INSURANCE
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CITY tF CLEARWATER
Interdepartment Correspondence Sheet
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TO: Operation/S"~
FROM: Risk Management
COPIES:
SUBJECT: Certificate of Insurance
DATE: 12-/1-87
Attached certificate of Insurance rreets lease specifications, with following
exceptions:
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PRODUCER'
.- ROGER BOUCHARD INSURANCE, INC.
P.O. BOX 6090
CLEARWA ~R, FL 33518
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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.
COMPANIES AFFORDING COVERAGE
COMPANY A Massachusetts Bay Insurance Company
LETTER
CLEARWATER SHUFFLEBOARD CLUB
1020 Calumet Street
Clearwater, FL 33515
COMPANY B Xh
LETTER FIRE
COMPANY C
LETTER
S FUND INSURANCE CO ANY
INSURED
COMPANY D
LETTER
THIS IS TO CERTIFY THAT 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 CONDI-
TIONS OF SUCH POLICIES.
COMPANY E
LETTER
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'J CO TYPE OF INSURANCE POLICY NUMBER POliCY EffECTIVE POLICY EXPIRATION ALL LIMITS IN THOUSANDS
1 LTR DATE (MMlDDfYY) DATE (MM/DDIYY)
1 GENERAL LIABILITY GENERAL AGGREGATE $ 500
(A COMMERCIAL GENERAL LIABILITY Z231 45 71 11/11/87 11/11/88 ~RODUCTS.COMP/OPS AGGREGATE $ 500
, D OCCURRENCE
CLAIMS MADE PERSONAL & ADVERTISING INJURY $500
OWNER'S & CONTRACTORS PROTECTIVE EACH OCCURRENCE $ 500
FIRE DAMAGE (ANY ONE FIRE) $
MEDICAL EXPENSE (ANY ONE PERSON) $
AUTOMOBILE LIABILITY
ANY AUTO CSL $
ALL OWNED AUTOS BOOIL Y
INJURY
SCHEOULED AUTOS (PER PERSON) $
HIRED AUTOS BOOILY
INJURY
NON.OWNED AUTOS tJ~DENn $
GARAGE LIABILITY PROPERTY
DAMAGE $
EXCESS LIABILITY EACH
OCCURRENCE
$ $
OTHER THAN UMBRELLA FORM
1 STATUTORY
WORKERS' COMPENSATION 11/23/87 11/23/88
IB 2 15 WZA 802008375 $ 100, (EACH ACCIDENT)
AND
EMPLOYERS' LIABILITY $ 500, (DISEASE.POLlCY LIMIT)
$ 100,
OTHER
DESCRIPTION OF OPERATIONS I LOCA TIONSI VEHICLES I RESTRICTIONS I SPECIAL ITEMS
IThe certificate holder shown below is additional insured
on the General Liability policy.
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lCITY OF CLEARWATER
JDEPT. OF PARKS & RECREATION
~Attn: Donald Peterson
", P.O. Box 4748
Clearwater, FL 34618-4748
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX.
PIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE COMPANY. ITS AGENTS OR REPRESENTATIVES.
HO ZED REPRESENTATIVE
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