CERTIFICATE OF INSURANCE (3)
From: Alvina Davis At Roe Insurance FaxlD: 727-376-2262 To: Rhonda
Date: 12/17/04 03:28 PM Page: 2 of 3
(
ACORD. CERTIFICATE OF LIABILITY INSURANCE OP 10 :sz4 DATE (MWDDIVYVY)
FAliaRES 12/17/04
PRODUCER THIS CERTIRCATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONfERS NO RIGHTS UPON THE CERTIRCATE
Roe Insurance, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
9851 state Road 54 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
New Port Richey F.L 34655
Phone: 727-376-0030 Fax: 727-376-2262 INSURERS AFFORDING COVERAGE NAlC#
INSURED INSUlER A: 01375
Granite stat. XnaUX'an~ Co.
INSlIlER B: CranJ.t. stAt. In.vance Co. 01375
FamillaResources, :Inc. INS\JlER c:
Jane ~r ED WK.1n9ton %nsuZ'UlC'e c~
5959 Cen rai Ave. INSUlER 0:
st. Petersburg F.L 33701
INSUlER E:
COVERAGES
r
\...
THE POliCIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOO INDICATED, NOlWlTHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF I>Nf CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHlOi THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. THE INstJR.ANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL n-E TERMS, EXa.USIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClAIMS.
LTR NSR[ TYPE OF IIlSURANCE POUCY NUMBER OATEP."MmWj DATE (MMIDDIYV) LIMITS
GENERAL LIABILITY EAOi OcaJRREJICE $1,000,000
r-
A X COMMERCIAL GENERAL LIABILITY LX3295772-1 09/21/04 09/21/05 PREMISES tEe oeturenee) $100,000
~ Q CLAIMS MADE ~ OCClR tIED EXP (Any one person) $15,000
PERSQNl\L & I'DV INJURY $1,000,000
GENERAl. AGGREGATE $ 3,000,000
GEN'l. AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMPIOP AGG $3,000,000
I POLlCY n '1& n LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $1,000,000
A ANY AUTO CA6266613-1 09/21/04 09/21/05 lEe eccldenl)
f--
X ALL OWNEO AUTOS BOOIL Y INJURY
r- (Pet person) $
SCHEOULED AUTOS
f--
X HIRED AUTOS BOOR. Y INJURY
f-- $
~ NON-OWNED AUTOS (Pili ecddenl)
PROPERTY DAMAGE $
(Pet ecddenl)
GARAGE LIABILITY AUTO <m. Y - EA ACCIDENT $
R ANY AUTO OTHER lW\N EA ACe $
AUTo<m.Y I'GG $
EXCESSIUMBRELLA LIABILITY EAOi OCCURRENCE $2,000,000
A ~ OCCUR o aAlMS MADE 004659011-1 09/21/04 09/21/05 AGGREGATE $2,000,000
$
~ DEDUCTIBlE $
X RETENTION $10,000 $
WORKERS COMPENSATION AND X hOR'Y tlQIrs I IVER
B EMPLOYERS' LIABILITY WC7484027 01/01/04 01/01/05 E,L, EACH ACC10ENT $ 500,000
I>N( PROPRIETORIPARTNERIEXEcunve
OFFICERlMEMBER EXClUDEO? E.L. DISEASE. EA EMPLOYEE $ 500,000
If yes, desertbe under E.L, DISEASE - POlICY LIMIT $500,000
SPECIAL PROVISIONS below
OTHER
C Property Covg 6045591 09/21/04 09/21/05 Special 300,000
W/'l'beft
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES' EXCLUSIONS ADDED BY ENllORSEMENT , SPECIAL PROVISIONS
Faxed to insured as requested.
CERTIFICATE HOLDER
CZ'l'CLEA
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRtBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO IolAIl ~ DAVS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO 'THE LEFT, BUT FAILURE TO DO so SHALL
IMPOSE NO DBLIGA TlON OR UABlLITY OF N>lY KIND UPON THE 1IlSURER, ITS AGEII/TS OR
CITY OF CLEARWATER
CITY HALL
112 S. OSCEOLA AVE
CLEARWA'l'ER FL 33756
@ACORD CORPORATION 1988
ACORD 25 (2001/08)