CERTIFICATE OF INSURANCE (003)
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CLEARWATER
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POST OFFICE BOX 4748
C LEA R W ATE R, F LOR I.D A 33518 - 4748
December 8, 1983
Nationwide Mutual Insurance Company
3300 Williston Road
Gainesville, Fl. 32602
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Gentlemen:
We are enclosing a copy of Insurance Certificate for Policy 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
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Sue Lamkin
Assistant City Clerk
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"Equal Employment and Affirmative Action Employer" DEe 19 1983
'C\TY CLERK
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Certificate of Insuranc}
NW 01 98
(Ed, 12.82)
The Nationwide Mutual Insurance Company or the Nationwide Mutual Fire Insuran~e Company certifies that the insuran~ afforded by the policy or policies
numbered and described below is in force as of the effective date of this certifictle and that this Certificate of Insurance does not amend, extend or otherwise
alter the terms and conditions of insurance coverage contained in any policy or, policies numbered and described below.
Certificate Holder's Name and Address: ' :~ E C ;,:_ i V F.:~ D
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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,
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POLICY POLICY LIMITS OF LIABILITY IN THOUSANDS (000)
EFFECTIVE EXPIRATION EACH
TYPE OF INSURANCE POLICY NUMBER DATE DATE OCCURRENCE AGGREGATE
GENERAL LIABILITY
D Comprehensive Form 77-CS-518-529-0001 08-24-83 08-24-86 Bodily Injury $ $
. 0 Premises-Operations Property Damage $ $
D Explosion and Collapse Hazard ','
D Underground Hazard
D Products/Completed Operations Bodily Injury and ' '
Hazard Property Damage $1,000 $1,000
D Contractual Insurance Combined
D Broad Form Property Damage ,
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K] Independent Contractors
D Personal Injury Owners & Contractors Protecti Ire Personal Injury $ 1 ,000
D Broad Form Comprehensive G,L.
Endorsement
AUTOMOBILE LIABILITY Bodily Injury ". r
D Comprehensive Form (Each Person) $
DOwned Bodily Injury
D Hired (Each Accident) $
D Non.Owned Property Damage $
Bodily Injury and
Property Damage $
Combined
EXCESS LIABILITY Bodily Injury and
D Umbrella Form Property Damage $ $
Combined
WORKERS' COMPENSATION Statutory
HI 1"\ (Each
r\r,u
EMPLOYERS' LIABILITY $ Accident)
OTHER 77-CS-518-529-0001 08-24-83 08-24-86
RI1;lclpr., Ri.,k 760.000 Prop. Coverage
Additional Information: Description of Work. Ag~nt .
...... . , . . , . , . . . . . ' .. .
, Location of Work . S.a,l\l~ .a,n<l. .t~mpOra,ry. .work. sites
el~~.wll.~~~, :in, th~, s,t.at~. .of.FL
Insurance in force only for hazards indicated by X,
Nalionwide agrees to 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 certificate
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- 28-83
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, Ohi~
~;~;C~O~:~~YSide Blvd., Suite H (}ft. ~~ECEIV' {2 Lf?,~;.~cf
Clearwa ter, FL 33575 . Countersigned at: O!'" 1,9 1983 AuthOrIZed Representative
~ Ga1nesville, FL V
Auto 5737,8
760 FL sh
'::CITY CLERK