CERTIFICATE OF LIABILITY INSURANCE
.;
ttI: 63
ACORD.,. CERTIFICATE OF LIABILITY INSURANCE
F
PROO\IC~
USI of Souther... California
LicU351162 - 818-251.3000
POBox 4367
Woodland HIlls, CA 91387
DATE \MJNDgfy\'n')
09l03lO4
l"HIS CERTIFICATE IS IHUED AS A MATTER OF INFORMATION
ONLY AND CONn!RS NO RIGHTS UllOM me CERTIFICATE
HOlDER. THIS ceRTIFICATE DOES NOT AMeND, EXTI!I\lD QR
ALTER TtIE COVERAGE AFFORDliD BV THE POUCIK. ISUW.
Churoh of ScienllOlogy IntematioR1lI
DBA: IIlag Service Organization
503 CI",el8nd st
Clearwater, FL 34616
COVERAGES
INSURERS AFFORDING COVERAGi
INSUREltA: Zurich/American InS. Grr>
1N!iU~" &;
IIlSIJIlEIl C!
INSURER 0:
INSURER E:
NAIC ,
99999
IN~D
THE POLICIES OF INSURANc:E uS'lEl BELOW HAve BEEN ISSUED 10 THE IN8UMD NAL4!D ABOVE FOR THE POLICY PE~II;lD INDICATED. NOTWITM$'TANOING
ANY RrECUIREMeNT. TERM OR CQNOITION OF At>('( eoNTRACT OR Ontl!A OOCUMEIlT WI'TH ~I!SPECTTO WHICH THIS CERTlIfCATI! MAY BE ISSUED olli
MAV PIIltT.A,liII. THe IN$UAANCE AFFO~OI!D BYnE F'O~eJl!S OESCRlSiC HI!REJllIS SUBJIiC'I' TO ALL nfE 11!1lIM$. exCLUBlONSA!'iO CONDITIONS OF SUCH
P01.1CII!S, AGGR&iQ,ll.TI! LIMITS SHOWN MAY HA~ IlIiI!N ReDUCED BV PAlO Cl.AN8,
""'PE OF IIIBURAlla! POIJC'(N....'1t ~ C11YIi P':f~.~!!!e-J:lON LllllTS
~TR SR
A ...!!!NlIltAllIABIUT'I' GL092973S706 08115104 08115105 ....C;;H QCCUMeNCe s
~eRClAl. GENSIAI. UABlll1Y gAJ,l~E TO RENTED $
- ClAIMS t.t.\CIE 0 OOCUR
- MEC!X1' I.., Of19 ......,\ S
I'I!RSONAl. So ADV INJURY S
GENERAL AGGRI!GATf S
n~AGO~n~"~ AnS PER: Pl'lQOI,ICT$. CCMP,op AGG S
PWCY - ~~ lac::
ROIlIILlllABlL1TY COMBINED :!DNGLE L IMIl
ANY A'JrO (II .=idonll S
f-- i ,l.I.l. OWNIiD AUTOS BOOIL V INJURV $
SCl1e"u~o AUTOS (P~ pa"'on)
l-
f-- IlIItE~ ALTOS BODILY INJURY
(""'~-) $
~ NONoOVVMdC AUTOS
f-- PROi'E~ r"'AGE S
(FOe,""t ..
~RAlliIlIAB1Lrrv AUTO O~l V . III AeCICEtIT s
H N('(I<lJTQ OT\-l;R TIo;AN eA H:,C;; $
AUTO Otft. Y: AGG S
D~$SIUMBRE~~" \.lA8I1JI"( UCH OCCU~RENOIi $
OC:OUI'l 0 (;1.1\,"'$ w.De "'Gl$/l~&ATJ; S
5
~ ~l!DUcn.~e S
R'T'JoITIO'" , I $
WORKl!Rll OOMr!!NllAftOH AND we STAlU- IO]~
IUPLOYliRS'lIABILlTY E.l. EACH ACClOiiN'l' $
AlN PROPRIE'l'ORIPARTNC~UTI\I5
OFFICEMlliMQ;R IiXCLUO c.l. OISEASE .I!A fM~O"Yee' $
:r~M1'11:~Jl~~~JS ba!o" 1I~. OI!l;MIl. POUCV ~I""" $
Ol1;&R
OIi!&CRP1l<lN Qf OPERA-llONS I L.OOATlONS lVEtOCI.&$/ E)lC!-UBION8 AIXlUl IV DDOiiSamtT I $Ht:lAL PIl.OVl3IONS
City of Clemwater is additional insured as respecW a monitor ...,.or
atte~h.d to a ojtv~wn8c1 "nee IGClIted to the north of Hacienda Gardens.
oetwefln Saturn Ave" and Keen. Rd,
City of Clearwater
P.O. Box 4748
Clearwater, Fl 337~
CAACELLAT10N
SllOOUJ ANY Of"Tl1E ABCI\/E DESCltIBEllI'O.ICE& BE CANCB.Llill JO&FORE THE EXPIRAllO"
DAn 1M_a,. THE I=YI<O INQJIUR WILL ENlllliA~ TO MAIL ~ [lAYS WRITTEN
NO'ftCE 10 THE CEallFICATE HO~~ NAMEO TO me ~i:I'T, auT PAILURETO DO liOliHALL
IMP<I'I! 110 CIIUGAilQIl OR UADIUJ'f OF MV I(IND lJ~N 'IllE INSUl;I!..~ irS dE!ll'TS OR
~ AT1VE!l.
Au'nIOIllZEllIlEPRES!NTA TIllE
~ ICo 1.:u4
CERT1FICA T 1ol0LDER
ACORD 25 42001/08)1 of 2
#S25St27/M255125
ENE
@ ACORD CPRPORATION 1988
!
#.
IMPORTANT
If the certifICate holder is an ACOITIO~ INSURED. the poliqr(ies) must blil IiIndCnad. A statement
01'\ thitl certificate does not eonfer r1ghlS to the cerIificlU holder in lieu of $U';h endOtsement(a).
If SUBROGATION IS WAIVED, subject ttJ th.tennsand coodttionsofthe po!icy, certain pOlicies may
require an end0nl8ment. A statement on this cerllftcate dOe& not confer rightS to the. certif'ic8te
holder in lieu of IUc:h IiInclorsemen'(s).
DISCLAIMER
The Certlllca1e of Insurance en the reve"o _de of this form does not eonstitute a ~ntrac.t bliltween
the i$Suing insurer(G), authorimd fepre$el1la'..ive or producer, and the certlflcate holder. nor does it
aflir~tively or negatively amend, extend or aItef the cove!'age afforded by !he policies listed thereon.
,
ACORD 254 ('1)01J08) 2 of 2
#S255'27~255125