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INSURANCE CERTIFICATES I CITY OF CLEARWATER I ROUTE SLIP , ~at-~ . ~(Ug'. DATE: -1Y~7k~ c '" 30-1~ RECEIVED FR0I1 : Parks and Recreation Department - ~~~ ~/1/fbr~/VJ AUt; 30 1982 TO: SUBJECT: FOR YOUR INFORHATION. ~ INVES~IGA':'E & REPORT PLEASE SEE ME JOB ACCOMPLISHED SUBIfiT RECOMI-1ENDATION OR t;OMI-1ENTS IN WRITIN.G FOR NECESSARY ACTION OTHER mlARKS: ~ rVl{)~ + ~ ~ '" 9,~~.t C.W. BOLLINGER CO. 499 Bloomfield Avenue Montclair, NJ 07042 COMPANIES AFFORDING COVERAGES COMPANY LETTER A B C o E FEDERAL INSURANCE COMPANY ECEIVEO COMPANY LETTER NAME AND ADDRESS OF INSURED AMATEUR SOFTBALL ASSOCIATION OF AMERICA COMPANY LETTER Insured Team(s)/League: - Clearwater Bombers COMPANY LETTER Cert. # G-8015 COMPANY LETTER This is to certify that policies of insurance listed below have been issued to the insured named above and are In force at this time. 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 herem IS subject to all the terms, exclusions and conditions of such policies, COMPANY LETTER TYPE OF INSURANCE POLICY NUMBER POLICY EXPIRATION DAH Limits of Liability in Thousan EACH OCCURRENCE GENERAL LIABILITY A [JCOMPREHENSIVE-FORtllr [X] PRt:MISES-OPERATIONS * o EXPLOSION AND COLLAPSE HAZARD o UNDERGROUND HAZARD o PRODUCTS/COMPLETED OPERATIONS HAZARD o CONTRACTUAL INSURANCE o BROAD FORM PROPERTY DAMAGE o INDEPENDENT CONTRACTORS o PERSONAL INJURY BODILY INJURY $ PROPERTY DAMAGE 7307900 -6Z 12/31/8 3 BODIL Y INJURY AND PROPERTY DAMAGE COMBINED $ 1,000 $1 ,000 PERSONAL INJURY $ AUTOMOBILE LIABILITY o COMPREHENSIVE FORM DOWNED o HIRED o NON.OWNED BODILY INJURY (EAC H PERSON) BODILY INJURY (EACH ACCIDENT) EXCESS LIABILITY PROPERTY DAMAGE BODIL Y INJURY AND C PROPERTY DAMAGE COMBINED o UMBRELLA FORM o OTHER THAN UMBRELLA FORM BODILY INJURY AND PROPERTY DAMAGE $ COMBINED WORKERS' COMPENSATION and EMPLOYERS' LIABILITY DESCRIPTION OF OPERA T10NS/LOCA'nONSNEHICLESAma1:eu rSoftba II' Team (s) ..- 1 CITY OF CLEARWATER FLORIDA IS INCLUDED AS ADDITIONAL INSURED, APPLICABLE TO THE USE OF THE FIELD BY THE NAMED INSURED. *Insurance provided under this certificate excludes bodily injury and property damage claims resulting from hazardous field conditions arising out of improper maintenance and upkeep of such fields, including bleachers, grandstands, concession areas, dugouts, playing surfaces, backstops, fences, and parking facilities, unless the registered teamS/leagues of the Amateur Softball Association of America are legally responsible for such maintenance and upkeep via ownership, lease or other written contractual agreement. Cancellation: Should any of the above desCribed policies be cancelled before the expiration date thereof, the issuing com- pany will endeavor to mail --1.Cl- days written notice to the below named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the company. NAME AND ADDRESS OF CERTIFICATE HOLDER. CITY OF CLEARWATER FLORIDA 210 S. COACHMAN ROAD CLEARWATER, FLORIDA 33575 C. W. BOLLINGER CO. 499 Bloomfield Avenue Montclair, New. Jersey 07042 COMPANIES AFFORDING COVERAGES m~~~NY A NORTHEASTERN FIRE INSURANCE CO. OF PA. NAME AND ADDRESS OF INSURED COMPANY B LETTER COMPANY C LETTER COMPANY D LETTER COMPANY E LETTER This Is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time, Notwithstanding any requirement, term or cond.ition 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. AMATEUR SOFTBALL ASSOCIATION of AMERICA Insured Team(s)/League: CLEARWATER BOMBERS Cert.#G8273 TYPE OF INSURANCE POLICY NUMBER POLICY EXPIRATION DATE A GENERAL LIABILITY -0 ~OMPREHENSIVE FO-RM ~ PREMISES~OPERATIONS O EXPLOSION AND COLLAPSE GL55972 HAZARO o UNDERGROUND HAZARD " o PRODUCTS/COMPLETED OPERATIONS HAZARD o CONTRACTUAL INSURANCE o BROAD FORM PROPERTY DAMAGE o INDEPENDENT CONTRACTORS o PERSONA~ INJURY BODILYlNJURY, r $ _ $- 12/31/82 PROPERTY DAMAGE $ $ BODIL Y INJURY AND PROPERTY DAMAGE $ 1, 000 $ 1,000 COMBINED AUTOMOBILE LIABILITY o COMPREHENSIVE FORM o OWNED o HIRED o NON.OWNED PERSONAL INJURY EXCESS LIABILITY BODILY INJURY (EACH PERSON) BODilY INJURY (EACH ACCIDENT) PROPERTY DAMAGE BODIL Y INJURY AND PROPERTY DAMAGE COMBINED $ $ o UMBRELLA FORM o OTHER THAN UMBRELLA FORM BODIL Y INJURY AND PROPERTY DAMAGE COMBINED WORKERS' COMPENSATION and EMPLOYERS' LIABILITY OTHER DESCRIPTION OF OPERATlONS/LOCATIONSNEHICLES Amateur Softba 11 Team( s) 1 CITY OF CLEARWATER is included as an additional insured, applicable to the use of the field by the named insured. Cancellation: Should any of the above described policies be cancelled before the expiration date th.ereof. the issuing COm- pany will endeavor to mail ~- days written notice to the below named certificate holder. but failure to mail such notice shall impose no obligation or liability of any kind upon the company. NAME AND ADDRESS OF CERTIFICATE HOLDER CLEARWATER BOMBERS 210 S. COACHMAN ROAD CLEARWATER, FL 33515 ACORD 2S (1.79) ~ I CERTIFICATE OF INSURANCE NON-RENEWABLE BLANKET ATHLETIC ACCIDENT EXPENSE POLICY I ,~ 'I.: touo Life in~~~A~n,y <J1: Amenica ers SCHEDULE $2,500.00 Accidental Dismemberment Benefit- Maximum Payable $5,000.00 Medical Expense Benefit Practice or Play of Amateur Softball Accidental Death Benefit Deductible Maximum Amount Payable $100,000.00 $ None Policyholder: AMATEUR SOFTBALL ASSN. OF AMERICA Insured Team/League: CIFARWATFR BOMRFR~i' Address: P. O. BOX 216 CLEARWATER, FL 33517 Master Policy number: T-ASA-82Y Certificate Number: T -8273 Effective Date: 3/13/82 Termination Date: December 31, 1982 DEFINITIONS "Injury" wherever used in this policy means injury caused by an accident occurring while this policy is in force as to the Insured and resulting directly and independently of all other causes in loss covered by this policy, provided such injury is sustained by the insured: A. while participating in a practice session or game of the Athletic Activity for which coverage is indicated in the Schedule, which session or game is approved by and under the supervision of proper authority of the Holder; or B. while traveling directly to or from such practice session or game with other insureds under the supervision of proper authority of the Holdp.r. "Other Insurance Plan" shall mean any group plan providing benefits for or by reason of hospital care, treatment, or confinement, or the performance of surgery and/or anesthesia, which benefits are provided by (1) any group Blue Cross or Blue Shield plan, or any group or blanket insurance, employee benefit plan, or any plan arranged through an employer, trustee, union, or employee benefit association, or (2) any plan or program created by national or state government, or agencies thereof. "Allowable Expenses" shall mean any necessary, reasonable, and customary item of hospital, surgery, and/or anes- thesia expense for which valid and collectible benefits are provided by other Insurance Plan(s), including the reasonable cash vaue of benefits provided in the form of services, rather than in direct cash payments, Part I. ACCIDENTAL DEATH BENEFIT When injury shall result in loss of life of the Insured within 180 days of the accident,the Company will pay the Accidental Death Benefit stated in the Schedule. Part II. ACCIDENTAL DISMEMBERMENT BENEFIT When Injury does not result in loss of life of the insured within 180 days of the accident but does result in one of the following losses within said 180 days the Company will pay the indicated percentage of the Maximum Payable for this benefit as stated in the Schedule, for loss of: Both Hands or Both Feet ....,.............,........................ 100% Entire.oSight of Both Eyes. . . . . . . . ., . . . . . . . . : . , . . . . . . . . . . . . . . . . . . . . .. 100% One Hand and One Foot. , . . . . . . , . . . . . . . . , . . . . . . . . . . . , . . . . . . .' . . . . . " 100% One Hand and the Sight of One Eye. . . . . . . . . . . . . . . , . . . . . . . . , , . . . , . . . " 100% One Foot and the Sight of One Eye. . . . . . . . . . . . . . . . . . . . . , . . . . . . . . . . . . .. 100% One Arm or One Leg. . . . . . . . . . . . . , . . . . . . . . . . . . , , . . . . . . . . . . . . . . . . . . .. 75% One Hand or One Foot. . . . . . . . . . . . , . . , . , . . . . . . . . . . . . . . . . . . . . . . . . . . . 50% Sight of One Eye. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . , . . . . . . , . . . 50% "Loss" as used with reference to hand or foot means permanent loss by complete severance through or above the wrist or ankle joint; as used with reference to arm or leg means permanent loss by complete severance through or above the elbow or knee joint; and as used with reference to eye means irrecoverable loss of the entire sight thereof. I ndemnity under this Part will not be paid for more than one of the losses, the greatest, sustained by anyone Insured as the result of anyone accident. Part III. MEDICAL EXPENSE BENEFIT A. When Injury shall require treatment by a currently licensed physician or surgeon, or by any practitioner of the healing arts, confinement within a hospital or employment of a graduate or licensed nurse, the Company will pay the reasonable expense actually incurred by the Insured within fifty two weeks after the date of the accident for such treatment, hospital confinement and nurse service which is in excess of the Deductible, if any, stated in the Schedule, not to exceed in the ag- gregate the Maximum Amount Payable stated in the Schedule as the result of anyone accident as to anyone Insured. In no event shall the Company's payment for surgery exceed $45.00 times the unit value shown in the 1974 Relative Value Studies, 5th Edition, California Medical Association. Subject to the amount stated above, dental treatment shall be payable only if made necessary by injury to sound and natural teeth only. "Reasonable expense': means the usual and customary fee or charge for services rendered or supplies furnished in the area where rendered or furnished, which services or supplies are prescribed or approved by a currently licenses physician or surgeon who is not a member of the Insured's family. B. Provided further that the Company shall be liable only for that portion of hospital expenses resulting from confinement as a bed patient or for that portion of surgeon's and anesthetist's ex"enses resulting from surgery performed in the hospital, which are in excess of Allowable Expenses, as defined herein, under other Insurance Plans, as defined herein; and; in no event, will the Company pay that portiorl of hospital, surgeon's, or anesthetist's expenses which are covered by Allowable Ex- penses of other Insurance Plans. . T-ASA-01-C '" Part IV.. EXCLUSIONS · This policy does not cover any 101 caused by or resulting from: (1) declared or ldeclared war or any act of war; nor dcres this policy cover the expense of (2) replacing eyeglasses or prescriptions therefor; or (3) first aid treatment at the scene of the accident; or (4) injury for which the Insured is entitled to benefits under any Workmen's Compensation Act or Law or similar legislation, or injury for which the Insured is entitled to benefits under any Automobile Reparation Act, Automobile No-Fault Law, or similar legislation. Part V. ELIGIBILITY FOR AND EFFECTIVE DATE OF INDIVIDUAL INSURANCE All players, managers and coaches who are active members of the athletic team(s) of the Holder and named in the roster of such team are eligible for insurante hereunder. Insurance as to each eligible person shall take effect on the date of eligibility, but in no event prior to the effective date ofthe policy. Part VI. INDIVIDUAL TERMINATION The insurance of any Insured shall immediately terminate , (A) on the date this policy is terminated; or (B) on the date the Insured ceases to be a registered umpire of the Holder; whichever first occurs. Part VII. UNIFORM PROVISIONS ENTI RECONTRACT; CHANGES. This policy constitutes the entire contract between the parties, and any statement made by the Holder or the person insured shall be deemed a representation and not a warranty. No such statement shall void the insurance or reduce the benefits under this policy or be used in defense to a claim hereunder unless a copy of the instru- ment containing the statement is furnished to the claimant, nor shall any such statement be used in defense of a claim after the policy has been in force for two years from the date of its issue. No change in this policy shall be valid unless approved by an executive officer of the Company and unless such approval be endorsed hereon or attached hereto. No agent has authority to change this policy or to waive any of its provisions. . NOTICE OF CLAIM: Written notice of claim must be given to the Company within 60 days after the occurrence of the accident, or as soon thereafter as is reasonably possible. Notice given by or on behalf of the claimant or the beneficiary to the Company at its Home Office or to any authorized agent of the Company, with information sufficient to identify the Insured Person, shall be deemed notice to the Company. CLAIM FORMS: The Company, upon receipt of a written notice of claim, will furnish to the claimant such forms as are usually furnished by it for filing proofs of loss. If such forms are not furnished within 15 days after the giving of such notice the claimant shall be deemed to have complied with the requirements of this Policy as to proof of loss upon submitting within the time fixed in the Policy for filing proofs of loss, written proofs covering the occurrence, the character and the ex- tent of loss for which claim is made. . PROOFS OF LOSS: Written proof of loss must be furnished to the Company within 90 days after the date of such loss. Failure to furnish such proof within the time required shall not invalidate nor reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is furnished as soon as reasonably possible. TIME OF PAYMENT OF CLAIM: Indemnities payable under this Policy will be paid as they accrue immediately upon receipt of due written proof of such loss. PAYMENT OF CLAIMS: Indemnity for loss of life will be payable in accordance with the beneficiary designation and the provisions respecting such payment which may be prescribed herein and effective at the time of payment. Any other accrued indemnities unpaid at the Insured Person's death will be paid to such beneficiary. If no such designation or provision is then effective, such indemnity shall be payable to the estate of the Insured Person. All other indemnities will be payable to the I nsured Person. Subject to any written direction of the insured in an application or otherwise all or a portion of any indemnities provided by this policy on account of hospital, nursing, medical or surgical service may, at the Company's option, and unless the I nsured requests other~se in writing not later than the time for filing proof of such loss, be paid directly to the hospital or person rendering such services, but it is not required that the service be rendered by a particular hospital or person. .. PHYSICAL EXAMINATION AND AUTOPSY: The Company at its own expense shall have the right and opportunity to examine the person of any individual whose injury is the basi~ of a claim, when and as often as it may reasonably require during the pendency of a claim hereunder, and to make an autopsy in case of death, where it is not forbidden by law. LEGAL ACTIONS: No action at law or in equity shall be brought to recover on this Policy prior to the expiration of 60 days after written proof of loss has been furnished in accordance with the requirements of this Policy. No such action shall be brought after the expiration of three years after the time written proof of loss i~ required to be furnished. The provisions of the Master Policy principally affecting the Individual's insurance are described in this Certificate. All benefits described herein are covered by and are subject in every respect to the Ma$ter Policy, which alone constitutes the agreement under which payments are made. d~~ Secretary ~~ . 7reSident T-ASA-01-C