CERTIFICATE OF INSURANCE (238)
ACORDTII
I
CERTIFICATE OF INSURANCE
I
PRODUCER
MCGRIFF, SEIBElS & WilLIAMS OF GEORGIA, INC.
5605 Glenridge Drive - Suite 300
Atlanta, GA 30342
ISSUE DATE
10/06/2004
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,
Company
A
INSURED
CompBenefits Corporation
100 Mansell Court East
Suite 400
Roswell, GA 30076
Company
B
Company
C
Company
o
Company
E
COMPANIES AFFORDING COVERAGE
National Surety Corporation
The American Insurance Company
Executive Risk Specialty
I
This is to certify that the policies of insurance described herein have been issued to the Insured named herein for the policy period indicated, Notwithstanding
any requirement, term or condition of 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, conditions and exclusions of such policies, Limits shown may have been reduced by paid claims,
CO TYPE OF INSURANCE
LT
A GENERAL LIABILITY
[RJ Commercial General Liability
o Claims Made [RJ Occurrence
o Owners' and Contractors' Protection
o
o
General Aggregate Limit applies per:
o Policy 0 Project [RJ Location
A AUTOMOBILE LIABILITY
o Any Automobile
[RJ All Owned Automobiles
o Scheduled Automobiles
[RJ Hired Automobiles
[RJ Non-owned Automobiles
o
B WORKERS' COMPENSATION
AND EMPLOYERS' LIABILITY
POLICY NUMBER
MZX80826280
EFFECTIVE
EXPIRATION
04/01/2004
04/01/2005
MZX80826280
04/01/2004
04/01/2005
WZC80921125
04/01/2004
04/01/2005
EXCESS LIABILITY
o Occurrence 0 Claims Made
C MANAGED CARE E&O LIABILITY
81692174
04/01/2004
04/01+2005 -
LIMITS OF LIABILITY
EACH OCCURRENCE $
FIRE DAMAGE $
MEDICAL EXPENSE $
PERS, AND ADVERTISING INJURY $
GENERAL AGGREGATE $
PRODUCTS AND COMP, OPER. AGG, $
COMBINED SINGLE LIMIT
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE (Per accident)
COMPREHENSIVE
COLLISION
WC Statutory Limit I x I Other I I
EL EACH ACCIDENT
EL DISEASE (Each employee)
EL DISEASE (Policy Limit)
EACH OCCURRENCE
AGGREGATE
1,000,000
1,000,000
10,000
1,000,000
2,000,000
2,000,000
$
1,000,000
$1000 deductible
$1000 deductible
$
$
$
1,000,000
1,000,000
1,000,000
Aggregate Limit $ 1,000,000
- . ~_._- --- - - ----- ----- .._-.- --------~-
City of Clearwater is included as Additional Insured on the General Liability and Automobile Liability policies referenced herein, as required by written contract,
subject to policy terms, conditions and exclusions,
CERTIFICATE HOLDER
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, THE INSURER WILL ENDEAVOR TO MAIL 30
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT A FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
LIABILITY OF ANY KIND UPON THE ISSUER, COMPANY, ITS AGENTS OR
REPRESENTATIVES,
City of Clearwater
City Clerk
P,O. Box4748
Clearwater, Fl 33758
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Certificate 10: LQY JEWQR