Okaloosa County BOCC — October 21, 2014 — BILL SMITH ELECTRIC FINAL PAYMENT — reading text

an endorsement. A statement on this certificate does not confer tights ta the certificate holder in lieu of such endorsement(s). PRODUCER Renee’ Lynne.Tecu ial West Garden strode ne BuRN enn. (800) 487-2073 [TE no. (850) 438-4678 Pensacola, FL 32502 FouRESS: INSURER(S) AFFORDING COVERAGE NAIC # insurer a :Amerisure Insurance Company INSURED INsuRERB ;Amerisuré Mutual Insurance Co. Bill Smith Etectric, Inc. INSURER : Laura Smith RERD: PO Box 1057 INSURER D Gonzalez, FL 32560 INSURER E : INSURER F ; COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS I$ 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. WSR [ADDLISUBRY POLICY EFF | POLICY EXP, LTR TYPE OF INSURANCE Insp | wyp POLICY NUMBER: (MMIODNYYY) | MMODIYYYY) LIMITS A | X | COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 ] CLAMS: MADE occur IGL20778950202 07/24/2014 | 07/24/2015 | PRewigee x oerence) _| 100,000 MED EXP (Any oie parson}: $ 5,000! —_ PERSONAL & ADV INJURY | $ 1,000,000 GENL AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 POLICY Loc PRODUCTS - COMP/OP AGe | ¢ 2,000,000) OTHER § COMBINED SINGLE LIMIT. AUTOMOBILE LIABILITY. (Ea accident) $ 1,000, 009 A |X | any auto CA20778940202 07/24/2014 | 07/24/2015 | BODILY INJURY (Per person) | $ ALL OWNED SCHEDULED a aos [| AOS BODY NAURY (Per sete $ — O OPERTY DAI HIREDAUTOS AUTOS (ber ace den $ $ X | UMBRELLALIAB |X | occu, EACH OCCURRENCE q 1,000,000 B EXCESS LIAB CLAIMS-MADE lcu20778970203 07/24/2014 | 07/24/2015 | aserecare § veo |X] Reventions Y Aggregate $ 1,000,000 WORKERS COMPENSATION PER OTH. AND EMPLOYERS’ LIABILITY YIN siature |_| ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT OFFICER/MEMBER EXCLUDED? NIA g (Mandatory in NH) E.L. DISEASE -EA EMPLOYEE] ¢ ifyes, describe under DESCRIPTION.OF OPERATIONS below E.L.DISEASE -poicy Limit | § DESCRIPTION OF OPERATIONS! LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space [s required) Project: Russell Stephenson Electrical Manhole Rehabilitation WS03-14 Should any of the above policies cancel before the expiration date thereof, 30 days written notice will be mailed to certificate holder. Certificate Holder Note: Certificate Holder is Additional Insured 'in regard to General Liability, Auto Liability and Umbrella Liability if required by written contract, SEE ATTACHED ACORD 101 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Board of County Commissioners Okaloosa County, FL AGCORDANCE WITH THE POLICY PROVISIONS, 602-C North Pearl Street Crestview, FL 32536 AUTHORIZED REPRESENTATIVE a © 1988-2014 ACORD CORPORATION. Ail rights reserved. ACORD 25 (2014/01) The ACORD name and foge are registered marks of ACORD AGENCY CUSTOMER ID: BILLSMI-01 JLTECU ann Loc#: 4 ACORD ADDITIONAL REMARKS SCHEDULE Paye 1 of 1 Fisher Brown Bottrell Insurance, inc. Bill Smith Electslc, Inc. Laura Smith POLICY NUMBER PO Box 1057 SEE PAGE 1 Gonzalez, FL 32560 CARRIER NAIC CODE SEE PAGE 4 ISEE.P4 EFFECTIVE DATE: SEE PAGE 4 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD 25 FORM TITLE: Certificate of Liability Insurance Description of Operations/Locations/Vehicles: General Liability is primary and non-contributory if required by written contract. Waiver of Subrogation applies in favor of Certificate Holder in regard to General Liability, Auto Liability and Umbrella Liability if required by written contract. General Liability Additional Insured Endorsement is attached. ACORD 101 (2008/01) ® 2008 ACORD CORPORATION. All rights réserved. The ACORD name and logo are registered marks of ACORD THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. CONTRACTOR’S BLANKET ADDITIONAL INSURED ENDORSEMENT This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM All of the terms, provisions, exclusions, and limitations of the coverage form apply except as specifically stated below. SECTION Il - WHO IS AN INSURED is amended to include as an insured any person or organization, called an additional insured in this endorsement: 1, Whom you are required to add as an additional insured on this policy under a written contract or agreement relating to your business; or 2, Who is named as an additional insured under this policy on a certificate of insurance. However, the written contract, agreement or certificate of insurance must require additional insured status for a time period during the term of this policy and be executed prior to the "bodily injury", "property damage", “personal injury", or “advertising injury” giving rise to a claim under this policy. If, however, “your work” was commenced under a letter of intent or work order, subject to a subsequent reduction to writing within 30 days from such commencement and with customers whose customary contracts require they be named as additional insureds, we will provide additional insured status as specified in this endorsement. 3. if the additional insured is: {a) An individual, their spouse is also an additional insured. (b) A partnership or joint venture, members, partners, and their spouses are also additional insureds. (c) A limited liability company, members and managers are also additional insureds, {d) An organization other than a partnership, joint venture or limited liability company, executive officers and directors of the organization are also additional insureds. Stockholders are also additional insureds, but only with respect to their liability as stockholders, (e) A trust, you are an insured. Your trustees are also insureds, but only with respect to their duties as trustees, The insurance provided to the additional insured is limited as follows: 1. That person or organization is only an additional insured with respect to lability arising out of: {a) Premises you own, rent, lease, or occupy, or {b) Your ongoing operations performed for that additional insured, unless the written contract or agreement or the certificate of insurance requires “your work" coverage (ar wording to the same effect) in which case the coverage provided shall extend to “your work" for that additional insured. Premises, as respects this provision, shall include common or public areas about such premises if so required : in the written contract or agreement. : Ongoing operations, as respects this provision, does not apply to “bodily injury” or “property damage” occurring after: (1) All work including materials, parts or equipment furnished in connection with such work on the project (other i then service, maintenance or repairs) to be performed by ar on behalf of the additional insured(s) at the site : of the covered operations has been completed: or : Includes copyrighted material of Insurance Services Office, inc., with its permission, Copyright Insurance Services Office, Inc., 2003 CG 70 48 03 04 Page 1 of 2 (2) That portion of “your work” out of which the injury or damage arises has been put to its intended use by ary person or organization other than anather contractor or subcontractor engagad in performing operations for a principal as a part of the same project. The limits of Insurance applicable to the additional insured are the least of those specified in the written contract of agreement, or in the certificate of insurance or in the Declarations for this policy. If you also carry an Umbrella policy, and the written contract or agreement or certificate of insurance requires that the additional insured status also apply to such Umbrella policy, the limits of insurance applicable to the additional insured under this policy shall be those specified in the Declarations of this policy. The limits of insurance applicable to the additional insured are inclusive of and notin addition to the limits of insurance shown in the Declarations, The additional insured status provided by this endorsement does not extend beyond the expiration or termination of a premises lease or rental agreement nor beyond the term of this policy. Any person or organization who is an insured under the terms of this endorsement and who is also an insured under the terms of the GENERAL LIABILITY EXTENSION ENDORSEMENT, # attached to this policy, shall have the benefit of the terms of this endorsement if the terms of this endorsement are broader. If a written contract or agreement or a certificate of Insurance as outlined above requires that additional insured status be provided by the use of CG 20 10 11 85, then the terms of that endorsement, which are shown below, are incorporated into this endorsement as respects such additional insured, to the extent that such terms do not restrict coverage otherwise provided by this endorsement: ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS (FORM B) This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART. SCHEDULE Name of Person or Organization: Blanket Where Required by Written Contract, Agreement, or Certificate of Insurance that the terms of CG 20 10 11 85 apply (If no entry appears above, information required to complete this endorsement will be shown in the Declarations as applicable to this endorsement.) WHO IS AN INSURED (Section II) ls amended to include as an insured the person or organization shown in the Schedule, but only with respect to liability arising out of "your work" for that insured by or for you. Copyright, insurance Services Office, Inc., 1984 CG 20 10 11 85 The insurance provided to the additional insured does not apply to "bodily injury", "property damage’, "personal injury", or “advertising injury" arising out of an architect’s, engineer's, or surveyor’s rendering of or failure to render any professional services including but not lmited to: 1, 2, The preparing, approving, or failing to prepare or approve maps, drawings, opinions, reports, surveys, change orders, design specifications; and Supervisory, inspection, or engineering services, Any coverage provided in this endorsement is excess over any other valid and collectible insurance available to the additional insured wheather primary, excess, contingent, or on any other basis unless the written contract, agreement, or certificate of insurance requires that this insurance be primary, in which case this insurance will he primary without contribution from such other insurance available to the additional insured. Includes copyrighted material of insurance Services Office, inc., with its permission. Copyright Insurance Services Office, Inc. 2003 Page 2 of 2 CG 70 48 03 04