CERTIFICATE OF LIABILITY INSURANCE (5)
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ACORDTM
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYYI
2/03/03
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.
PRODUCER
ACORDIA EAST - TAMPA BAY
P.O. Box 31666
Tampa, FL 33631-3666
727-796-6666
INSURERS AFFORDING COVERAGE
INSURED
INSURER A:
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
Maryland Casualty Ins Co
Zenith Ins Co
Chi Chi Rodriguez Youth
Foundation, Inc.
3030 McMullen Booth Road
Clearwater FL 33761
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 ~9..~gY EFFECTIVE POLICY EXPIRATION lIM ITS
A ~ERAL LIABILITY CMM58582652 2/01/03 2/01104 EACH OCCURRENCE $ 1000000
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any Cirielire) $ 100000
ICtAtMS MADE W OCCUR -
1-' .... MED EXP (Anyone person) $ 5000
PERSONAL & ADV INJURY $ 1000000
GENERAL AGGREGATE $ 2000000
~'L AGGREn LIMIT APn PER: PRODUCTS - COMP/OP AGG $ 2000000
X POLICY ~~9.;. LOC
A ~TOMOBILE LIABILITY BAP2997221 2/01/03 2/01/04 COMBINED SINGLE LIMIT
$ 1000000
ANY AUTO (Ea accident)
f---
ALL OWNED AUTOS BODILY INJURY
I-- $
r-X- SCHEDULED AUTOS (Per person)
L HIRED AUTOS BODILY INJURY
$
L 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 UBA58582991 2/01/03 2/01/04 EACH OCCURRENCE $ 1000000
:lSJ OCCUR D CLAIMS MADE AGGREGATE $ 1000000
$
~ DEDUCTIBLE $
X RETENTION $ 10000 $
B WORKERS COMPENSATION AND Z836521203 2/01103 2/01/04 I T~~JI~~s I IOTH-
ER
EMPLOYERS' LIABILITY -. 500000 . ..~
" .- -e:CEACHACCIDENT $
E,L, DISEASE - EA EMPLOYEE $ 500000
E,L. DISEASE - POLICY LIMIT $ 500000
OTHER
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DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS nC\....d::1 V CU
GLEN OAKS GOLF COURSE AT 1345 COURT ST" CLEARWATER, FL & CHI CHI
RODRIGUEZ GOLF COURSE AT 3030 MCMULLEN BOOTH ROAD, CLEARWATER, FL FEB o 4 2003
CERTIFICATE HOLDER IS AN ADDITIONAL INSURED IN RESPECTS TO
GENERAL LIABILITY
RISK MANAGEMENT
CERTIFICATE HOLDER I X I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
CITY OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
ATT-LEO SCHRADER/RISK MGMT DIV NOTICE TO THE CERTIFICATE HOLOER 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
CLEARWA TER, FL 33758 REPRESENTATIVES,
AUTHORIZED RE~ATIVE
I ~~--~
ACORD 25-S (7/97) ~ ~! P ClA)L45- 6 , \.J @ACORD CORPORATION 1988
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(iesl must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(sl.
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(sl.
DISCL:AiMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(sl, 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.
~P..O, ......
--1-..
RECEIVED
FEB 0 4 ?nn~
RISK MANAGEMENT
ACORD 25-5 (7/971