CERTIFICATE OF INSURANCE
ACOR~M
"
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDNYI
04/08/04
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
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PROl>JCER
ACORDIA EAST - TAMPA BAY
P,O, Box 31666
Tampa, FL 33631-3666
727-796-6666
INSURERS AFFORDING COVERAGE
INSURED
INSURER A:
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
Scottsdale Insurance Company
Clearwater Chargers Soccer
% Cathy Weatherilt
880 Bay Esplanade
Clearwater FL 33767
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.
INSR TYPE OF INSURANCE POLICY NUMBER ~<J.';!gY EFFECTIVE POLICY EXPIRATION LIMITS
TR
A GENERAL LIABILITY CPS0625546 2/19/04 2/19/05 EACH OCCURRENCE $ 1000000
-
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 50000
I CLAIMS MADE W OCCUR MEO EXP (Anyone person) $ 5000
PERSONAL & ADV INJURY $ 1000000
-
GENERAL AGGREGATE $ 1000000
-
GEN'L AGGREGATE LIMIT APPLIES PER: ~ PROOUCTS, COMP/OP AGG $ 1000000
I POLICY n ~~~T n LOC ,-~-
~TOMOBILE L1AB.ILlTY ~t.-. ." "l, \
~ " ,.'-. COMBINED SINGLE LIMIT
,,~ '- ..' $
ANY AUTO "< (Ea accident)
,
- \
ALL OWNED AUTOS 'UA BOOIL Y INJURY
- $
SCHEDULEO AUTOS ,oj ,-- (Per person)
- '"' t' t"-
HIRED AUTOS
- .1 BODILY INJURY $
NON,OWNEO AUTOS ;;.;;:-- (Pt:lr i:1ccident)
:" ".,'
- \..............;..It-,-~ ~-- '-'\<~'';~ ~-
- ~--,.~ PROPERTY DAMAGE $
(Per accident)
==jAGE LIABILITY ...... AUTO ONLY, EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
=:J OCCUR D CLAIMS MADE AGGREGATE $
$
=1 DEDUCTIBLE $
RETENTION $ $
1WC STATU" I 10TH,
WORKERS COMPENSATION AND TORyj,nlTS ER
EMPLOYERS' LIABiliTY E,L. EACH ACCIDENT $
E,L. DISEASE, EA EMPLOYEE $
E,L. DISEASE, POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATlONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CITY OF CLEARWATER IS NAMED AS AN ADDITIONAL INSURED WITH RESPECTS TO-
GENERAL LIABILITY.
CERTIFICATE HOLDER I X I ADDITIONAL INSURED; INSURER LETTER: CANCEllATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF CLEARWATER DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -1Q.... DAYS WRITTEN
'J ~'J I~?
ATTN: Rt$.1~ M/\I\1ALieFf f /- f"'- ,-' NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
POBOX 4748 IMPOS:~ OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
CLEARWA TER, FL. 33758 REPRES TA)WES, i)
AUTHOf'ZED t/i~SE~T~~VE . ',- (L,7 ,:c'. it
I ;/'l~ ~t[,L..",::t <.., , "I ,{ (.A'C/v,
ACORD 25,5(7/97) 46- 40 (/ @ACORD CORPORATION 1988
\,
4
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 25-5 (7/97)