CERTIFICATE OF LIABILITY INSURANCE (4)
ACORD CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYYYY)
.
1M 07/31/2003
PRODUCER (407)886-3301 FAX (407)886-9530 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
GENTRY INSURANCE AGENCY INC ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
POBox 2046
Apopka Fl 32704-2046 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Valley Forge Insurance Co
Clark Sales Display Inc INSURER B: Auto-Owners Ins Co 18988
POBox 1007 INSURER C:
Tavares Fl 32778 INSURER 0:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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/MMIDDIYY DATE IMM/DDIYY LIMITS
GENERAL LIABILITY BAPP2072710292 08/01/2003 08/01/2004 EACH OCCURRENCE $ 1,000,000
'--
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurence\ $ 100,000
I CLAIMS MADE 0 OCCUR MED EXP (Anyone person) $ 5,000
A PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000
Xl .n PRO- nLOC
X POLICY JECT
AUTOMOBILE LIABILITY 4253955700 10/25/2002 10/25/2003 COMBINED SINGLE LIMIT
- (Ea accident) $
~ ANY AUTO 1,000,000
ALL OWNED AUTOS BODILY INJURY
- (Per person) $
SCHEDULED AUTOS
B ~
X HIRED AUTOS BODILY INJURY
- (Per accident) $
~ NON-OWNED AUTOS
.
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EAACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY BAPP2072710292 08/01/2003 08/01/2004 EACH OCCURRENCE $ 2,000,000
o OCCUR D CLAIMS MADE AGGREGATE $ 2,000,000
A ~mbrella Form $
8 DEDUCTIBLE $
X RETENTION $ 10,000 $
WORKERS COMPENSATION AND I TORY LIMITS I IOJ~-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE EL. EACH ACCIDENT $
OFFICER/MEMBER EXcLUDED? EL. DISEASE - EA EMPLOYE $
If yes, describe under EL. DISEASE - POLICY LIMIT
SPECIAL PROVISIONS below $
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
E: Holiday Decorating Services
ity of Clearwater is included as Additional Insured on General liability and Auto Li abil i ty.
eissue of certificate of insurance dated & mailed 09/10/01.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
City of Clearwater -3..0..- 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 LIABILITY
PO Box 4748 OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES,
Clearwater, Fl 33758-4748 AUTHORIZED REPRESENTATIVE Q)Jn, rJ iJJk,. aJ:k.
Debra liebknecht/PATT
ACORD 25 (2001/08) FAX: (727) 562-482 5
@ACORDCORPORATION 1988
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,
ACORD 25 (2001/08)