CERTIFICATE OF INSURANCE (210)
ROGER BOUCHARD INSURANCE
101 St4'U-Cl-ettt Dr t PO 80x 6090
CLEARWATER, FL 34618
THIS CERTlFICA1E 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
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PRODUCER
COMPANIES AFFORDING COVERAGE
813-447-6481
COMPANY A
LETTER
The Travelers Insurance Co
INSURED
Conso l idated Bul ldi n9 Concepts
221 Be lchel.' Road
ClearNate,-
COMPANY B
LETTER
Auto ONners Insurance Company
IWt na LI f. ~ tt""il\l t~
f~~ ~ '&~\
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COMPANY C
LETTER
FL 34618
COMPANY D
LETTER
THIS IS -rO.CERTIF,(, THAT THE POLlCIESOF:JNSURANGEUSIEDBELQW I-tAVE sEEN ISSUED TO THE INSUREDNAMEDABOVE 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
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DDIYY) DATE (MM/DD/YY)
ALL LIMITS IN THOUSANDS
GENERAL LIABILITY
AX COMMERCIAL GENERAL L1ABILlTy660-906.J5681-COF-
CLAIMS MADE X OCCUR,
OWNER'S & CONTRACTOR'S PROT,
XPD Ded $1000.
2/01/91
2/02.1'92
GENERAL AGGREGATE
$
1000
1000
50a
500
50
AUTOMOBILE LIABILITY
B X 'ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON.OWNED AUTOS
GARAGE LIABILITY
20159852
2/01/91
2/01/92
PRODUCTS-COMPIOPS AGGREGATE $
PERSONAL & ADVERTISING INJURY $
EACH OCCURRENCE $
FIRE DAMAGE (Anyone fire) $
MEDICAL EXPENSE (Anyone person) $
COMBINED
SINGLE $
LIMIT
BODILY
INJURY $
(Per person)
BODILY
INJURY $
(Per accident)
5
EXCESS LIABILITY
A X UMBRELLA FORM SMCUP-906J722-0-9
2/01/91
2/01/92
EACH
O~~CE
$J.VVV $
PROPERTY $
DAMAGE
C
AND
09-1123-90066-000
2/27/90
2/27/91
STATUTORY
100
500
100
(EACH ACCIDENT!
(DISEASE-POLICY LIMIT)
(DISEASE-EACH EMPLOYEE
OTHER THAN UMBRELLA FORM
WORKER'S COMPENSATION
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERA TIONS/LOCA nONS/VEHICLES/SPECIAL ITEMS
Re: Additions and Alterations to .Jack Russel Stadium
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPII~610N DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
+l: MAIL - DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
if LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
,;
n LIABILITY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES,
City of Clearwater
P.O. Box 4748
Ctearwate,-,. FL 34618-4748
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