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2021-085A
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Entry Properties
Last modified
7/2/2021 5:03:42 PM
Creation date
7/2/2021 4:55:21 PM
Metadata
Fields
Template:
Official Documents
Official Document Type
Contract
Approved Date
06/15/2021
Control Number
2021-085A
Agenda Item Number
8.D.
Entity Name
Florida Site Contracting
Subject
4th Street Culvert Replacement at 90th Avenue,
Project Number
IRC-2022
Bid Number
2021045
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VEHICLE OGJIPM1�J`�'EQ�'IF-f OF INSURANCE 06/1812021 (MMfDD7VYYY) <br />a6/ia!2a21 <br />THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS <br />BELOWCERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, 'EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES <br />REPRESENTATIVE <br />CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE OR PRODUCER, ANO THE CERTIFICATE HOLDER. IS INSURER(S), AUTHORIZED <br />This form is used to report coverages provided to a single specific vehicle or equipment. Do not use this form to report liability coverage <br />Provicled to multiple vehicles under a sfttgle policy. Use ACORD 25 for that purpose. <br />PRODUCER <br />- CONTACT <br />NAE1F: PICK Mathews <br />Rich Mathews State Farm Agency PHONE _ <br />INC. No. Ext)• 239 992-8896 lti/c -992-2957 <br />9510 Corkscrew Palms Circle, Suited E4Yall Hol 239 <br />33925 <br />Estero, ADDRESS: - <br />FI D I rn en <br />INSURED <br />Ag Scope Services Inc <br />865 11111 Ct SW <br />Vero Beach, FL 32962 <br />DESCRIPTION OF VEHICLE OR <br />YEAR FAAKE I MANUFACTURER <br />_1998 Gmc <br />DESCRIPTION <br />Farm Mutual Automobile Insurance Company 25178 <br />9: <br />IN1WHER E; <br />PMENT <br />MODEL BODYTYPE <br />2500 FlVEHICLE IDENTIFiGATION NUMBER <br />Flat Bed 1GDJ6H1J6TJ501185 <br />VEHICLFJEQUIPMENT VALUE I SERIAL NUMBER <br />COVERAGES S <br />CERTIFICATE NUMBER-. <br />TNlS IS TO CERTIFY THAT THE POLICY(IES) OF INSURANCE LISTED BELOW HAS!HAVEBEEN TO THIEVISION NU <br />E WSABOVE FOR THE POLICY <br />PERIOD(S)D(S) INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERiA OR CONDITION OF AtVIISSUED '.CON7RACT OR OTHER DOCUMENT WITH RESPECT TO <br />WHICH THIS CERTIFICATE NIAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED 6Y THE POLICYNES) DESCRIBED HEREIN IS/At2E SUBJECT TO <br />ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICY(IES). <br />NSR nn"•L - <br />_7R ItdSRe TYPE OF INSURANCE POLICY NUtde ER POLICY EFFECTIVE POLICY EXPIRATION <br />DATE (hIMIDDfYYri) DATE (MM7DD/YYV Y) LIMITS <br />X VEHICLE LIABILIry <br />989 1241 -F15 -59A <br />GENERAL LIABILITY <br />OCCURRENCE <br />CLNrAS MADE <br />tyPE OF INSURANCE POLICY NUMBER <br />}.j VEH COI.LiRiON LOSS <br />i 989 1241 -F15 -59A <br />Y, IVEH COMP ! I VEH DTC <br />1 989 1241 -F15 -59A <br />EQUIPMENT <br />BASIC @ROAD <br />SPECIAL <br />Personal Injury Protect. <br />989 1241 -F -15-59A <br />Ob -15-2021 1 12-15-2021 i OS DEDUCTIBLE <br />REMARKS (INCLUDING SPECIAL CONDITIONS r pTHER COVERAGES) (Attach ACORD 101, AJditlanal Remarks Scnotlula, it more Space 15 required) <br />_ADDITIONAL INTEREST <br />Select elle of the following: <br />X The add)liunal Interest described below has been added to the policy(ieS) listed neral, by policy number(s). <br />A request has berm Sabrmfled to add the additional interest descnb0J belart to the policy(les) <br />rcln_9 herein [, ^,lie neniUartal. <br />VEHICLE I EQUIPMENT INTEREST: <br />LEASED FINANCED <br />NAtAE At1D AUDRESS OF ADDITIONAL INTEREST <br />INDIAN RIVER COUNTY PURCHASING DIVISION <br />1800 271h SLreot BuildinU " {3 <br />Vero Beach; FL 32960 <br />10,000 <br />CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE <br />DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br />DESCRIPTION OF THE ADDITIONAL INTEREST <br />ADDITIONAL INSURED LOSS PAYEE <br />LENDER'S LOSS PAYEE 15 Named Insured <br />LOAN / LEASE N_1_11 <br />AUTHORIZED <br />ACORD 23 (2016!03'2015 ORD <br />AC ' j <br />99 <br />O 17.GO `M <br />The ACORD name and logo are registered marks. Of ACORD TION. All rights reserved. <br />1004361 142967:3 01-262016 <br />COMBINED SINGLE LIMIT <br />S 1,000,000 <br />06-15-2021 <br />12-15-2021 <br />BOUILYINJURY(Perperon) <br />S — <br />eODILYINJURY(Per aeciden-) <br />S -- <br />__ <br />PROPERTY DAMAGC <br />g <br />EACH OC.11ENCE <br />VENERALAGGREGATE <br />$ <br />POLICYEFFECT(VE <br />DATE (Mhl/DD/YYYY). <br />POLICY EXPIRATION <br />DATE <br />S <br />ttAM/DD)YYYYj <br />LIMITS /DEDUCTIBLE <br />U6-15-2021 <br />12-15-2021 <br />n ACV ❑ AGRF.EDAtAT <br />S LIMIT <br />_ <br />❑ ❑ STATEDAMT <br />S 1,000 OED <br />OG -15-2021 <br />12-15-2021 <br />ACV ❑ AGREE 0AMT i <br />b LIMIT <br />---- <br />❑ 0 STATED AMT <br />5 1,000 DED <br />(� ACV ❑ AGREED AMT <br />----�---- <br />❑ RC ❑STATED Atrr <br />S LIMIT <br />__ <br />❑ <br />S DED <br />Ob -15-2021 1 12-15-2021 i OS DEDUCTIBLE <br />REMARKS (INCLUDING SPECIAL CONDITIONS r pTHER COVERAGES) (Attach ACORD 101, AJditlanal Remarks Scnotlula, it more Space 15 required) <br />_ADDITIONAL INTEREST <br />Select elle of the following: <br />X The add)liunal Interest described below has been added to the policy(ieS) listed neral, by policy number(s). <br />A request has berm Sabrmfled to add the additional interest descnb0J belart to the policy(les) <br />rcln_9 herein [, ^,lie neniUartal. <br />VEHICLE I EQUIPMENT INTEREST: <br />LEASED FINANCED <br />NAtAE At1D AUDRESS OF ADDITIONAL INTEREST <br />INDIAN RIVER COUNTY PURCHASING DIVISION <br />1800 271h SLreot BuildinU " {3 <br />Vero Beach; FL 32960 <br />10,000 <br />CANCELLATION <br />SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED <br />BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE <br />DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. <br />DESCRIPTION OF THE ADDITIONAL INTEREST <br />ADDITIONAL INSURED LOSS PAYEE <br />LENDER'S LOSS PAYEE 15 Named Insured <br />LOAN / LEASE N_1_11 <br />AUTHORIZED <br />ACORD 23 (2016!03'2015 ORD <br />AC ' j <br />99 <br />O 17.GO `M <br />The ACORD name and logo are registered marks. Of ACORD TION. All rights reserved. <br />1004361 142967:3 01-262016 <br />
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