CERTIFICATE OF INSURANCE (213
ACORQM
CERTIFICATE OF INSURANCE
ISSUE DATE
03/29/2005
PRODUCER
MCGRIFF, SEIBElS & WilLIAMS OF GEORGIA, INC.
5605 Glenridge Drive - Suite 300
Atlanta, GA 30342
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
Company
A
National Surety Corporation
INSURED
CompBenefits Corporation
100 Mansell Court East
Suite 400
Roswell, GA 30076
Company
B
The American Insurance Company
Company
C
Executive Risk Specialty
Company
o
Company
E
This is to certify that the policiesof insurance describedhereiri 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 POLICY NUMBER EFFECTIVE LIMITS OF LIABILITY
LT EXPIRATION
A GENERAL LIABILITY MZX80840728 04/01/2005 EACH OCCURRENCE $ 1,000,000
00 Commercial General Liability 04/01/2006 FIRE DAMAGE $ 1,000,000
D Claims Made 00 Occurrence MEDICAL EXPENSE $ 10,000
D Owners' and Contractors' Protection
D PERS, AND ADVERTISING INJURY $ 1,000,000
D GENERAL AGGREGATE $ 2,000,000
General Aggregate Limit applies per: PRODUCTS AND COMP, OPER. AGG, $ 2,000,000
D Policy D Project IRl Location
A AUTOMOBILE LIABILITY MZX80840728 04/01/2005 COMBINED SINGLE LIMIT $ 1,000,000
D Any Automobile 04/01/2006 BODILY INJURY (Per person)
IRl All Owned Automobiles BODILY INJURY (Per accident)
D Scheduled Automobiles
IRl Hired Automobiles PROPERTY DAMAGE (Per accident)
00 Non-owned Automobiles COMPREHENSIVE $1000 deductible
D COLLISION $1000 deductible
B WORKERS' COMPENSATION WZC80930187 04/01/2005 WC Statutory Limit I x I Other I I
AND EMPLOYERS' LIABILITY 04/01/2006 EL EACH ACCIDENT $ 1,000,000
EL DISEASE (Each employee) $ 1,000,000
EL DISEASE (Policy Limit) $ 1,000,000
EXCESS LIABILITY EACH OCCURRENCE
D Occurrence DClaims Made AGGREGATE
..c MANAGED ~ARE: E:~() L1~I1'IJI"IJY .~~ 81692174 04/01/2005 Aggregate Limit $ 1,000,000
~ .-. --- -"-
04/01/2006
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
City of Clearwater
City Clerk
P,O, Box 4748
Clearwater, Fl 33758
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,
A,",orimd R"",,","\;,. JIjd: f!
Certificate 10: R1 L4-00K