CERTIFICATE OF LIABILITY INSURANCE (3)
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ACORDTM CERTIFICA 11: OF liABILITY INSURAI\(CE I DATE (MM/DDIVYI
2/01/02
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ACORDIA EAST - TAMPA BAY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 31666 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tampa, FL 33631-3666
727-796-6666 INSURERS AFFORDING COVERAGE
INSURED INSURER A: Zurich Insurance Company
Chi Chi Rodriguez Youth Zenith Insurance Co
Foundation, Inc. INSURER B:
3030 McMullen Booth Road INSURER C:
,Clearwater FL 33761 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~i': TYPE OF INSURANCE POLICY NUMBER ~~';!~Y EFFECTIVE POLICY EXPIRATION L1M ITS
A ~ERAL LIABILITY CMM5.8582959 2/01/02 2/01/03 EACH OCCURRENCE $ 1000000
X COMMERCIAL GENERAL LIABILITY ..FIRE DAMAGE (Any'one-fire) $- --,----~ 100000 .'.
... -' -. . -.'-"
I. I-CLAIMS MADE m OCcolf --,----- .----- - ,- - ..
- - .... MED EXP (Anyone person) $ 5000
PERSONAL & ADV INJURY $ 1000000
-
GENERAL AGGREGATE $ 2000000
-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000
Xl POLICY n P'~Ri- n LOC
A ~TOMOBILE LIABILITY BAP2997221 2/01/02 2/01103 COMBINED SINGLE LIMIT 1000000
(Ea accident) $
ANY AUTO
f--
f..- ALL OWNED AUTOS BODILY INJURY
$
~ SCHEDULED AUTOS (Per person)
~ HIRED AUTOS BODILY INJURY
$
~ NON.OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
==i ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
A EXCESS LIABILITY UBA58582991 2/01102 2/01/03 EACH OCCURRENCE $ 1000000
~ OCCUR D CLAIMS MADE AGGREGATE $ 1000000
$
=::i DEDUCTIBLE $
X RETENTION $ 10000 $
B Z836521202 2/01102 2/01/03 I WC STATU. I IOTH-
WORKERS COMPENSATION AND TORY L1MIT~ I ER
EMPLOYERS' LIABILITY ." $- 500000~
1-.....- Ie --'- E,L, EACH ACCIDENT
E,L. DISEASE - EA EMPLOYEE $ 500000
E.L. DISEASE - POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATIONS/LOCATlONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RECEIVeD
GLEN OAKS GOLF COURSE AT 1345 COURT ST" CLEARWATER, FL & CHI CHI
RODRIGUEZ GOLF COURSE AT 3030 MCMULLEN BOOTH ROAD, CLEARWATER, FL
CERTIFICA TE HOLDER IS AN ADDITIONAL INSURED IN RESPECTS TO FFR o 4 lUU2
GENERAL LIABILITY
RISK MAf\lAI~r:n,jL:'i\IT
CERTIFICATE HOLDER I X 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 ENDEAVOR TO MAIL ~ DAYS WRITTEN
ATT-LEO SCHRADER/RISK MGMT DIV NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
P.O. BOX 4748 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
CLEARWATER, FL 33758 REPRESENTATIVES, .-.
AUTHORIZED REPRESENTATIVE ~ d'/
I
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ACORD 25-S (7/97) e~lG'" CIN c.t:.~ (( 45- 69 (~/ ~RD CORPORATION 1988
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement, A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCl..4.IMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
RECEIVED
FFR 0 4 2002
RISK MANAGEMENT
ACORD 25-5 (7/97)