CERTIFICATES OF LIABILITY INSURANCE 12/13/98 THROUGH 12/13/01
ACORD.. CERTIFICATJ: OF LIABILITY INSU~NC~B~:3 I DATE (MMlDDIYY)
., 12/29/00
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Roger Bouchard Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
101 Starcrest Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
PO Box 6090 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Clearwater FL 33758-6090 INSURERS AFFORDING COVERAGE
Phone: 727-447-6481 Fax:727-449-1267
INSURED INSURER A: AUTO OWNERS INSURANCE CO
INSURER B:
Clearwater Shuffleboard INSURER C:
1020 Calumet Street INSURER 0:
Clearwater FL 33755
I INSURER E:
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 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.
INSR TYPE OF INSURANCE POLICY NUMBER ~\ti'M~~ ~ALf~~~'r,.)WN LIMITS
LTR
GENERAL LIABILITY 12/13/00 I EACH OCCURRENCE $ 500000
r- ._------
A X COMMERCIAL GENERAL LIABILITY 20540898 12/13/01 FIRE DAMAGE (Anyone fire) $ 50000
I CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 5000
PERSONAL & ADV INJURY $ 500000
-
GENERAL AGGREGATE $ 500000
-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/OP AGG $ 500000
,nPRO- n
POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
r- $
ANY AUTO (Ea accident)
~
ALL OWNED AUTOS BODILY INJURY
~ $
SCHEDULED AUTOS (Per person)
-
HIRED AUTOS BODILY INJURY
- ~.-.: .. $
NON-OWNED AUTOS (Per arodenl)
.. - '.. ...,.;
- -'-'i~ '
, PROPERTY DAMAGE $
r- (Per aCCident)
.
GARAGE LIABILITY "',.,,, V 2001 AUTO ONLY. EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
.' AUTO ONLY: AGG $
.'
EXCESS LIABILITY . " '..,' EACH OCCURRENCE $
=:J OCCUR D CLAIMS MADE AGGREGATE $
$
DEDUCTIBLE $
, RETENTION $ $
WORKERS COMPENSATION AND I TORY L1MrrS I IU~R-
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $
E.L. DISEASE. EA EMPLOYEE $
I E.L. DISEASE. POLICY LIMIT $
OTHER I
I I
I
DESCRIPTION OF OPERATIONSlLOCATIONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
SHUFFLEBOARD CLUB / 1020 CALUMET ST, CLEARWATER, FL RECEIVED
JAN [I 3 ?nn1
RISK u^",,..._
CERTIFICATE HOLDER I N I ADDIT10NAL INSURED; INSURER LETTER: CANCELLATION
CITYCLW SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO~
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAlL 30 DAYS WRITTEN
-
CITY OF CLEARWATER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
ATTN; RISK MANAGEMENT IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
POBOX 4748
CLEARWATER FL 33758 4748 REPRESE~TIVES.
I (j ')I-~
ACOR915-5 (7/97) /) ~. () c-.'
.~: (~KS' ~ "C-'- I f\- \ ;) K.
@ ACORD CORPORATION 1988
PRODUCER
Roger Bouchard Insurance, Inc.
101 Starcrest Drive
PO Box 6090
Clearwater FL 33758-6090
Phone:727-447-6481 Fax:727-449-1267
CERTIFICATt: OF LIABILITY INSU~NC~~A~:3 I DA~Ed~~~D70)o
- 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,
ACORDN
INSURED
Clearwater Shuffleboard
1020 Calumet Street
Clearwater FL 33755
I
COVERAGES
ANY AUTO
--
ALL OWNED AUTOS
-
1--- SCHEDULED AUTOS
HIRED AUTOS
e----
NON-OWNED AUTOS
e----
e----
GARAGE LIABILITY
R ANY AUTO
EXCESS LIABILITY
o OCCUR D CLAIMS MADE
n DEDUCTIBLE
N-REfEN'fI0N--'--S-' -'C <> --
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
--._- --_."-
OTHER
INSURERS AFFORDING COVERAGE
AUTO OWNERS INSURANCE CO
INSURER A:
INSURER B:
INSURER C:
I INSURER D:
. INSURER E:
b2~lfrMlij,bt~YE P~,k+~~~f6'rJ.}?N
I. . ----..,. '-'.--
-:[2/13/60 1- 12/13/01
!
- - - ------1 -'-
I
I
!
i
i
DESCRIPTION OF OPERATIONSlLOCATlONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
SHUFFLEBOARD CLUB / 1020 CALUMET ST, CLEARWATER, FL
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.
I~f: TYPE OF INSURANCE POLICY NUMBER
GENERAL LIABILITY 1
. -A .X'i:~:"':.:'ar:'":j20540m-_m .. .
~'L AGGREGATE LIMIT APPLIES P~: I I
I POLICY n ~r8i n LOC
AUTOMOBILE LIABILITY
--
CERTIFICATE HOLDER
I N I ADDITIONAL INSURED; INSURER LETTER:
CANCELLATION
LIMITS
$ 500000
_ ~'__= _m_.=-==-~.~_ ,.,_,,_____,"_...--,-,-
---. --,--
FIRE DAMAGE (Anyone fire) $ 50000
MED EXP (Anyone person) $ 5000
PERSONAL & ADV INJURY $ 5 0 0 0 0 0
GENERAL AGGREGATE $ 5 0 0 0 0 0
PRODUCTS - COMP/OP AGG $ 50 0 0 0 0
EACH OCCURRENCE
COMBINED SINGLE LIMIT
(Ea accident)
$
BODILY INJURY
(Per person)
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
AUTO ONLY - EA ACCIDENT $
EA ACC i $
AGG I $
$
$
$
$
I OTHER THAN
I AUTO ONLY:
EACH OCCURRENCE
AGGREGATE
- - - -
$- .-
I TORY L1MrrS I IOJ~-
I E.L. EACH ACCIDENT $
El. DISEASE - EA EMPLOYEE $
El. DISEASE - POLICY LIMIT $
RECEIVED
JAN (I 3 ?nn1
RISK UAI "..... "'":I\IT
CITYCLW SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
CITY OF CLEARWATER
ATTN; RISK MANAGEMENT
POBOX 4748
CLEARWATER FL 33758 4748
I
ACOR~5-S (7/97) DC'
C~: ,f\-R /-<"5 ~ "e I
K ~ S-K-
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENIJ\.TIVES.
(j'y~
@ACORD CORPORA nON 1988
CLEARWATER SHUFFLEB~D CL~B YEARLY FINANCIAL RIPORT
January 31,1999 to January 31,2000
Balance on hand as of January 31,1999
AMENDED
RECEIPTS:
Donations
Annual Dues
weekly,Monthly Dues
Office Sales
Sales Tax
Kitchen Sales
Tournament Entries
City Court Maintenance
Misc.
CD'S
Interest Earned
TOTAL RECEIPTS:
DISBURSEMENTS:
Employees wages
Telephone.
Court Expenses
Cleaning Expenses
Office Expenses
Fl. State Sales Tax
Supply Purchases
Kitchen Expenses
Tournament Expenses
Misc. Activities
Misc.
State & Federal Taxes
$774.50
3,278.30
52.30
4,465.05
546.13
4,153.51
6,670.50
2,400.00
1,673.50
3,500.00
268.15
6,506.42
399.01
2,856.99
144.45
483.09
505.20
4,172.10
3,377.72
1,5l4.21
2,851.50
4 ,J34L-3_3
'95:}.06;
';',t
Balance on hand as 9f January 31,2000
187015706 $2,789.07 Matures
187012513 $2,795.43 Matures
18702052 $12,084.50 Matures
187024526 $2,500.00 Matures
18702600 $4,000.00 Natures
R,: ~''''',. f'-'''''' k""'" , "';',-- D
. t:L;ei V c.
APR 0 b 2000
CITY CLERK DEPt\f.jTMEN'(
10/17/01
2/04/01
12/23/00
6/01/00
7/11/00
1
$2,427.72
27,781.94
30,209.66
28-,609.08
.
1,600.58
ACORDm
......~..EB..~m.I...f..I..Q~-r.~.......(1).~.......~.I.ifj.~.J.~.I..m~.....J.r<J.~.l..J...I..,~.m.ill<r.~.......................... DA~~7~~~
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
Inc.
PRODUCER
Roger Bouchard Insurance,
101 Starcrest Drive
PO Box 6090
Clearwater FL 33758-6090
Phone No. 727 -447 -6481 Fax No. 727 -449 -12 67
INSURED
COMPANY
A
AUTO OWNERS INSURANCE CO
Clearwater Shuffleboard
1020 Calumet Street
Clearwater FL 33755
COMPANY
C
RECEIVED
JAN 1 8 lOOO
COMPANY
B
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE 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, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
CO TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE I POLICY EXPIRATION LIMITS
L TR DATE (MMIODIYY) DATE (MMIODIYY)
A
COMMERCIAL GENERAL LIABILITY 2 054 0 8 9 8
CLAIMS MADE ~ OCCUR
OWNER'S & CONTRACTOR'S PROT
12/13/99
12/13/00
GENERAL AGGREGATE I $ 500000
PRODUCTS. COMP/OP AGG $ 5000 0 0
PERSONAL & ADV INJURY I $
EACH OCCURRENCE I $ 5 0 0 0 0 0
FIRE DAMAGE (Anyone fire) I $ 500 0 0 0
MED EXP (Anyone person) I $ 50 0 0
COMBINED SINGLE LIMIT I $
1$
1$
1$
AUTO ONLY. EA ACCIDENT I $
BODILY INJURY
(Per person)
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
BODILY INJURY
(Per accident)
PROPERTY DAMAGE
GARAGE LIABILITY
ANY AUTO
OTHER THAN AUTO ONLY:
EACH ACCIDENT ! $
AGGREGATE i $
EACH OCCURRENCE I $
i EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
AGGREGATE
!$
THE PROPRIETOR!
PARTNERs/EXECUTIVE
OFFICERS ARE:
OTHER
R.INCL
EXCLi
1$
EL DISEASE. POLICY LIMIT I $
EL DISEASE. EA EMPLOYEE ! $
DESCRIPTION OF OPERA TIONSIlOCA TIONSNEHICLESlSPECLAlITEMS
SHUFFLEBOARD CLUB / 1020 CALUMET ST, CLEARWATER, FL
CERTlfIGAI$.E-lOLDER",....,..
CITYCLW
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF A~N~~PANY. ITS AGENTS OR REPRESENTATIVES.
,. .i............'......,.,.'...'......(.....>...<<.........'.ACQRPCORB9RATIClN't988.'"
CITY OF CLEARWATER
ATTN; RISK MANAGEMENT
POBOX 4748
CLEARWATER FL 33758 4748
C.lT1-tC-C6fLK-jP~f6. ~EC) R lSlL
ACQRP25-$,(11~5)../.................."..
CLEARWATER)SHUFFLEBOARD CLUB - YEARLY'~PORT
January 31,1998 to January 31,1999
Balance on hand as of January 31,1998
$3,301.78
RECEIPTS:
Annual Dues
weekly Dues
Office Sales
Sales Tax
Kitchen Sales
Tournament Entries
City Court Maintenance
Misc.
CD1S
4,214.36
4.65
6,684.74
769.22
3,996.98
5,024.50
2,600.00
37,041.48
24,158.41
TOTAL RECEIPTS:
84,494.34
87,796.12
DISBURSEMENTS:
Maintenance Contract
Telephone
Court Expenses
Cleaning Expenses
Office Expenses
Fl. State Sales Tax
Supplp Purchases
Kitchen Expenses
Misc. Activities
Tournament Expenses
Misc.
CD1S
7,200.00
449.74
9,522.54
320.91
464.47
736.94
7,371.96
2,529.00
1,059.92
4,486.28
31,187.27
20,039.37
85,368.40
Balance on hand as of January 31,1999 $2,427.72
0187015706 $2,500.00 Matures 10-17-99
0187012513 $2,500.00 Matures 4-30-00
770093130 $1,000.00 Matures 5-14-01
Ada Armstrong ~~ prize money fund $20,000
I
I
AGENCY 1 2 - 02 0 8 - 0 0 POLICY 9 6231 2 - 20540898
ROGER BOUCHARD INSURANCE INC
PO BOX 6090
CLEARWATER, FL 34618
13271 (3-95)
Ufe Home Car Business
TfI4'1Vofk6&,.\~
CLEARWATER SHUFFLEBOARD CLUB
BOX 30660, LANSING, MICHIGAN 48909-8160 . 517/323-1200
AUTO-OWNERS INSURANCE COMPANY
AUTO-OWNERS LIFE INSURANCE COMPANY
HOME-OWNERS INSURANCE COMPANY
OWNERS INSURANCE COMPANY
PROPERTY-OWNERS INSURANCE COMPANY
SOUTHERN-OWNERS INSURANCE COMPANY
1020 CALUMET ST
CLEARWATER, FL 33755-1813
Thank you for allowing Auto-Owners to handle your insurance needs.
Auto-Owners Insurance Group is financially sound with sufficient reserves to be ranked among the leaders in the in-
dustry for financial security. Our A+ + (Superior) rating by the A.M. Best Company signifies that we have the finan-
cial strength to provide the insurance protection you need.
Feel free to contact your Auto-Owners agent with any questions you may have about your insurance needs.
Your agent's phone number is (727) 447-6481.
e
Auto-Owners Insurance - The "No Problem" People
'-> Serving Our Policyholders and Agents for More Than 80 Years '->
~
Agency Code 12-0208-00
I
Policy Number 962312-20540898
I
Florida
POLICYHOLDER INFORMATION AND ASSISTANCE
59246 (4-98)
We are here to serve you and as our policyholder your satisfaction is very important to us. Should you have any
questions or a complaint regarding your policy that cannot be resolved by your agent, you may contact us at the fol-
lowing telephone numbers.
If you reside in the panhandle area of Florida, you may contact our Montgomery, Alabama Branch Office for informa-
tion and assistance by calling 334-279-0323. All other Florida residents should contact our Lakeland, Florida Branch
Office for information and assistance by calling 941-687-4505.
Auto-Owners Insurance Company
Owners Insurance Company
Southern-Owners Insurance Company
.Auto-Owners I
Page
1
55039 (11-87>
Issued 10-07-1998
TAILORED PROTECTION POLICY DECLARATIONS
I
INSURANCE COMPANY
6101 ANACAPRI BLVD., LANSING, MI 48917-3999
AG~CY ROGER BOUCHARD INSURANCE INC
12-0208-00
INSURED CLEARWATER SHUFFLEBOARD CLUB
Renewal Effective 12-13-1998
POLICY NUMBER 962312-20540898-98
CLEARWATER, FL 33755-1813
POLICY TERM
12:01 a.m. 12:01 a.m.
12-13-1998 to 12-13-1999
ADDRESS 1020 CALUMET ST
In consideration of payaent of the preBiuB shown below, this policy is renewed. Please .ttach this
Declarations and attachments to your policy. If you have any questions, please consult with your agent.
COM"ON POLICY INFORMATION
BUSINESS DESCRIPTION: Club
ENTITY: Club
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PART(S).
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
COMMERCIAL GENERAL LIABILITY COVERAGE
PREMIUM
$179.00
TOTAL
$179.00
FORMS THAT APPLY TO ALL COVERAGE PARTS SHOWN ABOVE (EXCEPT GARAGE LIABILITY, DEALER'S
BLANKET, COMMERCIAL AUTOMOBILE, IF APPLICABLE)
55000 (01-87>
Countersigned By: \,. Oxe).~\SY\ <E... '--&L\.e\--Ct~
..Auto-Owners I
Page
1
55040 01187>
Issued 10-07-1998
TAILORED PROTECTION POLICY DECLARATIONS
I
INSURANCE COMPANY
6101 ANACAPRI BLVD., lANSING, MI 48917-3999
AGE~Y ROGER BOUCHARD INSURANCE INC
12-0208-00
INSURED CLEARWATER SHUFFLEBOARD CLUB
Renewal Effective 12-13-1998
POLICY NUMBER 962312-20540898-98
CLEARWATER, Fl 33755-1813
POLICY TERM
12:01 a.m. 12:01 a.m.
12-13-1998to 12-13-1999
ADDRESS 1020 CAl UMET S T
In consideration of paynant of the pre.iun shown below, this policy is renewed. Please .ttach this
Declarations and attachments to your policy. If yOU have any questions, please consult with your agent.
COMMERCIAL GENERAL LIABILITY COVERAGE
LIMITS OF INSURANCE
General Aggregate limit
(Other Than Products-Completed Operations)
Products-Completed Operations Aggregate limit
Personal And Advertising Injury limit
Each Occurrence limit
Fire Damage limit
Medical Expense limit
$500,000
500,000
500,000
500,000
50,000 Any One Fire
5,000 Any One Person
"General Aggregate limit" shown above, is reinstated once per policy period at no
additional charge, in accordance with form 55050.
AUDIT TYPE: Non-Audited
FORMS THAT APPLY TO LIABILITY: 55118 (08-91)
55029 (07-87) CG0001 (11-88) CG0220 (07-92)
55064 (07-87) Cl175 (02-86) 55069 (01-88)
55146 (07-96) 55160 (11-95) 55168 (11-95)
IL0021 (11-85)
IL0017 (11-85)
CG2147 (09-89)
59246 (04-98)
55081
55050
55137
(08-88)
( 07-87>
(06-92)
LOCATION OF PREMISES YOU OWN, RENT OR OCCUpy
LOC 001 BLDG 001 1020 Calumet Street
Clearwater, Fl 34615-1813
TERRITORY: 004
COUNTY: Pine11as
Premium
Classi'ficatian Subline Basis Rates Premium
CODE 41669 Members Each 1
Clubs - Civic Service Or Social - Prem/Op 175 1.024 $179.00
No Buildings 6r Premises Owned Or
leased Except For Office Purposes
Including Products And/Or
Completed Operations
(For-Profit)
CODE 49950
Additional Interests
Managers/lessors Of Premises Prem/Op If Any $0.00
City Of Clearwater
lOCATION 001 PREMIUM
$179.00
. 'Agl!ncy Code 12-0208-00
I
Policy Number 962312-20540898
I
55168 (11-95)
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - MANAGERS OR LESSORS OF
PREMISES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
1.
Designation of Premises (Part Leased to You):
1020 CALUMET STREET CLEARWATER FL 34615
Name of Person or Organization (Additional Insured):
CITY OF CLEARWATER
2.
3.
Additional Premium:
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
1. WHO IS INSURED (Section II) is amended to include
as an insured the person or organization shown in
the Schedule but only with respect to liability arising
out of the ownership, maintenance or use of that 2.
part of the premises leased to you and shown in the
Schedule and subject to the following additional ex-
clusions:
This insurance does not apply to:
1. Any "occurrence" which takes place after you
cease to be a tenant in that premises.
2. Structural alterations, new construction or de-
molition operations performed by or on behalf
of the person or organization shown in the
Sched u Ie.
The following is added to LIMITS OF INSURANCE
(Section III):
8. The limits of liability for the additional insured
are those specified in the written contract or
agreement between the Insured and the man-
ager or lessor of premises, not to exceed the
limits provided in this policy. These limits are
inclusive of and not in addition to the limits of
insurance shown in the Declarations.
Includes copyrighted material of Insurance Services Office, Inc., with its permission
Copyright, Insurance Services Office, Inc., 1984
I
I
~I A.~.tlllt. ~~':::::::':'''.''.''':
.,.~. ......;i::,..
ROGER BOUCHARD INSURANCE
101 Stlrcrest Dr. PO Box 6090
CLEARWATER. FL 34618
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 COVERAG
Clelrwlter Shufflebolrd Club
1020 Cllumet Street
Clelrwlter. FL 33755
COII'ANV
A Auto Owne
CQIoPANV
B
<XM'ANV
C
RECQVED
JAN 0 9 1998
1~~;::~:::::i:.:~~<<~~~:~~{.;{~~ll~~ili:;i1m1ili1~~trflli~1~i.tdm....:... .. .. .~;~:.:....... ........... '. '.: .. '.~:::~l~fi~mt~i~mit~t~Mf.<<~~tf.t.~t..?:....~............ ...>;...... .~;:. ...=*..>.......~
THISIS TO CERTIFY THA T THE POLICIESOFINSURANCE LISTEDBELOWHAVEBEENISSUED TO THEINSURED NAMEDAB
INDICA TED,NOTWITHST ANDINGANYREQUlREMENT, TERMORCONDITIONOF ANYCONTRACTOROTHERDOCWENT WITHRESPECT TOWHlCHTHlS
CERTIFICA TE MA Y BE ISSUED ORMA Y PERT AN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LMlTS SHOWNMAY HAVE BEEN REDUCED BY PAID CLAMS.
00 POLIOY I!PROTIW POLIOY I!XPIRAT
L 11 TYPI!OI' INSURANOE POLIOY NUMIII!R DATI! (MM/DDIYV) DATI! (MM/DDIYV) LIMITS
Gl!NERAL LlABLITY
A X COMMERCIALClEtERAlLlABILITV 20540898
CLAIMS MADE [2t] ~
ow~s II. CONTRACTOR'S PROT
ClEtERAl AOOREOATE .
12/13/97 12/13/98 PRODl.CTS.COMP/OP AOO .
PERSONAL II. ADV INJ.R( .
EACH oc:culRENCE .
FIRE DAMAClE (Any one fire) .
lED EXP (Any one pel'soo) .
AUTOMOBILI! LIABLITY
AWi AUTO
ALL OwtED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.owtED AUTOS
COll3ltED SINCl.E LIMIT
.
BODIL V INJ.R(
(per pel'son)
.
BODILV I~Y
(per accident)
.
PROPERTY DAMAOE .
THE PROPRIETORI
PARTtERS/EXECUTlVE
OFFICERS ARE:
OTHER
1NCl.
EXCL
AUTO ON.. V . EA ACCIDENT .
OTHER THAN AUTO ON.. V: ~/~~~~~~~~/nnnnnn//
EACH ACCIDENT .
AlXflEOATE .
EACH oc:culRENCE .
AOOREOATE .
l
STATUTORY LIMITS H~~HtH\nn~HH?
EACH ACCIDENT .
DISEASE. Pa.ICV LIMIT .
DISEASE - EACH EIlPl.OVEE .
GARAQI! LlABLITY
AWi AUTO
I!llOESSLlABILITY
Ut.UlELLA FORM
NfERTHANUMBRELLXf'
WORKI!RS OOhlPENSATION AND
I!MPLOYERS'LlABLITY
Shufflebolrd Club
1020 C.lumet St.. Clelrwlter. FI
's/l i t
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IHOULD ANY 01' lHI! AIIOVI! __mil POLIOII!II _ OANOl!Ul!D II!PORI! THe:
I!llPIlATION DATI! THERI!OI'. THI! IaUING OO"ANY WI.&. DIlI!AVOR TO MAL
City 0 f C le-rwI te r 45 DAYS WRITTI!N NOTIOI! TO THI!Ol!RTPIOATI! HCll.DI!R NAMI!D TO THI!LI!I'T.
At t n : R i s k M I n Ig emen t BUT PALURt: TO MAL IUOH NOTIOI! SHALL IMPOSt: NO OBLIGATION OR LlABLITY
P.O. Box 4748 01' ANY KIND W'ON THE OO"ANY, ITS AGI!NTI OR REPAEl!NTATIVD.
Clurwlter. FI. 33758-4748 €...~ ~,-v"'\\ 153825000
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Cc.. ~ C1/\hD ~
I
,
b~~ Y "~Ngl\td~FERS~~N8u RtGHfs MUPON" THE CERTIFIJA~~
ROGER BOUCHARD I NSURANCE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
10 1 St a rc res t Dr PO Box 6090 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
.
CLEARWATER Fl 346 18 COMPANIES AFFORDING COVERAGE
.
coaf>ANY
8 1 3-447-648 1 A Auto Owners I nsuranee ComDanV
I'lliURm COliPANY
CI ea rwater Shuf f I eboud CI ub B
1020 Ca I ume t St ree t coaf>ANY
CI ea rwater . FL 33755 C
COAI>ANY
I 0
ti!Y!!liHlflt:ttltttt::t::t::::MMM:mtllMltttttlllmttWWilit::tt:tltMltJlWMt:t:t::::m::t:::::::t:::::::::::::::::t:t:t:::::tlmttttttttt:::::::t::t:ttltltMW.l~Mt::lttt::tt:t:tm:tt::::::::tt
THIS IS TOCERTlFV THA T THE POLICIES OF INSURANCE LISTEDBELOWHAVE BEENISSUED TO THEINSURED NAMEDABOVEFORTHEPOLlCY PERIOD
INDICA T ED. NOT WITHST ANDINGANYREQUIREMENT. TERM ORCONOITKJNOF ANY CONTRACT OROTHERDOCLMENT WITHRESPECT TO WHICHTHIS
CERTlFICA TE MAY BEISSUEDORMAY PERT AIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LMITS SHOWNMAV HAVE BEEN REDUCED BY PAID CLAMS.
i'W" ". .. - - '." I POLIOY!f'PEOTIVE POLIOY I!XPRATIOft -
LTR TYPE Of' INSURANOe POLICY NUMBER DATE (hlMIDDIYY) DATE (hlMIDDIYY) LIMITS
GENERAL LIABILITY ClEt-ERAL AOOREOATE . 500000
I--
A X COMMERCIAL ClEt-ERAL L IABllI TY 20540898 12/13/96 12/ 13/97 PROOUCTS.COliP/OP AQQ . 500000
f:f8- b CLAIMS MAllE [X] ~ PERSONAL a. ADV IN..UW .
~
OWt-ER'S a. CONTRACTOR'S PROT EACH OCClJlRENCE . 500000
I--
FIRE DAMAOE (Any one Ii'.) . 500000
I--
lED EXP (Any one pet'son) . 5000
AUTOhlOBIL.E LIABILITY COIl3I t-ED SItae LIMIT .
I--
ANY AUTO
I--
ALL Owt-ED AUTOS BOOIL V IN..UW .
I-- (pet pet'son)
SCHElllED AUTOS
I--
HIRED AUTOS BOOIL Y IN..UW .
I-- (pet accident)
NON.OWt-ED AUTOS
I--
I-- PROPERTY DAMAOE .
GARAGI! L1ABLITY AUTO Otl.V EA ACCIDENT .
I--
ANY AUTO OTtER THAN AUTO Otl. Y: ;~ ~~ ~ ~ ~ ~ ~~;; ~ ~ ~; ~;; ~ ~; ~;; 1 ~ 1;; ;;; 1; ~ ~
i--
EACH ACCIDENT .
I--
AOOREOATE .
I!XOESS L1ABLITY EACH OCClJlRENCE .
R UII3RELLA FORM AClQREOATE .
OTHER THAN UII3RELLA FORM .
WORKERS OOhfPENlATION AND I STATUTORY LIMITS mHHWH11Hl11;1;;;;;;;;;;;;H1;
EhfPLOYERI'L1ABLITY EACH ACCIDENT .
THE PROPRIETORI RIOCL DISEASE POLICV LIMIT .
PARTt-ERS/EXECUTlVE
OFFICERS ARE; EXCL DISEASE . EACH ElI>LOYEE .
OTHI!R
,Im_
Sh u ff I eboa rd C I ub
1020 Ca I umet St . C I ea rwate r . F I
isla ist
SHOULD ANY Of' THE ABOve: DESOAIIED POLIOIEI &I: OANOELLED BEFORI! THE
I!llPRATION DATI! THEREOf'. THE ISSUING OO"ANY WU ENDEAVOR TO hlAL
C i ty 0 f C I e Irwa te r DAYS WRITTDI NOTIOE TO THE OEIlT.IOATI! HOLDa NAMED TO THE LEPT.
-
At tn : Ri s k Management BUT P ALURI! TO MAL IUOH NOTIOE SHALL IMPOSE NO OBLIGATION OR L1ABLITY
P O. Box 4748 Of' ANY KIND UPON THE OO"~Y. ITS AGENTS OR REPRESENTATIVES.
C'n,wet.,. Fl. 337......7.. '~ L~.
I ~
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C}C. (~L-h"1 .,C/l('-_
CLEARW~ SHUFFLEBOARD CLUB-YEARLI REPORT
January 31,1997 to January 31,1998
.
Balance on hand as of January 31,1998
RECEIPTS:
Annual Dues
Daily,weekly,Monthly Dues
Office Re-Sales(Cues,beads,wax)
Sales Tax
Kitchen Donations
City Court Maintenance
Donations
Tournament Entries
CD'S
Misc.
Interest Earned
TOTAL RECEIPTS:
$6,180.90
$3,702.56
86.42
7,534.47
792.35
2,237.75
2,200.00
2,748.26
6,047.55
6,500.00
227.36
588.24
32,664.96
38,845.86
DISBURSEMENTS:
Kitchen Expenses
Maintenance Contract
Telephone
Court Supplies
Cleaning Supplies
Office Supplies
Florida State Sales Tax
Payment to City
Supply Purchases
Tournament Expenses
CD'S
Misc.
1,479.19
6,490.00
424.37
2,064.61
223.60
149.67
818.58
2,500.00
6,755.00
2,325.06
12,000.00
314.00
35,544.08
$3,301.78
Balance on hand as of January 31,1998
457-009248-8
457-005274-8
457-009240-5
457-009313-0
017012513
3001457398
187015706
$4,000.00 Matures 4-26-98
$5,000.00 Matures 3-16-99
$5,000.00 Matures 4-26-01
$1,000.00 Matures 5-14-01
$2,500.00 Matures 1-04-99
$7,000.00 Matures 8-20-98
$2,500.00 Matures 10-17-99
SUBMITTED BY:
IbJdb-j{ ~/D/
TREASURER
.:~ E' C:..; Ii.".' ~'l r E: f~
i:i.P, ~c t: e.ii ", ~.:
I~ - e.!:......\...: '5;" .!>... ~,H_
FEB 13 1995
P th"r,S :'\C
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ROGER BOUCHARD INSURANCE
101 St.rcrest Dr. PO Box 6090
CLEARWATER. FL 34618
ONL Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW.
COMPANIES AFFORDING COVERAGE
CI..rw.ter Shufflebo.rd Club
1020 C.lumet Street
CI..rw.ter. FL 33755
COIiPANV
A Auto Owne
COII'ANV
B
COII'ANV
C
COII'ANV
o
;m:.:. :tiill;rilil$f&t'''!timMJ~tf$Tf:1ili.t\t!tjm~~~litmW/MJl$.~a1ftltf~1&f~*Thi~~~@~j1~tl~*~~JliWjf*.~. " .:~~~.... .~:~%~t
T!-ISIS TO CERT IFY T HA T T HE POLICIES OF INSURANCE LIST EDBELOWHA VE BEENISSUED TOT HE INSURED NAMED ABOVE FOR T I-E POLICY PERIOD
INDCA TED. NO TWIT HST ANOINGANYREOUlREMENT . T EfI>.1 ORCOIIDT IONDF ANYCONTRACT ORO T HERDOCLMENT WITHRESPECT TO WHCH THIS
CERTFICA TE MA Y BE ISSUED ORMAY PERT AIN. THE NSURANCE AFFORDED BY HE POLICES DESCRIBED HEREIN IS SUBJECT TO ALL THE TEfI>.1S.
EXQ.USIONS AND CONDITIONS OF SUCH POLICES. LMTS SHOWNMAY HAVE BEEN REDUCED BY PAil) ClAMS.
00 POLIOY D'ROTNE POLIOY UP.AT
LTI TVPI!Gr .=uR~ POl.IllYMI.-R DAlE (M'-'YY) DAlE (MWIDOIYY) LIWITS
AVnIiMOllU UABLITY
ANY AUTO
All OwtED AUTOS
SOED..lfD AUTOS
HIRED AUTOS
N)N.OWta) AUTOS
CE~ AOCJlEOATE .
12/13/97 12/13/98 PRCn..CTS-COII'/CP AOO .
PERSONAl L AnV IN.J...RY .
EAOi OCClRREta .
FIRE DAlIAOE (Any one lire) .
foE[) EXP (Any one pet'1On) .
COIllJta) SItQ.E LIMIT
aBIERAL UABLITY
A X COloAERClALCEhERAlllABILlTV 20540898
. . . Q,AIMS MAllE [XJ ~
OWhER'S L CONTRACTlFS PROT
ElCDIl Y IN.J...RY
(p.. pel'1Cl'l)
ElCDIl Y IN.J...RV
(p... accident)
PRCJ>ERTY DAlIAOE
UllAGE L1ABLITY
AIN AUTO
AUTO ON. Y . EA ACCICENT .
OTI-ER THAN AUTO ON.V: /U~<<<<<>>
EACH ACCIDENT .
AOO'lEOATE .
EACH OCClRREta .
AOCJlEOA TE .
.
DClDSLIABLITY
UI8lELLA FOR"
OTtER THAN UI8lELLA FORM
WGIICBIS oo..-ENSATION AND
~..u.""'LIABLITY
lJoE PRCFRIETORI
PARTIERS/EXEOJTIVE
CFJ'JCERS ARE:
cnHa
ItCl
EXCL
STATUTORY LllIlTS
EACHACCIlENT
DISEASE. Pa.1CV LIMIT
DISEASE. EAOi EIoPI..OVEE
... ......
~ ~ ~ ~ i ~ ~ ~; ~ ~ ~ i ~ H i i j ~ ~ ~ ~ ~ H ~ j j ~ 1H 1 j i
Certificate holder is an additional insured for General Liability.
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IHCM.D ANY 01 TH~ AllOW DDORIII!D POLIOES . OANCI!U.I!D .,oe THe:
UPRATION DAlE THI!Al!OI. TH~ IlSUINCI CO"ANV WU I!NIlI!AVOR TO MAL
City 0 f C Ie. rw. te r 45 DAYS WRIT1ENNOTIOIi:TO THU~RT.IOAlEHOI.IlI!R rw.E>>TO TH~LDT.
At tn: Ri s k M.n.gement BUT PAu. TO MAL SUCH NOTIOIi: IHALL I~NO OllLIllATION OR L1ABLITY
P.O. Box 4748 01 ANY ICHI UPON TH~ oo"ANY. ITS AC2NTS OR II!PRESDlTATIVn.
CI..rw.ter. Fl. 33758-4748 T \ ~ ~ ~~~~8~000
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