CERTIFICATE OF LIABILITY INSURANCE (6)
ACORQM
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CERTIFICATE OF LIABILITY INSURANCE
PRODUCER (727)521-4253 FAX (727)527-9455
ARC Northeast Assurance, Inc
4790 1st Street North
P.O. Box 7506
St. Petersburg, FL 33703
INSURED Countrys1de Gol Practice & Learning Center
2987 Mcmullen Road
Clearwater, FL 33761
DATE (MM/DDIYYYY) ,
07/10/2003
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.
INSURERS AFFORDING COVERAGE
INSURER A: Burlington Insurance Company
INSURER B:
INSURER C,
INSURER 0,
INSURER E:
NAIC#
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOTWITHSTANDIN
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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,
: INSR DD'l TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY TBD 07/19/2003 07/19/2004 EACH OCCURRENCE $ 1000000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 50000
I CLAIMS MADE [!] OCCUR MED EXP (Anyone person) $ 1000
A PERSONAL & ADV INJURY $ 1000000
-
GENERAL AGGREGATE $ 2000000
-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COM~OPAGG $ 2000000
Xl n PRO- nLOC
POLICY JECT
AUTOMOBILE LIABILITY F"- --;~;~'-'~");j~:? COMBINED SINGLE LIMIT
;:'. - (Ea accident) $
ANY AUTO '.it;:,""":,,;.:,,,,!
- >';/
ALL OWNED AUTOS i.~' .... BODILY INJURY
- '..::~ I: (Per person) $
SCHEDULED AUTOS .,
- ,
HIRED AUTOS '-" . I
- I BODILY INJURY $
NON-OWNED AUTOS L ; (Per accident)
,-, -
I:; .~ " , PROPERTY DAMAGE
- . , $
:: <;,':<i: "U (Per accident)
..,,,. .....,...-" .''',"
GARAGE LIABILITY ~ --, ". AUTO ONLY - EA ACCIDENT $
~ ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
.'
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
=:J OCCUR D CLAIMS MADE AGGREGATE $
$
~ DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I T~~~T~J1?~ I IOJ~-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? E,L. DISEASE. EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below EL DISEASE - POLICY LIMIT $
OTHER
j-ESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
ttn: Mike Fax #727-799-6076
City of Clearwater
C/O Parks & Recreation Dept.
Po Box 4748
Clearwater, FL 34618
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES,
AUTHORIZED REPRESENTATIVE
On File With Com an
ACORD 25 (2001/08)
@ACORD CORPORATION 1988