CERTIFICATE OF LIABILITY INSURANCE (3)
.ACORD CERTIFICATE OF LIABILITY INSURANCE
. TII
PRODUCER (407) 88 6 - 33 0 1
GENTRY INSURANCE AGENCY,
2121 E. SEMORAN BLVD.
P. O. BOX 2046
APOPKA, FL 32704-2046
INSURED Clark Sales Display
PO Box 1007
Tavares, FL 32778
FAX (407)886-9530
INC.
DATE (MMlDD/YY)
08/06/2002
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
Inc
INSURER A:
INSURER B:
INSURER C:
INSURER D:
INSURER E:
Republic Western Ins Co
Auto-Owners Ins Co
United National Ins Co
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.
'rf~ TYPE OF INSURANCE POLICY NUMBER . DATE (MMlDDIYY) DATE (MMlDD/YY) LIMITS
GENERAL LIABILITY MPOO02432-02 08/01/2002 08/01/2003 EACH OCCURRENCE $ 1,000,000
I-- FIRE DAMAGE (Anyone fire) $
X COMMERCIAL GENERAL LIABILITY 100,000
I-- o CLAIMS MADE [TI OCCUR MED EX? (Anyone person) $
5,000
I-- PERSONAL & ADV INJURY $
A 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS.COM~OPAGG $ 2,000,000
rxl 'nPRO- n
X POLICY JECT LOC
AUTOMOBILE LIABILITY 253955700 10/25/2001 10/25/2002 COMBINED SINGLE LIMIT
I-- (Ea aCCident) $
X ANY AUTO 1,000,000
I--
ALL OWNED AUTOS BODILY INJURY
I-- (Per person) $
SCHEDULED AUTOS
B l-
X HIRED AUTOS BODILY INJURY
f-- (Per aCCident) $
X NON-OWNED AUTOS
I-
PROPERTY DAMAGE $
(Per aCCident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABIUTY U76323 01/01/2002 08/01/2003 EACH OCCURRENCE $ 2,000,000
~ OCCUR o CLAIMS MADE AGGREGATE $ 2,000,000
C $
~ DEDUCTIBLE $
X RETENTION $ 10,000 $
WORKERS COMPENSATION AND I TORY LIMITS I IVEFr
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE. S
E.L. DISEASE - POLICY LIMIT $
OTHER ~253955700 10/25/2001 10/25/2002 Comprehensive Deductible $250
!tired/Non-Owned Auto
B Physical Damage Collision Deductible $250
overaae
DESCRIPTION OF OPERATIONSlLOCATlONSlVEHlCLESlEXCLUSlONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
- .. . . , ~ - .- - -'. . -'GI"V.' ':c:~
.~ . .,""' I . WUoJ ...~~""'. ...., u~
ity of Clearwater is included as Additional Insured on General Liability and Auto Liability.
~eissue of certificate of insurance dated" mailed 09/10/01.
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER cANcELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
City of Clearwater ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: Debbie Reid BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABlLlTY
PO Box 4748 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
Clearwater, FL 33758-4748 AUTHORIZED REPRESENTATIVE ~. ditPk,.otk-
Debra Liebknecht/IRMA
- llfD~
FAX. (727)562 4825
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.