLY: AGG $ I EXCESS / UMBRELLA LIABILITY I.EACH OCCURRENCE. :$ 25:,000,000 c-~ :...!J OCCUR ;----; L.J CLAIMS MADE rGGREG~T~_ mm~ 1:­ i5:~00'OOO C DEDUCTIBLE ~i 8251346 110/1/2012 110/1/2013 ~ ____ ~__ L$~_. ~--~- l-~4-~LX~lRETENT~IO~N~~____~l~O,~O~O~O~_____~--______- ­ __~__~I------------i-------~--~~,-i~~~~--Icn~'~$~----------__l A WORKERS COMPENSATION 0TH X I IQRY.JJMII"---L. WC STATU:;., , • AND EMPLOYERS' LIABILITY - ..ER.+-_ .. - - - - - ­ ANY PROPRIETOR/PARTNER/EXECUTIVE ~E:1\9t1 A(;9'QEfiT_ --i $ _ hO O~ 000 '1~:~~;::~~~~~~EXClUDED? C015684064 _ FL 10/1/2012 10/1/2013 : ELDISE:J\SE_Ef',_EMf'~()YE:0 ~_l(.Q.Q.O,.QQO If yes, describe under 250,000 Deductible EL DISEASE - POLICY LIMIT 1,000 000 i---+,...:S""P.=.ECIAL PROVISIONS below 10/1/2013 ,Limit - is Over the 5,000,000 B 10THERExcess L i a b i l i t y ZUP-llR92592-12-NF 110/1/2012 1 $25,000,000 Umbrella 1 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Northwest Florida Regional Airport IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR 1701 State Road 85 N REPRESENTATIVES, Eglin AFB, FL 32542 AUTHORIZED REPRESENTATIVE ---~--- .. -­ v~y~~ Jeff Lett/LISA ACORD 25