CERTIFICATE OF INSURANCE (002)
~~
Deoember 8, 1983
Nationwide Mutual Insurance Company
3300 Williston Road
Gainesville, Fl. 32602
Gentlemen:
We are enclosing a copy of Insuranoe Certificate for Polioy No.
77-CS-518-529-0001 covering E.P.C. Ltd. We have been unable to find
any reference to the insured in our files. If the pOlicy is related
to a construction contract we would appreciate being advised of the
name of the project.
May we hear from you at your earliest convenience.
Very truly yours,
Lucille Williams, CMC
City Clerk
Sue Lamkin
Assistant City Clerk
SL/ss
Encl.
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Certificate of Insurance
NW 01 9
(Ed. 12-82
The Nationwide Mutual Insurance Company or the Nationwide Mutual Fire Insurance Company certifies that the insurance afforded by the policy or policie
numbered and described below is in force as of the effective date of this certificate and that this Certificate of Insurance does not amend, extend or otherwis
alter the terms and conditions of insurance coverage contained in any policy or policies numbered and described below.
Certificate Holder's Name and Address: RECEIVED
I
I
City of Clearwater &
Its Employees
112 S. Osceola Ave.
L Clearwater, FL 33516 ~ DESCRIPTIVE SCHEDULE ,CITY CLERK
This is to certify that policies of insurance listed below have been issued to the insured named above and are in forte at this time.
POLICY POLICY LIMITS OF LIABILITY IN THOUSANDS (000)
<~ EffeCTIVE EXPlRAf/ON-' ~.c'-EACHc
DATE DATE OCCURRENCE AGGREGATE
eCT 6
1983
TYPE OF INSURANCE
GENERAL LIABILITY
o Comprehensive Form
o Premises-Operations
o Explosion and Collapse Hazard
o Underground Hazard
o Products/Completed Operations
Hazard
o Contractual Insurance
o Broad Form Property Damage
~ I ndependent Contractors
o Personal Injury Owners
o Broad Form Comprehensive G.L.
Endorsement
.--AUTOMOB!LE.LIABI UIY
o Comprehensive Form
DOwned
o Hired
o Non.Owned
POLICY NUMBER
77-CS-518-529-0001
08-24-83 08-24-86 Bodily Injury $
Property Damage $
$
$
Bodily Injury and
Property Damage $1 ,000
Combined
$1,000
& Contractors Protecti e
Personal Injury
$1,000
WORKERS' COMPENSATION
AND
EMPLOYERS' LIABILITY
OTHER
Bodily InjlJIYn
(Each Person)
Bodily Injury
(Each Accident) $
Property Damage $
Bodily Injury and
Property Damage $
Combined
Bodily Injury and
Property Damage $
Combined
Statutory
$
EXCESS LIABILITY
o Umbrella Form
$
77-CS-518-529-0001
08-24-83 08-24-86
760 000 Pro
Description of Work, ,Ag~:mt, . , , .
Additional Information:
Location of Work , S,a,Itl~ ,q.J;l4, . t~lD.PQr;3,I;y,work , sit. s
~l,$~wi:l~.r,~, iA, 1:h~, ~:t,a,t~, ,of, .EL, , . , , . , , . , , , . ,
.....,...,.,......,......,.....,.."....... .
Insurance in force only for hazards indicated by X,
Nationwide agrees t~ mail the Certificate Holder named hereon at this indicated address (a) at least 10 days' prior notice of cancellation of the policy or policies and/or this certificate; except that this certifi te
shall expire on the expiration date if it is shown above; and (b) notice of any other material change in the policy or policies,
This certificate is executed by Nationwide Mutual Insurance Company if said company has issued Date Certificate Issued 09- 2 8-8 3
the policy to which this certificate is attached; it is executed by Nationwide Mutual Fire Insurance
Company if said company has issued the policy to which this certificate is attached. NATIONWIDE MUTUAL INSURANCE COMPANY
Insured's Name and Address: I NATIONWIDE MUTUAL FIRE INSURANCE COMPANY
Columbus, Ohio /J _ /l f)
E.P.C. Ltd. r.;n.. ~.A+-~:+H:.Q, {/as::..eLU~
2515 Countryside Blvd., Suite H LJ'1.1~~ Preside..
Clearwa ter, FL 33575 Countersigned at: Authorized Represent tive
~ Gainesville, FL
760 FLsh
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