Date Company Address City State Zip ATTN: Contact ... - RR Simmons

PRODUCER
Insurnce Agent/Broker Name
Insurnce Agent/Broker Street Address or P.O. Box
Insurnce Agent/Broker City, State & Zip Code
Contact & Phone Number
INSURED
Vendor Name
Vendor Street Address or P.O. Box
Vendor City, State & Zip Code
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD/YYYY)
Month/Date/Year
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICIES BELOW.
INSURERS AFFORDING COVERAGE NAIC #
INSURER A: Name of Insurance Company Enter NAIC#
INSURER B: Name of Insurance Company (if applicable) Enter NAIC#
INSURER C: Name of Insurance Company (if applicable) Enter NAIC#
INSURER D: Name of Insurance Company (if applicable) Enter NAIC#
INSURER E: Name of Insurance Company (if applicable) Enter NAIC#
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
A
A
ADD’L
INSRD
TYPE OF INSURANCE
GENERAL LIABILITY
COMMERICAL GENERAL LIABILITY
CLAIMS MADE OCCUR
Independent Contractor
Contractural Libility
XCU Coverage
GEN’L AGGREGATE LIMIT APPLIES PER:
POLICY PROJECT LOC
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
POLICY NUMBER
Enter Policy #
Enter Policy #
POLICY EFFECTIVE
DATE (MM/DD/YY)
Enter Effective
Date
Enter Effective
Date
POLICY EXPIRATION
DATE (MM/DD/YY)
Enter Expiration
Date
Enter Expiration
Date
LIMITS
EACH OCCURENCE $500,000
DAMAGE TO RENTED
PREMISES (Ea occurrence) $50,000
MED EXP (Any one person) $5,000
PERSONAL & ADV INJURY $500,000
GENERAL AGGREGATE $1,000,000
PRODUCTS - COMP/OP AGG $1,000,000
COMBINED SINGLE LIMIT
(Each Occurrence)
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
$
$500,000
$500,000
$500,000
PROPERTY DAMAGE
(Per accident)
$500,000
GARAGE LIABILITY
AUTO ONLY - EA ACCIDENT $
A
ANY AUTO
EXCESS/UMBRELLA LIABILITY
OCCUR
CLAIMS MADE
DEDUCTIBLE
RETENTION $5,000
Enter Policy # (if
required)
Enter Effective
Date
Enter Expiration
Date
OTHER THAN
AUTO ONLY:
EA ACC $
AGG $
EACH OCCURRENCE $1,000,000
AGGREGATE $1,000,000
$
$
$
A
WORKERS COMPENSATION AND
EMPLOYERS’ LIABILITY
ANY PROPRIETOR/PARTNER/EXECU-
TIVE OFFICER/MEMBER EXCLUDED
If yes, describe under
SPECIAL PROVISIONS below
Enter Policy #
Enter Effective
Date
Enter Expiration
Date
WC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT $100,000
E.L. DISEASE - EA EMPLOYEE $500,000
E.L. DISEASE - POLICY LIMIT $100,000
OTHER
See Exhibit A
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Project: USF Athletic Facilities, Project No. 579
R. R. Simmons Construction Corporation, University of South Florida, and USF Financing Corporation are added as additional insured, including completed operations,
with respect to the Commercial General , Automobile, and Excess/Umbrella Liability policies with a seperation of insured provision that is primiary and non-contributory. A
waiver of a right to recovery or subrogation is included in all policies in favor of R. R. Simmons Construction Corporation, Univeristy of South Florida and USF Financing
Corporation. Coverage will not be cancelled or allowed to expire until at least 30 days notice has been given to all named insured, except 10 days for nonpayment. All
endorsements are attached hereto.
CERTIFICATE HOLDER
R. R. Simmons Construction Corporation
13112 Telecom Drive
Tampa, FL 33637
Facsimile Number: (813) 632-5500
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE INSURER AFFORDING COVERAGE WILL ENDEAVOR TO
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT., BUT
FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE