HomeMy WebLinkAboutExhibit 11EXHIBIT D
Aront. CERTIFICATE OF LIABILITY INSURANCE
OP 341..1 DATE (MMIDOWYYY)
ACTIIO 2 . 07/05/ 07
'rants Inssrancl :Agency, Inc.
430 West F1ag1,:r Street
Tani FL.33144
tone:31)5-648-7)70 Fax:305-643-7090
SEEtD
Action Community Center Inc.
970 SW . Street #304
Miami FI 33130
THIS CERTIFICATE IS ISSUI s; AS A MATTER OF INFORMATION
ONLY AND CONFERS NO R 3HTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICA7 :DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE At': ORDED Sf THE PCLICIES BELOW.
I NAM it
I INSURERS AFFORDING COVI RAGE
IINSURER A: Associated Indust'iss las. Co.
INSURER 8: Scottsdale Lissom :e Compacy
INSURER C: National Lndemait co of Muth
INSURER 0:
ITT Hartford insu ance Ccepanl
INSURER E:
OVERAGE:i
THE POLICIEU'OF 1NSURANC i LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PER100 INDICA'
ANTREOUtRCMENT, TERM 0 I CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE
AtAYPERTAIN, THE NSURAN :E AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO
POLICIES. AGGREGATE LIMIT. 3 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
:0. NOTWITHSTANDING
'AY BE ISSUED OR
:ONOITIONS OF SUCH
rrRR MSRO TYPE OF I ISURANCE POLICY ?Queen
GENERAL LIABILIT '
X ; COMMERCIAL 3ENERAL LIABILITY CPS0811173
CLAMS A ADE ® OCCUR
GEIfLAGGREGATE UMRAPPLIES PER:
I POLICY JEC n LOC
AU'(OIAOBILELIAO LIT?
ANY AUTO
ALL OWNED A JTOS
SCHEDULED! JTOS
HIRED AUTOS
NON -OWNED .UTOS
GAUGE UABIUT
IANY AUTO
EXCESSNMBRELL t UABIUTY
IOCCUR (D CLAIMS MADE
DEDUCTIBLE
. 1 r--I RETENTION S
WORKERSCOMPENSAT )NAND
FJIPLOYERLS' LIA8IUTY
a
ANY PRO RIETORJPART( ER/EXECUTIVE
OFF)CER.MEMBER EXCLI DEDT
ryes, desmbs under
SPECIAL 5ROVISIONS be ay
74APN311949
74APN311949
74APN311949
2006327964
1R5t
DATE (MM/OIUYY) GIN T E (I MIO0i i )•
12/$1'06 12/31/07
i ( 41/
j�.�' t'v \ 1,
02/24/07
02/24/07
02/24/07
11/20/06
02/24/08
02/24/08
02/24/08
11/2Q/07
LIMITS
EACH OCCURRENCE
UANAGt 1 U NtN I tU
PREMISES iEa °cauanca)
$ 500,000
s 100,000
MED EXP (My one Pam)
s 1, 000
PERSONAL a ADV INJURY
s Included
GENERAL AGGREGATE
s 1,000,000
PRODUCTS -COMPIOP AGO
s Excluded
COMBINED SINGLE LIMIT
(Ea accident)
s 500,000
BODILY INJURY
(Per person)
BODILY INJURY
(Par accident)
$
PROPERTYOAMAGE
(Per accident)
AUTO ONLY- EA ACCIDENT
S
$
OTHER THAN EA ACC
AUTO ONLY: AGG
EACH OCCURRENCE
$
$
S
AGGREGATE
s
$
X ITOR UMJTS 146
UIH-
ER
$
EL EACH ACCIDENT
s500,000
E.L. DISEASE - EA EMPLOYEE
s 500, 000
E.L. DISEASE -POLICY LIMIT
_s 500000
OTHER
3 Personal Property CPS0811173 12/31/06 12/31/07
Business Incpine CPS0811173 12/31/06 12/31/07
ESCAIPTION OF OPERATION: I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
5% Wind& Hail Deductible/ Location: 970 SW 1st St. #304 Miami, FL).BOND 21BDDA37807 7/02/07-7/02/08 $100,000 $500 DED
:ncluding as adlitional insured City of Miami.
:ity of Miami List Payee.
1000 Ded
1000 Ded
33172
$20,000.
$30,000
:ERT)FICAI'E HOLDER
CANCELLATION
CITYM33
City of Miami
Departmsint of CIP and Transp.
Office iIf City Manager
444 SW ::nd Ave loth Floor
Miami F:.•33130
SHOULD ANY OF THE ABOVE OESCI 8E0 POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSUI :R WILL ENDEAVOR TO MAIL 30 OAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLD R NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILI 'Y OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AU
DitePRESn+�. IVE:,. V-%
s.:.r �Sr,,.
0ACORD CORPORATION 1988
DEPARTMENT OF RISK MANAGEMENT
INSURANCE/SAFETY APPROVAL FORM
Name
Lilia I. Medina
Department
City's Manager's/Office of Transportation
Review
Status
Description
Action Community Center, Inc.
Tracking .#
Date:
10/5/2007
Financial
Ratings Strength REQUIREMENTS:
Commercial General Liability
Scottsdale Insurance Company A+ XV
Owned, Hired and Non Owned Autos
National Indemnity of South A++ XV
Workers Comp:
Associated Industries Insurance Company
Personal Property/Business Income
Scottsdale Insurance Company A+ XV
Builder's Risk
Professional Liability
Garage Keepers Liability
Excess Liability:.
Crime Coverage
Pollution:
Insurance NOT Required
ity of Miami is Named Additional Insured
The City is providing insurance
City of Miami is Loss Payee
jBayfront Park Named Additional Insured
APPROVAL STATUS
APPROVED
3ncL
(Terry M. Quevedd—"
Insurance Unit
Not Approved
Coverage is insufficient
Not A Rated Company
A Type of Coverage is Missing
Other
The City NOT Named Additional Insured
Insurance/Safety Comments:
Third Amendment to Agreement between the City of Miami and Action Community Center, Inc.,
for the provision of transportation services. The amendment will extend the term of the Agreement for an
additional one-year period from October 1, 2007 thru September 30, 2008 for the amount of $319,000.
Risk 002.xls 10/5/2007 9:35 AM