CERTIFICATE OF LIABILITY INSURANCE (141)
ACORD
TM
PRODUCER (727)530-0684
Jack Rice Insurance,
13080 S. Belcher Rd.
Largo, FL 33773
FAX (727)536-9985
DATE (MM/DDIYYYY)
06/25/2003
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.
CERTIFICATE OF LIABILITY INSURANCE
Inc.
INSURED Cumbey & Fair, Inc.
2463 Enterprise Road
Clearwater, FL 33763-1790
INSURERS AFFORDING COVERAGE
INSURER A: Auto-Owners Ins. Co.
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
NAIC#
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN
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~$l~ ~~~~ TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
f-- DAMAGE T9"RENTED
COMMERCIAL GENERAL LIABILITY $
- -----.- .. LQIoA.lF\l1S}v1AlJE. C:lo~ __...__c_ - --' '-----"-,-- . -.-._~- ___,----_..C-_-.-O----- _ --- "---------- - MED _EXP l/V'ly ona,person) $--_. '-'-. -------
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $
h .nPRO- nLOC
POLICY JECT
AUTOMOBILE LIABILITY 4216336901 01/16/2003 01/16/2004 COMBINED SINGLE LIMIT
f-- (Ea accident) $
X ANY AUTO 1,000,000
f--
ALL OWNED AUTOS BODrL Y INJURY
f-- $
X SCHEDULED AUTOS (Per person)
A f--
X HIRED AUTOS BODILY INJURY
'"X $
NON-OWNED AUTOS (Per accident)
f--
f-- PROPERTY DAMAGE $
(Per accident) ..
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
tJ OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I WC STATU- I IOJ~-
EMPLOYERS' LIABILITY E.L EACH ACCIDENT $
.-. ~~~!f~=~~~~~~~m~W6;ECU~I~~_ . -'-- ---------"-- -- ----- --. ..-.------ --~- -- -- .. - -E.L:.D1SEASE' EA EMPlOYEE $ ...
If yes, describe under E.L DISEASE - POLICY LIMIT $
SPECIAL PROVISIONS below
~HER, Damage 4216336901 01/16/2003 01/16/2004 Compensation Oed $500
A YS1cal Collision Oed $500
~ESCRlPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
e: Project: 2003 Engineer of Record Contract
tity of Clearwater is additional insured with respects to Automobile Liability. {Job Owner}
* Except 10 Days for Non-Payment of Premium
C
IF CATE HOLDER
C
TION
City of Clearwater
Attn: Risk Management
PO Box 4748
Clearwater, FL 33758-4748
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL 1l'IBX~ MAIL
* 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
~XK~)()(a06~~~XX
~M~Jt}{X<UJ(JOrOO{~XXXXXXXX
dqtJ~
AUTHORIZED REPRESENTATIVE
Sandi Vernacchio/FLN
ACORD 25 (2001/08) c(L( C. '. c.e\'-\. ~L.-~
~C!.: ~,
Kt'5fL
@ACORDCORPORATION 1988
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 (2001/08)