CERTIFICATE OF LIABILITY INSURANCE (7)
A CORDm CERTIFICATE OF LIABILITY INSURANCE I DATE CMMIDDIYYI
04/05/04
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 Chi Chi Rodriguez Youth INSURER A: ZU RICH-AMERICAN-09 593
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,
l~;: TYPE OF INSURANCE POLICY NUMBER POUCY EFFE~~"'~ Pgk!~Y EXPlRAlION LIMITS
A ~NERAl L1ABIUTY CP03793718 2/01/04 2/01/05 EACH OCCURRENCE $ 1000000
.x 3MERCIAl GENERAL UABILITY FIRE DAMAGE (Any ene firel . 1000000
CLAIMS MADE W OCCUR MED EXP (Anyone personl $ 5000
-
- PERSONAL & ADV INJURY . 1000000
- GENERAL AGGREGATE . 2000000
~'L AGGREn LIMIT An PER: PRODUCTS. COMP/OP AGG $ 2000000
X POLICY ~~,Q;. LOC
~OMOBllE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO lEa accident)
-
- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS CPe, personl
-
- HIRED AUTOS BODILY INJURY
IPer accident) .
- NON-OWNED AUTOS
- PROPERTY DAMAGE .
IPer accident)
~A(lE L1ABIUTY AUTO ONLY - EA ACCIOENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
~' OCCUR 0 CLAIMS MADE AGGREGATE $
$
=J DEDUCTIBLE $
I
RETENTION $ $
WORKERS COMPENSATION AND 1~~~T~~sl 10l~'
EMPLOYERS' LIABILITY E.L, EACH ACCIDENT $
E,L, DISEASE - EA EMPLOYEE $
E,L. DISEASE - POLICYUMIT .
OTHER
DESCRIPTION OF OPERATIONSIlOCATIONSNEHIClES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAl PROVISIONS
GLEN OAKS GOLF COURSE AT 1345 COURT ST.. CLEARWATER, FL & CHI CHI
RODRIGUEZ GOLF COURSE AT 3030 MCMULLEN BOOTH ROAD, CLEARWATER. FL
CERTIFICATE HOLDER IS AN ADDITIONAL INSURED IN RESPECTS TO
GENERAL LIABILITY
CERTIFICATE HOLDER I X I ADDmONAL INSURED; INSURER LETTER. CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POUCIES 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 00 SO SHALL
P,O, BOX 4748 IMPOSE NO OBLIGATION OR UABILlTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
CLEARWATER, FL 33758 REPRESElQ:ATIVES, )
AUTH A1t f'n\ A
c...,.... ~ ""...".r .
ACORD.25-5 17/971
46-36
@ 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 endorsementls),
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,
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurerlsl. 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.
ACORD 25-$ 17/97)
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