COI_Automobile_Coverages_Needed_for_Mandatory_Project_Site_Tour.pdf

ACORD

CERTIFICATE OF LIABILITY INSURANCE I

DATE (M�VDDNYYY)

THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE H LDER. 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 certifi cate holder Is an ADDITIONAL INSURED, the policy{les) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and condi t ions of the policy, certain policies may require an endorsement. A s tatement on this certificate docs not confer righ t s to the cer t ificate holder in lieu of such endorsement(s).

PRODUCER CONTACT Agent Name NAME:

URProtecled Insurance Agency PHONE I r..ctNo): '"-'"' u ... � ... -n.

Address, City, State, Zip E,MAIL

ADDRESS:

Telephone: INSURER/SI AFFORDING COVERAGE NAIC" Fax: INSURER A: Lexington Insurance Co. (AM Best A, XV) 19437

INSURED INSURER B : Liberty Mutual Insurance Co. (AM Best A, XV) 23043 Other Party Name {Contractor/Lessee} INSURER C:

Address INSU�RO: ,n.. // City, State, Zip INSUR)R\: ;:'/ );,J II

INSURE�\ ' /-1 # /)'

COVERAGES CERTIFICATE NUMBER: '{, \ . \''- .,,#' REVISION NUMBER:

THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IS

D TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD

INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CO , ACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE P [\CIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCE�_,BY PAID CLAIMS.

INSR LTR TYPE OF INSURANCE

COMMERCIAL GENERAL LIABILITY

I CLAIMS-MADE OCCUR

GEN'L AGGREGATE LIMIT APPLIES PER:

POLICY □ JECT PRO•

OTHER:

AUTOMOBILE LIABILITY -

X ANY AUTO

-ALL OWNED

- AUTOS

HIRED AUTOS - -

□ LOC

SCHEDULED

AUTOS

NON-OWNED

AUTOS '

UMBRELLA LIAB � OCCUR

EXCESS LIAB ·MADE

OED I I REttl'.noN $ ;:;;;;;-

WORKERSCOMPEN

ir

N c ANO EMPLOYERS' LI ILITY y / N ANYPROPRIETOR/PA r E� CUTIVE

OFFICER/MEMBEREX VJ)E ?

(Mondalory In NH) If rn• desalbe onder D SCRIPTION OF OPERATIONS below I

ADDL

l>JCD y

/J

SUBR

WVD

y

I

POLICY NUMBER POLICY EFF

IMMIDDNYYYI /OLICY EXP MMIDDNYYYI LIMITS

EACH OCCURRENCE

UAMAGE I U Kt:N I t:U

PREMISES /Ea occ:..rencol MED EXP (Any ooe person) $

PERSONAL & ADV INJURY s

GENERAL AGGREGATE s PRODUCTS· COMP/OP AGG s 2,000,000

11F� $

', \\ COMBINED SINGLE LIMIT $ 1,000,000

/Ea accldenn BODIL y INJURY (Per person) $

AUT.Q.56.Z89 BODILY INJURY (Per eccldenl) $

�-1'�

PROPERTY DAMAGE

$ /Per ec:cldenll

EACH OCCURRENCE $

AGGREGATE $

I ��frurE I I ER

OTH-

E.L. EACH ACCIDENT

E.L. DISEASE· EA EMPLOYEE S

E.L, DISEASE · POLICY LIMIT $

DESCRIPTION OF OPERATIONS I LOCA,ONS I VEHICLES (ACORD 101, Addillonal Remarks Schedule, may bo allaehod If more space is roquirod)

CERTIFICATE HOLDER CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE

THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN

ACCORDANCE WITH THE POLICY PROVISIONS.

AUTHORIZED REPRESENTATIVE

In surance Ag enUBroker Signature or St am p

I © 1988-2014 ACORD CORPORATION. All r ights reserved.

ACORD 25 (2014/01) The ACORD name an d log o are reg is tered marks of ACORD

The Lee County Port Authority is named Additional Insured with respect to the Commercial General Liability policy on a Primary and Noncontributory basis and includes a Waiver of Subrogation in favor of the Authority.

The Lee County Port Authority is named Additional Insured with respect to the Automobile Liability policy on a Primary and Noncontributory basis and includes a Waiver of Subrogation in favor of the Authority.

The Lee County Port Authority is named Additional Insured with respect to the Umbrella/Excess Liability policy on a Primary and Noncontributory basis and includes a Waiver of Subrogation in favor of the Authority. Umbrella/Excess Liability policy follows form over (specify) liability.

The Workers Compensation and Employers’ Liability policy includes a Waiver of Subrogation in favor of the Lee County Port Authority.

Lee County Port Authority 11000 Terminal Access Road, Suite 8671 Fort Myers, FL 33913

$2M if airside FMY / $5M if airside RSW

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Larene Brubaker Highlight