Okaloosa County BOCC — July 7, 2015 — Certificate of Insurance — reading text

ACORD N CERTIFICATE OF LIABILITY INSURANCE OP ID: RB DATE (MM/DDIYYYY) 10/24/14 CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES IMPORTANT: certificate holder in lieu of such endorsement(s). If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. the terms and conditions of the policy, certain policies may require an endorsement. If SUBROGATION IS WAIVED, subject to A statement on this certificate does not confer rights to the PRODUCER Thames Batre' Insurance P. O. Box 6989 Fax: 251-473-9010 Phone: 251-473-9000] conre! Sandie Werneth PoeNe, Exy: 251-643-7029 [ o o). 251-473-9000 JMobile, AL 36660-0989 Eé“{}'{éss; sandie@thamesbatre.com Lewis E. Beville cUstower p #: GCULL-1 INSURER(S) AFFORDING COVERAGE NAIC # INSURED Gulf Coast Underground, LLC INSURER A: American International Group GCU, LLC insurer B : Admiral Insurance Company 3M1:bsilce),lifgzlé g{;ad INSURER ¢ : Sentry Insurance 24988 INSURERD : INSURERE : MSURERE, SOVERAGES CSERTIFICATE NUMBER: REVISION NUMBER; INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION THIS 1S TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD 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. OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS INSR ADDL[SUBI LIR. TYPE OF INSURANCE INSR WD POLICY NUMBER (MBBDNYYY) | (MWBDNY) LimMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,004 B | X [ commERCIAL GENERAL LIABILITY FEI-ECC-10567-02 101114 | 10111115 B&fi%‘%g%fi%fime; $ 100,004 I CLAIMS-MADE OCCUR MED EXP (Any one person) | § 5,00d X | Pollution Liab PERSONAL & ADV INJURY $ 1,000,000 X | Contractual Liab GENERAL AGGREGATE $ 2,000,004 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG | § 2,000,004 poLicy | X | BES: LoC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 101114 | 101115 p ™l i 1,000,006 c L ANY AUTO TSA04321 BODILY INJURY (Per person) | $ — ALL OWNED AUTOS BODILY INJURY (Per accident) | $ || SCHEDULED AUTOS PROPERTY DAMAGE s HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLALIAB | X | occur EACH OCCURRENCE $ 5,000,004 EXCESS LIAB MS- R 5,000,000 B X CLAIMS-MADE FEI-EXS-10568-02 1011114 10115 | ACCRECATE $ , DEDUCTIBLE $ RETENTION _ § 3 WORKERS COMPENSATION X I WG STATU- O AND EMPLOYERS' LIABILITY YIN TORY LIMITS ER A | ANY PROPRIETORPARTNER/EXECUTIVE WC009676730 1011114 | 1011115 | e EacH ACCIDENT $ 1,000,004 OFFICERMEMBER EXCLUDED? N/A {Mandatory in NH) E L. DISEASE - EA EMPLOYEE| $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT | § 1,000,00( ob No.: 41-457, RFB No WS29-13 efer to the attached for coverage extensions DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) e: Annual Maintenance Contract for Manhole Rehabilitation SRLIECS I HOLEER SAUGELLALION Okaloosa County Water & Sewer 302 N Wilson Street SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Crestview, FL 32536 AUTHORIZED REPRESENTATIVE gg;m)@mmo ACORD 25 (2009/09) © 1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD GCULLA1 PAGE 2 NOTEPAD INsURED's NAME Gulf Coast Underground, LLC OP ID: RB pATE 10/24/14 Worker's Compensation coverage extends to the following states for which a project begins during the policy term: AK, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, Ia, ID, IL, IN, KS, KY, La, MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, OK, OR, PA, RI, SC, sD, TN, UT, VA, VT, WI, WV . HOLDER CODE GCULLA1 NOTEPAD: INsURED's NAME GUulf Coast Underground, LLC OP ID: RB PAGE 3 DATE 410/24/14 General Liabili Additional Insutryed 8rovision agglies with respect to General Liability as pertforngs CG2010 0704 and CG2037 0704, attached, if required by written contract. Waiver of Subrogation provision applies with respect to General Liability, as per form ECC-320-0712, attached, if required by written contract Primary & Non Contributong/ %rovision applies with respect to General Liability, as per form ECC-548-0712. IAutomobile Liability . o [Additional Insured Status is granted to Board of County Commissions, Okaloosa County Florida per the attached form ANC 103 \Waiver of subrogation status is granted to Board of County Commissions, Okaloosa County Florida per the attached form ANC102. Worker's Compensation Waiver of Subrogation is granted to the \ ) 1 | older if required by contract, |subject to policy conditions & a 13 = Y 3] = ] o = O o o =2 . ACORD N CERTIFICATE OF LIABILITY INSURANCE OP ID: RB DATE (MMIDD/YYYY) 10/24/14 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. 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 IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. the terms and conditions of the policy, certain policies may require an endorsement. certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to A statement on this certificate does not confer rights to the PRODUCER Phone: 251-473-9000] Cff’n}g‘m Sandie Werneth Thames Batre' Insurance P. O. Box 6989 Fax: 251-473-9010] TG Mo, Ext): 251-643-7029 [ o o). 251-473-9000 JMobile, AL 36660-0989 Eé“{}'{éss; sandie@thamesbatre.com Lewis E. Beville ADDRESS: cusToMer Ip #: SCULL-1 EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSURER(S) AFFORDING COVERAGE NAIC # INSURED Gulf Coast Underground, LLC INSURER A: American International Group GCU, LLC insurer B : Admiral Insurance Company 3M1:bsilce),lifgzlé g{;ad INSURER ¢ : Sentry Insurance 24988 INSURERD : INSURERE : MSURERE, SOVERAGES CSERTIFICATE NUMBER: 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, INSR ADDL[SUBI LIR. TYPE OF INSURANCE INSR WD POLICY NUMBER (MBBDNYYY) | (MWBDNY) LimMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,004 B | X [ commERCIAL GENERAL LIABILITY FEI-ECC-10567-02 101114 | 10111115 B&fi%‘%g%fi%fime; $ 100,004 | cLams mace OCCUR MED EXP (Any one person) | § 5,009 X |Pollution Liab PERSONAL & ADV INJURY $ 1,000,00( X | Contractual Liab GENERAL AGGREGATE $ 2,000,004 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG | § 2,000,004 poLicy | X | BES: LoC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 101114 | 101115 p ™l i 1,000,006 c L ANY AUTO TSA04321 BODILY INJURY (Per person) | $ — ALL OWNED AUTOS BODILY INJURY (Per accident) | $ || SCHEDULED AUTOS PROPERTY DAMAGE s HIRED AUTOS (Per accident) NON-OWNED AUTOS $ $ UMBRELLALIAB | X | occur EACH OCCURRENCE $ 5,000,004 EXCESS LIAB MS- R 5,000,000 B X CLAIMS-MADE FEI-EXS-10568-02 1011114 10115 | ACCRECATE $ , DEDUCTIBLE $ RETENTION _ § 3 WORKERS COMPENSATION X I WG STATU- O AND EMPLOYERS' LIABILITY YIN TORY LIMITS ER A | ANY PROPRIETORPARTNER/EXECUTIVE WC009676730 1011114 | 1011115 | e EacH ACCIDENT $ 1,000,004 OFFICERMEMBER EXCLUDED? N/A {Mandatory in NH) E L. DISEASE - EA EMPLOYEE| $ 1,000,000 If yes, describe under DESCRIPTION OF OPERATIONS below E L DISEASE - POLICY LIMIT | § 1,000,00( DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) : Clean:l.n? and Televising of Sanitary Sewers Ozark, AL dditional Insured provision applies to Pol englneerlng, Inc. with respect to General Liability as per form CG2032 07 04 attached, if required ¥ oflg_g.en contract, and subject to policy conditions and’ the attached CG2243 SRLIECS I HOLEER SAUGELLALION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN . " ACCORDANCE WITH THE POLICY PROVISIONS. Polyengineering, Inc. E'OC:I'_IaB:XASL?’;G?’OZ AUTHORIZED REPRESENTATIVE B lobanetty ] © 1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD GCULLA1 PAGE 2 NOTEPAD INsURED's NAME Gulf Coast Underground, LLC OP ID: RB pATE 10/24/14 Worker's Compensation coverage extends to the following states for which a project begins during the policy term: AK, AR, AZ, CA, CO, CT, DC, DE, FL, GA, HI, Ia, ID, IL, IN, KS, KY, La, MA, MD, ME, MI, MN, MO, MS, MT, NC, NE, NH, NJ, NM, NV, OK, OR, PA, RI, SC, sD, TN, UT, VA, VT, WI, WV