CERTIFICATES OF INSURANCE
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Don Petersen, Risk Manager
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CITY OF CLEARWATER
Interdepartmental Memorandum
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El i zabeth S. Haeseker. Assi stant Ci ty Manager:~./ /
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Ream Wilson, Parks & Recreation Director
December 21, 1987
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SUBJECT: Clearwater For Youth (Baseball/Carpenter Field) -- Insurance Expiration
The above-referenced insurance policy is due to expire December 18, 1987.
Please forward a copy of the current Certificate of Insurance to me when you have
determined. the ~olicy meets the lease requirements.
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DATE:
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FEB 3 19S8
em CLERK
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The Nationwide Insurance Company
de~Cribed below is in force as of
or otherwise alter the Terms and
below.
Certificate of Insurance
i~coted below certifies that the insuronce affcxled by the policy or policies numbered and
the effective date of this certificate. This Certificate of Insurance does not amend, extend,
Conditions af Insurance coverage contained in any policy or policies numbered and described
Certificate Holder's Nome and Address:
Insured'sHame and Address,
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City of Clearwater
P. O. Box 4748
Clearwater; FL 34618-4748
Clearwater For Youth, Inc.
2037 Gulf to Bay Blvd.
Clearwater, FL 34624
e: Carpenter Baseball Field
DESCRIPTIVE SCHEDULE
,
POLICY NUMBER AND POLICY POLICY
TYPE OF INSURANCE EFFECTIVE EXPIRATION LIMITS OF LIABILITY
ISSUING COMPANY DATE DATE
GENERAL LIABILITY General 1,000,000
] Premises - Operations 77PR-018-655-8000 12-18-8/ 12-18-88 Aggregate
Pro Compo Op. Agg. 1,000,000
] Products - Completed
Operations Each Occurrence 1,000,000
] Personal and Any One Person or
Advertising Injury Organization 1,000,000
] Medical Expense Any One Person 5,000
] Fire Damage Legal , Any One Fire 50,000
,
] Other liability
AUTOMOBILE LIABILITY Bodily Injury OCCURRENCE
J Comprehensive Form (Each Person)
1 Owned Bodily Injury
I (Each Accident)
] Hired Property Damage
1 <
J Non-Owned Bodily Injury and
Property Damage
Combined
EXCESS LIABILITY Bodily Injury and
Property Damage Occ.
1 Umbrella Form Combined Agg.
1 Workers' Compensation STATUTORY LIMITS
j
Bodily Injury Each Accident
and by Accident
] Employers' Liability Bodily Injury Policy Limit
by Disease
Bodily Injury Each Employee
by Disease
. ,
surance in force only for hazards indIcated by X.
escriptian of Operations / Locations /
ehicles / Restrictions / Special Items
Youth Sports/Same and temporary work sites elsewhere in
the state of Florida.
Date Certificate tnued
1-20-88
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Countersigned at, C 1 ear w ate r, If'L
NA nONWlM MUTUAL INSURANCE COMPANY
NATIONWIDE MUTUAL FIRE INSURANCE COMPANY _
NATIONWIDE PROPERTY ND CASUALTY INSURANCE COMPANY
C ~US, 0 io
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See ',. ,; P"sid~n'
. ,1'.4 _ Authorized Ileore.entntiv..
ISSUE OA TE IMMiOOiYY'
7/29/87
SHAFER-BROWN INS INC
POBOX 1328
CLEARWATER FL 34617
THIS CERTIFICATE IS ISSUE!TAS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVER-
AGE AFFORDED BY.THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
PINELLAS YOUTH FOOTBALL CON IN
POBOX 71
LARGO FL 34294
COMPANY A CINCINNATI INS CO
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY D
LETTER
COMPANY E
LETTER
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THIS IS TO C:::RT1FV THAT ?OLiCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
P=:RIOD INDIC.;TED. NOrNITH5T""~JOING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH
RES?ECi TO 'NHICH THIS CERTIF:C;>..TE :v1AY BE ISSUED OR :v1AY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED
HEREIN IS SUBJECT TO ALL THE -:-E;<MS. C:XCLUSIONS. AND CONDITIONS OF SUCH POLICIES.
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1_TRI
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TYPE OF I NSU RANC~
?OLlCY NUMBER
POLICY EFFECTIVE POLICY EXPIRATIONI
DATE IMM/OOiYYI DATE IMM/DDiYYI
LIABILITY LIMITS IN THOUSANDS
~NERAL LIABILITY
~COMPREHENSIVE FORM
L.xi PREMISES/OPERA TI ONS
I i~~~C;S~~~~~OLLAPSE HAZARD
dPRODUCTS/CDMPLETED OPERATIONS
X CONTRACTUAL
'INDEPENDENT CONTRACTORS
AGL2984527
EACH
OCCURRENCE
AGGREGATE
3/01/87
3/01/88 BODILY
INJURY
PROPERTY
DAMAGE
g6t:~NED 500
BROAD FORM PROPERTY DAMAGE
X PERSONAL INJURY
PERSONAL INJURY
AUTOMOBILE LIABILITY
ANY AUTO
BODILY
INJURY
(PER
PERSON!
BOD I L Y
INJURY
(PER
ACCIDENTI
ALL OWNED AUTOS
HIRED AUTOS
NDN.OWNED AUTOS
PROPERTY
DAMAGE
GARAGE LIABILITY
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COMBI:IIED
EXCESS L1ABI L1TY
UMBRELL;" FORM
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WORKERS' COMPENSATION
AND
EMPLOYSrlS' L1AB! L1TY
ST A TUTORY
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IDISEASE-POllCY lIMITI
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"1.- CITY OF CLEARWATER
1 A TTN: LARRY DOWD
) POBOX 4748
'~ CLEARWATER FL34618
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SHAFER-BROWN INS INC
POBOX 1328
CLEARWATER FL 34617
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDE'R. THIS
CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE COVER-
AGE AFFORDED BY THE POLICIES BELOW.
COMPANY A CINCINNATI
LETTER
INS CO
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COMP."'NY B
LETTER
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PINELLAS YOUTH
POBOX 71
LARGO
FOOTBALL CON IN
COMPANY
LETTER C
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Tf~!S IS TO CeRTIFY ,'-;PT "G!.-:''::':S OF :NSUR;"NCE c.ISTED BELO;''! HAVE BE!O:N ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY
"'ORIOD :NDICAT::::>. '~o,'..."-'-,-,ST'''~D:.'JG ANY REQUIREME~n. TERM OR CO~~DITIO~~ OF A~JY CONTRACT OR OTHER DOCUMEN.T WITH
'<ESPO::CT TO WHICH :-'--'IS'::::RT:FICAT:': :,lAY 3E ISSUED OR MAY PE"TAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED
HEREIN IS SUBJECT ~-o .-"LL THE -ER~.~S. -O:XCLUSIONS, AND CONDIT]ONS OF SUCH POLICIES.
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"TYPE OF lNSUR":",I'\!CE
DOLIC' NUMBER
i POliCY 'Et:F!:CT!\/!: i?OL1CY.EXP'R~\T:~!'JI
I :JATE ',MM,DD,'YY~ i ;::':"7:: :\.1MiDD/Y'r} ;
LIABILITY LIMITS IN THOUSANDS
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! GENERAL LIABILITY
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L.XCC""PPEH~NSlIjE FCR~~'
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~ EXPLOSION & COLLAP~E HAZARD
UPROOUCTSICOMPLETED OPERA nONS
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rx: 'NDEPENDENT CONTRACTORS
nSROAD FORM PROPERTY DAMAGE
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X'PERSONAL ]NJURY
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3/01/871
3/01/88iBODILY
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DAMAGE
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DANY AUTO
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WHIRED AUTOS
UNON.OWNED AUTOS
I IGARAGE L1hBILlTY
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1 EXCESS L1ASI L1TY
i!UMBRELlA FORM
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! IOTHER T1-lAN U~-"'BREL:..A FOR\-'
BI & PO
(OMBINED 500
I "",ONAL 'NWev
180DIL Y
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BOD]LY I
INJURY
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PROPERTY I
DAMAGE
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; :JESCRIPTION OF OPERATIONS/LOCATI.ONS/VEH1CLES!S~ECIAL'TEMS
i GREENWdbo'-PANTHERS' FOB PRACTICE LOCATED
. n'AT" PH I LCIF' . JONES F"AR~( AND MARTIN LUTHER
KING FIELD/CITY OF CLEARWATER ADDL INSD
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SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRA,'ON DATE l'(fREOF. THE ISSUING COMPANY
WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO
THE <:ERTIFICATE HOLDER NAMf:.D TO ,HE LEFT, BUT FAILURE TO
MAIL SUCH NOT]CE SHALL IMPOS'" . 6LiGATlON OR LIABILITY OF
ANY KIND UPON THE COMPA~ . ITS AGENTS OR~' ESENTATIVES.
AUTHORIZED REPRESENTATIVE
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(DISEASE.POLlCY LIMIT) ~~i
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EMPLOYEr:lS' L1ASI LIlY
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ATTN: LARRY DOWD
POBOX 4748
CLEARWATER FL34618
STEPHEN D GROWN
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SHAFER-BROWN INS INC
POBOX 1328
CLEARW~TER FL 34617
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 COVER-
AGE ."IFFORDED BY THE POLICIES BELOW.
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IN
COMPANY A
LETTER
I COMPANY B
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LETTER
COMPANY
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COMPANIES AFFORDING COVERAGE
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PINELLAS YOUTH FOOTBALL
POBOX 71.
LARGO
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---H!S '578 C=Qi''::'.' -::-,p..;-- :~C:.~,C'~S ~_:F !NSURANC~ ~;STED BELO'N HAVE aE::::N :SSU::::O 70 THE INSURED !'lAMED ,.4,BOVE FOR THE POLICY
:)~~lCS l~lf~:C.~-;-::::C. ~.jC~"'/I-:-:-':S7 ':':'iL:li'JG .':"NY ~EQUIRE~.1E:-.JT, "7"E~i\/l OR ::O:"JCrT10r"1 OF :4.NY CCNT~ACT OR OTHER DOCUMENT WITH
_~:::S?EC7 TO 'NHIC:-i T:--.1lS C::::;;~:~!r.::.'-::"T:::: ,"I:1AY :3E !S5UED OP :'.-~AY :~~;:\T/~[N, -:....oE 1i'~SURANC::: ..4rr=GRDEO BY THE POLICIES DESCRIBED
:-1E:~~:I'J is SUSJEC- -:-0 .4:"":"" -;-i::: -:::'~l':iS. :-::><C~:..JSICi\lS. AND CO;"JOi--:-l0:'\JS ':JF SUC~ ?0L:C:ES.
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TYPE I,JF :NSUP.':"r"JC~
?OLlCY NUMBER
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~I' 'PRODUCTS:COMPL:TED OPEgATIONSI
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mPERSONAL INJURY I.
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LIABILITY LIMITS IN THOUSANDS
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aODI L Y
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.~ DESCRIPTION OF OPERATIONS/LOCA!tOO~~~~RIY~~D~CJRj~EOUGAHS"'F6F{'P.~ACTJCE~:'AT.'
~! "COUNTRYSIDE SPORTS COMF'LEX AI'.m l.JOODGATE
j PARK/CITY OF CLEARWATER ADDL INSD
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CITY OF CLEARWATER
ATTN: LARRY DOWD
POBOX .47.48
CLEARWATER FL34618
ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
BEFORE THE EXPIRATION DATE rOEREOF, THE ISSUING COMPANY
WILL ENDEAVOR TO MAIL DAYS WRITTEN NOTICE TO
THE CERTIFICATE HOLDER NAME.D TO HI;;: LEFT. BUT FAILURE TO
MAIL SUCH NOT~CE SI-'ALL IMPOSE NO C LIGATION OR LIABILITY OF
ANY KIND UPON THE COMPANY. G NTS OR . "to'- NTATIVES.
AUTI-'ORIZ::O REPRES:O:~ITATIVE
STEPHEN D 8ROl.JN
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