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HomeMy WebLinkAboutCertificate of Liability Insurance- t. 4 IINIVFN[�.01 KSANCHF7 ACORO" CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYYY)4/28/2021 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 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Ames & Gough 8300 Greensboro Drive Suite 980 CONTACT NAME: 7AX PHONE ) A/C, No ; (703) 827-2279 (a/c, No, Ext): ( 03 827-2277 E oR1Es • admin@amesgough.com INSURERS AFFORDING COVERAGE NAIC # McLean, VA 22102 INSURER A: Evanston Insurance Company 35378 INSURED INSURER B : INSURERC: Universal Engineering Sciences, LLC INSURER D : 3532 Maggie Boulevard Orlando, FL 32811-6697 INSURER E INSURER F : rnv�oer_Gc (`GRTICI(`ATF kittMRFR• REVISION NIIM1RFR- 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ILTR TYPE OF INSURANCE ADDL SUBR POLICY NUMBER POLICY EFF POLICMIDDNYraY EXP LIMITS COMMERCIAL GENERAL LIABILITY CLAIMS -MADE OCCUR EACH OCCURRENCE $ RENTED"PAEMIBETEoccurrec $ MED EXP (Anyoneperson) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: POLICY jECT LOC OTHER: GENERAL AGGREGATE $ PRODUCTS - COMP/OP AGG $ $ AUTOMOBILE LIABILITY ANY AUTO OWNED SCHEDULED AUTOS ONLY AUTOS AUTOS ONLY NON -OWNED OS ONLY C a accciden SINGLE LIMIT $ BODILY INJURY Perperson) $ BODILY INJURY Per accident $ PROPERTY AMAGE Per accident $ $ UMBRELLA LIAB EXCESS LIAR OCCUR EACH OCCURRENCE $ HCLAIMS-MADE AGGREGATE $ DIED I I RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY Y / N OFFICEWMEIMBER EXCLUDED? ECUTIVE ❑ (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below N /A PER OTH- ISTATUTE E.L. FJ1CH ACCIDENT E.L. DISEASE - EA EMPLOYE $ E.L. DISEASE - POLICY LIMIT A Professional Liab. MKLV7PL0004492 1/1/2021 1/112022 Per Claim/Aggregate 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required) RE: For Private Provider plan review and inspection services for lots: 1, 3, 4,11, 16,17,19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 83, 85, 87, 97, 106, 117, 120,121, 123,127 I-CoTIPIRATF Ho!DER CANCFLI_ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE St. Lucie County THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 2300 Virginia Avenue Fort Pierce, FL 34982 AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) ©1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 1 ® !�`� o CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 04/28/2021 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 REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the pol(cy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT Stephanie Kramer NAME: Brown & Brown of Florida, Inc. 1661 Worthington Rd Ste 175 HONE Ext ; (561) 688-5094 ac NO): (561) 686-2313 E-MAIL skramer@bb-wpb.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Valley Forge Insurance Company 20508 West Palm Beach FL 33409 INSURED INSURER B: The Continental Insurance Company .35289 Universal Engineering Sciences, LLC INSURER C : Continental Casualty Company 20443 Universal Engineering Inspections, LLC INSURER D : StarStone Specialty Insurance Company 44776 3532 Maggie Blvd INSURER E : Landmark American Ins. Company 33138 INSURER F : Orlando FL 32811 COVERAGES CERTIFICATE NUMBER! 2021-2022 Master 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INSR LTR TYPE OF INSURANCESUHR INSD WVD POLICYNUMBER POLICY EFF MM/DD POLICY EXP MM/DD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE %% OCCUR A PREMISES Ea occurrence $ 100,000 MED EXP (Any one person) $ 10,000 PERSONAL& ADV INJURY $ 1,000,000 A Y Y 7011856226 01/01/2021 01/01/2022 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY ❑X PEA LOC PRODUCTS -COMP/OPAGG $ 2,000,000 Employee Benefits $ 1,000,000 OTHER: AUTOMOBILE LIABILITY (Ea SINGLE LIMIT Ea accident $ 1,000,000 BODILY INJURY (Per person) $ X ANYAUTO B OWNED SCHEDULED AUTOS ONLY AUTOS HIRED NON -OWNED AUTOS ONLY AUTOS ONLY Y Y 7011857165 01/01/2021 01/01/2022 BODILY INJURY (Per accident) $ PROPERTY DAMAGE Per. accident $ Underinsured motorist $ 1,000,000 X UMBRELLALIAB X OCCUR RREW """' EACH OCCURRENCE 1,000,000 $ B EXCESS LIAB CLAIMS -MADE Y Y 7012083093 01/01/2021 01/01/2022 AGGREGATE $ 1,000,000 DEC) X RETENTION $ 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE Y / N OFFICER/MEMBERF�CCLUDED7 � (Mandatory In NH) NIA Y 7011858185 01/01/2021 01/01/2022 X STATUTE ERH E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE -EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 1,000,000 $ If yes, describe under DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, maybe attached If more space Is required) For Private Provider plan review and inspection services for lots: 1,3,4,11,16,17,19,20,21,22,23,24,25,26,27,28,29,30,31,32,83,85,87,97,106,117,120,121,123,127 CERTIFICATE HOLDER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN St. Lucie County ACCORDANCE WITH THE POLICY PROVISIONS. 2300 Virginia Avenue AUTHORIZED REPRESENTATIVE Fort Pierce FL 34982/C ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGES Ref # I Description Cyber Liability Coverage Code Form No. Edition Date Limit 1 1,000,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # I Description Uninsured motorist combined single limit Coverage Code UMCSL Form No. Edition Date Limit 1 1,000,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description PIP -Basic Coverage Code PIP Form No. Edition Date Limit 1 10,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description WC & Employer's liability Coverage Code WCEL Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium rOFADTLCV Copyright 2001, AMS Services, Inc. AGENCY CUSTOMER ID: LOC #: AC40 V ADDITIONAL REMARKS SCHEDULE AGENCY NAMED INSURED Brown & Brown of Florida, Inc. Universal Engineering Sciences, LLC POLICY NUMBER CARRIER NAIC CODE EFFECTIVE DATE: )DITIONAL REMARKS Page of THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, I FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance: Notes D) Type of Insurance: Excess Liability; Carrier: Starstone Specialty Ins; Policy number: 77102C200ALI; Limit: $4,000,000 - Excess over lead umbrella (7012083093) for General Laibility Only; Policy Period: 01/01/2021 - 01/01/2022. E)Type of Insurance: Excess Liability; Carrier: Landmark American Insurance Co.; Policy number: LHA092746; Limit: $2,000,000- Excess over lead umbrella (7012083093)forAuto Only; Policy Period: 01/01/2021 - 01/01/2022. ACORD 101 (2008/01) © 2008 ACORD CORPORATION. All rights reserve( The ACORD name and logo are registered marks of ACORD