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Home My WebLink AboutExhibit 5Attachment 4" Insurance Requirements (Certificate of Insurance follows this cover page) DEPARTMENT OF RISK MANAGEMENT INSURANCE/SAFETY APPROVAL FORM ame Description .ilia Martin Westnet epartment Project # Date: ire 11/7/2005 .eview Financial tatus Ratings Strength ci Mol a1 L-1au11ILy. he Travelers wned/Hired/Non Owned Auto late Farm Mutual lorkers Comp: tate of California iquor Liability uilder Risk: rofessional Liability: ontractor's Pollution Liability rime xcess Liability -ie Travelers erformance Bond PPROVAL STATUS r' �iPPRO'VETJ cx APPRO ED / I rank Gomez isurance Coordinator atrice Noval afety/ADA Coordinator REQUIREMENTS: Insurance NOT Required xx City of Miami is Named Additional Insured ❑The City is providing insurance City of Miami is Loss Payee DBayfront Park Named Additional Insured ❑ Not Approved Coverage is insufficient aA Type of Coverage is Missing ❑ Not A Rated Company ❑Other ❑ The City NOT Named Additional Insured isurance/Safety Comments: liscussed Performance Bond with Dania. Okay to waive bond requirement based on sole source rofessional Liability not an issue. Manufacturing exposure falls under Products/Comp. Ops. 1/7/2005. 4:00 PM r•ronn. Tablthe trm At: Stockdale Insurance Agency I-axlu: uol3LIJ,itov I O: l nlei —quidl voter ACORD CERTIFICATE OF LIABILITY INSURANCE OPID TIJ I DATE(MMIDDNYYY) WESTN-1 12/30/04 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Stockdale Ins (Fresno Office) ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE LICENSE #OC26131 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PO Box 5537 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Fresno CA 93755 GENERAL LIABILITY Phone:559-226-7611 Fax:559-226-7191 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA: The Travelers 39357 A INSURER B. Westnet, Inc. Richard K. Matheny. INSURER C, 16581 Burke Lane Huntington Beach CA 92647 I14SUREP0 INSURER E'. MED EXP (Any one person) $ 5,000 ,0T1]TJ:1:7_Tc7*9 THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR TIME POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE (MWDDNY) DATE(MMIDDIYY) LIMITS REPRESENTATIVES. Miami FL 33130 GENERAL LIABILITY EACH OCCURRENCE $ 7- , 000 , 000 A X X; COMMERCIAL GENERAL LIABILITY CLAIMS MADE a OCCUR 680-10SIB222 01/01/05 01/01/06 PREMISES (Ea occurence) $ 300,000 MED EXP (Any one person) $ 5,000 PERSONAL 8 ADV INJURY $ 1, 000 , 0 0 0 GENERAL AGGREGATE $ 2,000,00D GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000 P POLICY ECTRO PRO- 71 LOC AUTOMOBILE LIABILITY ANY A.L110 ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS APPPI 3 I - , l'L COMBINED SINGLE LIMIT (Ea accident) BODILY INJURY $ (Per person) BODILY INJURY $ (Per accident) 1 (j7 I PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ OTHER THAN EA ACC $ ANY AUTO - AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 2 , 000,000 A X OCCUR CLAIMS MADE CUP -8141W876 01/01/05 01/01/06 AGGREGATE $ 2,000,00() S $ DEDUCTIBLE X RETENTION $ O $ WORKERS COMPE14SATION AND EMPLOYERS' LIABILITY TORY LIMITS ER E.L. EACH ACCIDENT $ ANY PRCPRIETORIPRRTNER/EXECIlTIVE E.L. DISEASE - EA EMPLOYEE $ OFFICERIMEMBER EXCLUDED? It yes, aecnde uiXJgr E.L. DISEASE - POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS ( VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Fax: 305-400-5096. *10 days Notice of Cancellation in the case of non-payment of premium. Certificate Holder is named Additional Insured with regards to work performed by the Named Insured only. CERTIFICATE HOLDER CANCELLATION CITYOFM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN City Of Miami NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL Dept. of Fire Rescue Attn: Chief Reginald Duren IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR 444 S.W. Second Ave. REPRESENTATIVES. Miami FL 33130 AU THO I DR R ENTATIV ACUnu tz (covuuol e)ACORU CORPORATION 1988 CERTHOLDER COPY STATE- P.O. BOX 420607, SAN FRANCISCO, CA 94142.0807 COMvaNSATIOPQ IN$U AANGa FUND D CERTJ�ICATE OF WORKERS' COMPENSATION INSURANCE I ISSUE DATE: Y0 -16-201p4 GROUP: 000550 I; POLICY NUMBER: 536-2004 I. CERTIFICATE lo: 30 !' CERTIFICATE EXPIRES: 04-01-2005 04-01-2004/04-01-2005 CITY 07 MIAMI FLORID' DSPARTKENT OY FIRE SCVB 444 $,w 2" AVE u XIAXI FL 33130ED !I This is to certify that we have {¢sued a valid Worker's Compensation Insurance policy in e form approved by the California Insurance Commissioner to thio employdr named below for the pollcy period Indicated. This policy is not subject to ropcellation by the Fund except upon 30 days advance written notice to the employer. We will also give you 30 days advance notice should this policy be cancelled prior to Its normal expiration. This certificate of insurance is hot an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwlthst riding any requirement, term or condition of any contract or other document with respect to which this certiftcat of Insurance may be issued or to which it may pertain, the insurance afforded by the policy described herein is subject to It the terms, exclusions, and conditions, or such policy. I: AUTNOWEO REPRESENTATNE �' PAeCIOENY I. EMPLOYER'5 LIABILI Y LIMIT INCLUDING DEFENSE COSTS: S1,000,D00 PER OCCURRENCE. ENDORS19MENT #1600 RICHARD X X&THENY, PRES - EXCLUDED. ENDORSIkENT 02065NTITLED CERTIFICATE HOLDERS' NOTICE EFFECTIVE 05-19-3004 IS ATTACHED TO AND 80 S A PART OF THIS POLICY. I� I. I! i; i' ii EMF40YEA i. 113MET INC fI I! 16SPI BURKE LN HURVINOTN 9CH CA 9247 II t� (J1G,�GI SCIF tOM2- Acm ,t vI, c,nMu4 0n I! AUE 0. 1416.2000 P, 7 Ya' H� v 1v0+1 waamlwK Ihf•1 nvac'Of FIpPL STATE FUt;O oOGVMErIi' PAGE 1 OF t tl 12/06/2004 02:43 17148790660 STATE FARM INS PAGE 01 CERTIFICATE OF INSURANCE NSURANC E AS RESPECTS THE INTEREST OF THE CERTIFICATE HOLDER WILL, G CANCELED OR OTHERWISE TERMINATED WITHOUT GMNG 10 DAYS PRIOR EN NOTICE TO THE CERTIFICATE HOLDER NAMED BELOW, BUT IN NO EVENT THIS CERTIFICATE BE VALID MORE THAN 30 DAYS FROM THE DATE WRITTEN. ERTIFICATE OF INSURNCE DOES NOT CHANGE THE COVERAGE PROVIDED BY )LILY DESCJURED BELOW: hes that; X STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY of Bloomington, Illinois, of STATE FARM FIRE AND CASUALTY COMPANY of Bloomington, Z.U. ded coverage in force for the fallowing Named Insured as shown belorov: tsured Richard & Barbara Matheny DBA Westnet D ----------------------------------------------------------- fNamad.Insured 16581 BuiLc L.A. Hunting p Beach Ca 92647-4537 � ' ------- pol Cy I imbet P43 3414 -F26 -75E? R544242-C29-75DR23 8329 -A17 -75F E tz Daee u Pol CY 12/26/04-12/26/05 11/29/04-11/29/05 07/17/04-07/17/05 EMPLOYERS NON- 2004 FORD 1976 CHEVROLET De zip of OWNERSHIP EXCURSION SPORT VAN V c ; LLABILTI'Y VIN# VIN# 1FMSU43P74ED18053 CGI-256UI00610 LIU 97 OF LU 311 I-ry 1 Person ciCkmt $1,000,000 $1,000,000 11,W0,000 I P Dam i Co asivc $250 Deductible $250 Deductible Col si $IWO Deduc6bk $1000 Deductible E R'S N - YES NO NO OE P HI D ME YES CO NO NO Agrat Title NA, IE i ND ADDRESS Of CERTIFICATE HOLDER CI O MIAMI DE T. U7 FIRE & RESCUE A IEF DUREN 444 .W. ND AVE Ml fl, L33130 8058/F419 01/07/05 Agents Code Dat, NAME AND ADDRESS OF AGENT GEOP, E E. MONTGOMERY AGEN Llcelve # 04454M �Ntrt�re 115 S. HafbOr BW -,Ste. F Fullerton, GA 82632 Bus; {71 4) 566-2M