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PROOF OF INSURANCE <br />CONTINUING PROFESSIONAL A RCHITECTURAL & ENGINEERING SERVICES FIRMS ONLY (CCNA) <br />RFQ NO. 12-04-02 <br />COMPANY INFORMATION <br />INSR ADDLSUBRLTRINSRWVD <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 EFFPOLICY EXPTYPE OF INSURANCE LIMITS(MM/DD/YYYY)(MM/DD/YYYY) <br />GENERAL LIABILITY <br />AUTOMOBILE LIABILITY <br />UMBRELLA LIAB <br />EXCESS LIAB <br />WORKERS COMPENSATION <br />AND EMPLOYERS' LIABILITY <br />DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, 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 RENTEDCOMMERCIAL GENERAL LIABILITY $PREMISES (Ea occurrence) <br />CLAIMS-MADEOCCUR MED EXP (Any one person)$ <br />PERSONAL & ADV INJURY$ <br />GENERAL AGGREGATE$ <br />GEN'L AGGREGATE LIMIT APPLIES PER:PRODUCTS - COMP/OP AGG$ <br />$PRO-POLICY 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 />DEDRETENTION$$ <br />WC STATU-OTH-TORY LIMITSER <br />E.L. EACH ACCIDENT$ <br />E.L. DISEASE - EA EMPLOYEE$ <br />If yes, describe under E.L. DISEASE - POLICY LIMIT$DESCRIPTION OF OPERATIONS below <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 />COVERAGESCERTIFICATE NUMBER:REVISION NUMBER: <br />CERTIFICATE HOLDERCANCELLATION <br />© 1988-2010 ACORD CORPORATION. All rights reserved. <br />The ACORD name and logo are registered marks of ACORDACORD 25 (2010/05) <br />ACORDTM CERTIFICATE OF LIABILITY INSURANCE 11/10/2011 <br />USI Insurance Services, LLC-CL <br />200 West Cypress Creek Rd #600 <br />Fort Lauderdale, FL 33309 <br />954 607-4000 <br />954 607-4000 <br />Bermello, Ajamil & Partners, Inc. <br />2601 South Bayshore Drive <br />Suite 1000 <br />Miami, FL 33133 <br />Hartford Casualty Insurance Com <br />Hartford Fire Insurance Company <br />Continental Casualty Company <br />Hartford Ins Co of SE <br />29424 <br />19682 <br />20443 <br />38261 <br />A <br />X <br />X <br />21UUNKK370911/11/201111/11/20121,000,000 <br />300,000 <br />10,000 <br />1,000,000 <br />2,000,000 <br />2,000,000 <br />A <br />X <br />XX <br />21UUNKK370911/11/201111/11/20121,000,000 <br />A X <br />X10000 <br />21XHUKK326011/11/201111/11/20125,000,000 <br />5,000,000 <br />B <br />N <br />21WBZS632111/11/201111/11/2012X <br />1,000,000 <br />1,000,000 <br />1,000,000 <br />A <br />C <br />D <br />Property <br />Prof'l Liability <br />Inland Marine <br />21UUNKK3709 <br />AEH288262231 <br />21MSFKO7033 <br />11/11/2011 <br />11/11/2011 <br />11/11/2011 <br />11/11/2012 <br />11/11/2012 <br />11/11/2012 <br />Per Schedule on File <br />$1M Each Claim/Agg. <br />Per Schedule on File <br />SPECIMEN <br />1of 1#S6645068/M6644700 <br />BERMEAJAClient#: 31137 <br />SRYZP1of 1#S6645068/M6644700 <br />7