CERTIFICATE OF INSURANCE
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ACORDru CERTIFICATE OF LIABILITY INSURANCE
DATE (MMlDDIYY)
01/24/05
PRODUCER
Risk Management Services, Inc.
1-800-777-4930
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.
INSURERS AFFORDING COVERAGE
P.O. Box 32712
Phoenix, AZ 85064-2712
INSURED
CLEARWATER AQUATIC TEAM
USA Swimming eta1 Inc1 Local Swimming Committees
MIKE YEARWOOD
1501 N BELCHER ROAD, SUITE 229
CLEARWATER, FL 33765-1339
INSURER A: Lexington Insurance C any
INSURER B: Mutual of Omaha Insurance Com,pany
INSURER C:
INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE 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, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
I'~~: TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
A ~NERAL LIABILITY 1638683 12/31/04 12/31/05 EACH OCCURRENCE $ 2,000,000
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $100,000
l CLAIMS MADE 0 OCCUR MED EXP (Anyone person) $ EXCLUDED
X Participant Legal PERSONAL & ADV INJURY $1,000,000
~
~ Liability Included GENERAL AGGREGATE $ 4,000,000
n'L AGGRnE LIMIT APFlS PER: PRODUCTS - COMP/OP AGG $ 2,000,000
POLICY ~~R,: LOC
~OMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
-
- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
-
- HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per accident)
~AGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESS LIABILITY 3695969 12/31/04 12/31/05 EACH OCCURRENCE $ 3,000,000
t:~j' OCCUR D CLAIMS MADE AGGREGATE $ 8,000,000
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I WC STATU- I TOJ~-
EMPLOYERS' LIABILITY
E.L EACH ACCIDENT $
E.L DISEASE - EA EMPLOYEE $
E.L DISEASE - POLICY LIMIT $
OTHER
B XS ACC NED/DENTAL AD " D T5MPSP35054 01/01/05 01/01/06 Maximum $25,000
$
$
DESCRIPTION OF OPERATIONSlLOCATIONSlVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
Verification of General/Excess Liability for INSURED ACTIVITIES per attached. The Certificate Holder is included
as Additional Insured per attached ADDITIONAL INSURED ENDORSEMENT EFFECTrvE CERTIFICATE ISSUE DATE.
CERTIFICATE HOLDER I I ADDITIONAL INSURED' INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Clearwater DATE THEREOF, THE ISSUING INSURER WILL ~X~MAIL ~ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Kathy LaTurza ~~~~
100 S. Myrtle Ave. 33756
Mail: P.O. Box 4748 ~XX XXXXXXXXXXX
Clearwater, FL 33758-4748 AUTHORIZED REPRESENTATIVE <..' ~ " Q~
I USA .~ .~ (j. '{oJ ,
ACORD 25-S (7/97) FL-CAT
2439507
@ACORD CORPORATION 1988
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ATTACHMENT TO USA SWIMMING CERTIFICATE
ADDITIONAL NAMED INSUREDS:
1. United States Swimming, Inc. Member Clubs for Insured Activities.
(Please Note: Member Clubs must be in good standing, which means that all athletes and all
coaches must be United States Swimming members.)
2. Any Member of United States Swimming, Inc., or volunteer, while acting on behalf of and
with the approval of the Board of Directors of United States Swimming, Inc.
DEFINITIONS:
1. United States Swimming, Inc. Member Clubs are clubs that are members in good standing
with United States Swimming, Inc. and whose athletes and coaches are members of United
States Swimming, Inc.
2, Sanction as defined by United States Swimming, Inc. Rules and Regulations.
3. Approved Meet as defined by United States Swimming, Inc. Rules and Regulations.
INSURED ACTIVITIES:
A, Swimming events where a United States Swimming, Inc. Sanction has been issued.
B. United States Swimming, Inc. Approved Meets.
C. Swimming practices where all participating athletes and coaches are members of United
States Swimming. Must be held under the sole and direct supervision of United States
Swimming, Inc. Member Coaches.
D. Swimming tryouts under the sole and direct supervision of United States Swimming, Inc.
Member Club Coaches. May not last for a period of more than thirty (30) consecutive
calendar days in a 12-month period, for any individual.
E, Learn to Swim Program where all participating athletes and coaches are members of United
States Swimming, Inc. Must be held under the sole and direct supervision of United States
Swimming, Inc. Member Coaches.
F. United States Swimming, Inc. contracted Swim-A- Thons.
G. United States Swimming, Inc. approved social events where alcoholic beverages are not sold.
H. United States Swimming, Inc. approved fund raising activities.
"
ATTACHMENT TO USA SWIMMING CERTIFICATE
POLICY NUMBER: 1638683
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSUREDS - BLANKET
OWNERS AND/OR LESSORS OF PREMISES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE FORM
Policy # 1638683 is amended to include as an additional insured any person or organization of
the types designated below and as evidence by a Certificate of Insurance issued for you by us or
on our behalf, but only with respect to liability arising out of your operations:
1. Owners and/or lessors of the premises leased, rented, or loaned to you, subject to the
following additional exclusions:
A. This insurance applies only to an occurrence which takes place while you are
occupying in the premises;
B. This insurance does not apply to Bodily Injury or Property Damage resulting from
structural alterations, new construction or demolition operations performed by or on
behalf of the owner and/or lessor of the premises;
c. This insurance does not apply to any design defect or structural maintenance of the
premises by or on behalf of the owner and/or lessor.
With respect to any "Additional Insured" included under the policy by this endorsement, this
insurance does not apply to the sole negligence of such "Additional Insured".
Effective Date: The effective date of this endorsement shall be the issue date of the
certificate to which it is attached.