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<br />Request for Qualifications No. 11-11-02
<br />~
<br />
<br />C I tJ\A.
<br />
<br />ACORD@ CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIVYYYI
<br />~ 9/30/2011
<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(les) 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 />PRODUCER ~~,AA~CT Commercial Lines Division
<br />Jack Rice Insurance _~,:jg.NJO.Ext); (727) 530-0684 I fti~,.Nol' (727) 532-9602
<br />13080 S Belcher Rd .MAIL
<br /> ADDRESS:
<br /> :~~~~g~'~~ID#OOO09192 I NAIC#
<br />Largo FL 33773 INSURER(S) AFFORDING COVERAGE
<br />INSURED Jt!s,I,1~!',~,"',;':l'_r~y.E!).~~~.!l~l,lrance Co. 1~6170
<br /> J!'!s.Ji.~ER B ;Travelers Insurance (;9. i36:j,.~O_
<br />CIMA Engineering Corp. J!,!S.URER C :
<br />4101 Ravenswood Road llisJiRER 0 :
<br />Sui te #113 -- -------
<br /> INSURER E :
<br />Dania Beach FL 33312 INSURER F :
<br />
<br />COVERAGES
<br />
<br />CERTIFICATE NUMBER:CL1193022871
<br />
<br />REVISION NUMBER:
<br />
<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 />l~f~1 TYPE OF INSURANCE i~E~.;- ~~:I POLICY NUMBER I ~~M%MYYII ,~g76%MVv I LIMITS
<br /> GENERAL LIABILITY I I EACH OCCURRENCE 5 1,000,000
<br /> - I DAMAGETCHiE'NTED
<br /> 1L =r~ERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) S 100,000
<br />A CLAIMS,MADE [i] OCCUR TBD ' 0/1/2011 :10/1/2012 MED EXP (Anv one oerson\ S 5,000
<br /> - -I
<br /> - PERSONAL & ADV INJURY S 1,000,000
<br /> GENERAL AGGREGATE S 2,000,000
<br /> -
<br /> -'il'L AGGREnE LIMIT APnS PER: I PRODUCTS. COM PlOP AGG S 2,000,000
<br /> X POLICY ~~gT LOC I I S
<br /> AUTOMOBILE LIABILITY I I l/12/2011 I COMBINED SINGLE LIMIT S 1,000,000
<br /> - (Ea accident)
<br /> X ANY AUTO
<br /> - I BODILY INJURY (Per person) S
<br />B ALL OWNED AUTOS I TBD r""m'
<br />- I BODILY INJURY (Per accident) S
<br /> - SCHEDULED AUTOS PROPERTY DAMAGE
<br /> S
<br /> X HIRED AUTOS (Per accident)
<br /> X NON,OWNED AUTOS S
<br /> - I
<br /> , I S
<br /> X UMBRELLA L1AB ~ OCCUR I I EACH OCCURRENCE S 3,000,000
<br /> -
<br /> EXCESS L1AB CLAIMS-MAOE AGGREGATE S 3,000,000
<br /> DEDUCTIBLE I 5
<br />A X RETENTION S 10.000 TBD ~0/1/2011 110/1/2012 S
<br /> WORKERS COMPENSATION I UWC STATU'UTH.
<br /> AND EMPLOYERS' LIABILITY IORY,LIMllS ER
<br /> Y/N
<br /> ANY PROPRIETOR/PARTNER/EXECUTIVE D E,L EACH ACCIDENT S
<br /> OFFICER/MEMBER EXCLUDED? N/A
<br /> (Mandatory in NH) I EL DISEASE. EA EMPLOYE' 5
<br /> g~~~~~.m~~ ~~OPERATIONS below EL DISEASE. POLICY LIMIT S
<br />I I I I I I
<br />DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101. Additional Remarks Schedule, If more space Is required)
<br />The Tribe and The United State Dept. of the Interior Bureau of Indian Affairs are Additional Insured with respects to
<br />General Liability per form extend form. Waiver of Subrogation in favor of the Certificate Holder per extend form.
<br />
<br />CERTIFICATE HOLDER
<br />
<br />CANCELLATION
<br />
<br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
<br />THE EXPIRATION DATE THEREOF, NaTICE WILL BE DELIVERED IN
<br />ACCORDANCE WITH THE paLlCY PROVISIONS.
<br />AUTHORIZED REPRESENTATIVE
<br />Cynthia Webster/MMR C~ f'n " ~
<br />
<br />ACORD 25 (2009/09)
<br />INS025 (200909)
<br />
<br />@1988-2009ACORD CORPORATION. All rights reserved.
<br />The ACORD name and logo are registered marks of ACORD
<br />
<br />I elM A's Co mpa'n y ltn~fo r malt ilO"Ii1
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