|
ADDITIONAL REQUIRED INFORMATION 10
<br />95CITY OF SUNNY ISLES BEACH LANDSCAPE ARCHITECT SERVICES RFQ NO. 16-06-02
<br />INSR ADDL SUBRLTRINSRWVD
<br />DATE (MM/DD/YYYY)
<br />PRODUCER CONTACTNAME:
<br />FAXPHONE(A/C, No):(A/C, No, Ext):
<br />E-MAILADDRESS:
<br />INSURER A :
<br />INSURED INSURER B :
<br />INSURER C :
<br />INSURER D :
<br />INSURER E :
<br />INSURER F :
<br />POLICY NUMBER POLICY EFF POLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY)
<br />COMMERCIAL GENERAL LIABILITY
<br />AUTOMOBILE LIABILITY
<br />UMBRELLA LIAB
<br />EXCESS LIAB
<br />WORKERS COMPENSATION
<br />AND EMPLOYERS' LIABILITY
<br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
<br />AUTHORIZED REPRESENTATIVE
<br />INSURER(S) AFFORDING COVERAGE NAIC #
<br />Y / N
<br />N / A
<br />(Mandatory in NH)
<br />ANY PROPRIETOR/PARTNER/EXECUTIVEOFFICER/MEMBER EXCLUDED?
<br />EACH OCCURRENCE $
<br />DAMAGE TO RENTED $PREMISES (Ea occurrence)CLAIMS-MADE OCCUR
<br />MED EXP (Any one person)$
<br />PERSONAL & ADV INJURY $
<br />GENERAL AGGREGATE $GEN'L AGGREGATE LIMIT APPLIES PER:
<br />PRODUCTS - COMP/OP AGG $
<br />$
<br />PRO-
<br />OTHER:
<br />LOCJECT
<br />COMBINED SINGLE LIMIT $(Ea accident)
<br />BODILY INJURY (Per person)$ANY AUTO
<br />ALL OWNED SCHEDULED BODILY INJURY (Per accident)$AUTOS AUTOS
<br />HIRED AUTOS NON-OWNED PROPERTY DAMAGE $AUTOS (Per accident)
<br />$
<br />OCCUR EACH OCCURRENCE $
<br />CLAIMS-MADE AGGREGATE $
<br />DED RETENTION $$
<br />PER OTH-STATUTE ER
<br />E.L. EACH ACCIDENT $
<br />E.L. DISEASE - EA EMPLOYEE $If yes, describe under E.L. DISEASE - POLICY LIMIT $DESCRIPTION OF OPERATIONS below
<br />POLICY
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE POLICY PROVISIONS.
<br />THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
<br />INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
<br />CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
<br />EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
<br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
<br />CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
<br />BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
<br />REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
<br />IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
<br />the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the
<br />certificate holder in lieu of such endorsement(s).
<br />COVERAGES CERTIFICATE NUMBER:REVISION NUMBER:
<br />CERTIFICATE HOLDER CANCELLATION
<br />© 1988-2014 ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORDACORD 25 (2014/01)
<br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE 5/03/2016
<br />USI Insurance Services, LLC-CL
<br />2400 East Commercial Blvd.
<br />Suite 600
<br />Fort Lauderdale, FL 33308
<br />Dianne Kester
<br />954-607-4124
<br />Bermello, Ajamil & Partners, Inc.
<br />2601 S Bayshore Dr Ste 1000
<br />Miami, FL 33133-5437
<br />Hartford Casualty Insurance Com
<br />Twin City Fire Insurance Compan
<br />Continental Casualty Company
<br />29424
<br />29459
<br />20443
<br />A X
<br />X
<br />x
<br />21UUNKK3709 11/11/2015 11/11/2016 1,000,000
<br />300,000
<br />10,000
<br />1,000,000
<br />2,000,000
<br />2,000,000
<br />A
<br />x
<br />X X
<br />21UUNKK3709 11/11/2015 11/11/2016 1,000,000
<br />A X X
<br />X 10000
<br />21XHUKK3260 11/11/2015 11/11/2016 5,000,000
<br />5,000,000
<br />B
<br />N
<br />21WBAG1371 11/11/2015 11/11/2016 X
<br />1,000,000
<br />1,000,000
<br />1,000,000
<br />C Professional Liab
<br />Claims Made
<br />AEH288262231
<br />Retro Date
<br />11/11/2015
<br />11/18/2006
<br />11/11/2016 $5,000,000 per claim
<br />$5,000,000 aggregate
<br />$100,000 Deductible
<br />Request for Qualifications No. 16-04-02 Landscape Architect Services
<br />City of Sunny Isles Beach is included as an Additional Insured on a Primary and Non-contributory basis when
<br />it is required by a written contract or agreement. Waiver of Subrogation applies when it is required by a
<br />written contract or agreement. 30 day notice of cancellation applies except for non payment of premium.
<br />City of Sunny Isles Beach
<br />18070 Collins Avenue
<br />Miami, FL 33160
<br />1 of 1#S17796433/M16648594
<br />BERMEAJAClient#: 31137
<br />DYPER1of 1#S17796433/M16648594
<br />CERTIFICATE OF INSURANCE
|