CERTIFICATE OF INSURANCE (2)
04/05/2004 15:01
7277991285
NUSSEAR INS
PAGE 01
CERTIFICATE OF INSURANCE: CLEASHU CSR JB 04/05/04
I PRODUC~R THIS CERTIFICATE IS ISSUED AS A HATTER OF INFORMATION ~Y AND
I CONFERS NO RIGHTS UPON THE CERTIFICATE: HOLDBR. THIS C&RTIFlCATE
I NUSSEAR INSURANCE AGENCY I DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE
I 23 8 0 DREW STREET SUITE 5 I POLICIES BELOW.
1 CLEARWATER FL 33765 1---- ----- - __u__ ---- --___ __________ ___ _h____ _______ _ ____On _ _ _____
I I COMJi'Al'lIltS Ali'FOROING CO"BAAOlt
, 7 2 7 - 7 9 7 - 8 6 0 3 I COMPANY
1---------------_.______--____________________________________1 A AUTO OWNERS INSURANCE CO
I INSURED 1___________________________________________________________________
I I~~
liB
I 1____________________-____________________________________._________
I I COMPANY
,Clearwater Shuffleboard Club I c
110.2 0 Calumet St reet , - _h____ _u _ ____ _ _ ___oo _ __ __ _ _u _ _ _. _ _ hh__ u_ __ _ __ __ ___ ____n _ _ __
,Clearwater FL 33755-1813 / COMPANY
I I D
I> COVERAGeS ~----------.--..--.---...-..am~~=_m=~==~===m<<.~==~c~.~Kc~a.=a....m.a_.____.__..___._.~__.________________~.~~~.~._K.a
I THIS IS TO CERTIFY THAT '!HE POLICIES OF INSUl<ANCE LISTED BELOW HAVE BEBN ISSUED TO THE INSURED NAMED ABOVE POR mE POt.ICY
I PBRIOD INDICATED, NOTWITIfBTANDING ANY REQUIREMSN'r, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO
I WHICHTHtS CERTtFlCATB MAY BE ISSUED OR MAV PERT~IN, THE: INSURANCB AFFORDED BY THR POLICIES DESCRIBED HEREIN IS SUBJECT TO
I ALL THE TBRMS, EXCLUSIONS, AND CONDITIONS OF soca POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
1-----------------------------------------------------____________________________________________________________________________
I col TYPE OF INSURANCE 1 POLIC'l NUMB8R I POLICY EPF I POLICY EXP I LIMITS '
ILTRI I IOATE (MM/DD/YY) IDATB(MM/DD/YY) I
1---1-------------------------------1----------_._----__________1_______________1______________1__________________________________
I I OEN1l:1U\L LIABILITY I I I IGENERAL AGGREGATE I 500.000
I AI U{] COMMERCIAL GEN LIABILITY 120540898 112/13/03 /12/13/04 IPROD-COMP/OP AGG. I 500,000
I I [) CLAIMS MADE (X) OCC. I I I IP2Ra. 50 AoV. INJURY I 500,000
I I [ ) OWNERS'S.. CONTRACTOR'S 1 I I lEACH OCCURRENCE I 500,000
I I 5'ROTBC'r:tV2 I I I I FIRE DAMAGE I
I I ( J I I I I (ANY ONE: FIRE) 1 50,000 I
I 1 ( J I 1 I IMED. EXPENSE I 1
I I 1 I, I (ANY ONE: PER.sON) 1 5.000 I
1---1--------------------------.----1------._---------__________1_______________/--------------1---------__________/_____________..1
1 I AtlTOMOliHLE L!ABIL!T1t I I I I COMB. SINGLZ LIMIT I I
1 I [ ] ANY AtlTO I I / IBODILY IN~1/' I I
I I [ ] ALL OWNED Atl"l'OS 1 I I 1 (PER PERSoN), 1
I I [ 1 SCHBDULED Atl"l'OS I 1 I I I 1
I I ( ) tlIREI> AtJ'1'OS 1 I I 1 ElODILY INJURY 1 I
I 1 ( J NON-OWNBD AUTOS I 1 I I (PER ~CCIDENT) 1 I
I I ( ] I I 1 1 I I
I I ( ) I I I I PROPERTY DAMAGE I I
I---I-------------------------.-----I---------~-----------------1---------------1--------------1------------_______1_________-____1
1 I GARAGB LIABILITY I I 1 IAUTO ONLY (EA ACe) I f
I I [ ] ANY AUTO 1 I I IOTIl:I!R / AUTO ONLY: I I
I I [ J I I I I EACH ACCIDBNT I I
I I [ ] I I 1 I AGGREGATE I I
1---1-------------------------------1-----------------__________1_______________1______________1___________________1______________1
I I EXCESS LIABILITY I I / 'E1l.Cll OCCURRENCE I ,
I I [ ] UMBRELLA FORM I 1 I IAGGREGA.TE I I
I I [ ] OTHER 'mAN UMBRELLA FORM I I I I I I
1---1-------------------------------1-----------------__________/_______________1______________1___________________1______________1
I I WORKERS COMP. AND EMP. LIAB. I I, I 1 STAT LlM [ J OTIl: I I
I I THE PMPUl.'l'X'OR/PAR'tNERS/ I I I IEL !lA ACClDENT I I
I 1 EXECUTIve OFFICERS AAE: , I I IEL DISEASE-POL. J..J:MI I
I I [ ] INCL. [ ] EXCL. 1 I I IEL DISEASE-EA EMP. 1 I
1---1-------------------------------1-----------.-----__________1_______________1______________1__________________________________1
I I OTHE!l. I I I I I I
I I I I I I I 1
I I I 1 I I I I
I I I I I I I I
I 1 I I 1 I I I
/-DESCRIPTION of OPBRATIONS!LOCATIONS!VEHICLES/SPECIAL ITEMS-------_______________________________________________________________1
I I
I I
I I
I I
' I
I> CE~~IFICATE HOLDBR <---~---...-..............-----------> CANCELLATION <....-----------~--~-...<.~..____ I
I CITYCLE SHOULD ANY OF TIlE lUlOVE DBSCRIBED POLICIBS BB ;;;~;~~;~.;;;~;;.;:;---/
I EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL I
,CITY OF CLEARWATER 10 DAYS WRITTBN NOTICE TO THE CERTI!'ICATE HOLDE~ NAMED TO THE I
1562-4825 ATTN: JAN HARRISON LEFT, sO'!' FAILURE TO MAIL SUCH NonCE SHALL IMI'I:)~~,_"~~.~tION OR I
IPO BOX 4748 LllUlrLITV Oll' )>,Ny KIND UPON THE COMP)>,Ny, ITS EmS cia REJlRE:9MATIVES I
,CLEARWATER FL 33758 -----------------___hU_.'___h _:,
I AUTHORIZED REPRESENTA'U\fJ5: I
' I
I_ACORD 25-S (1/95) I Robert E _ Nussear I