CERTIFICATE OF INSURANCE
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a
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CIty of Clearwater
Interdepartmental Correspondence
TO:
FROM:
CO PIES:
SUBJECT:
DATE:
Margie Simmons, Finance DireCtor
Ream Wilson, Director, Parks and Recreation Depart~
vSusan Stephenson, Documents and Records Supervisor (~em only)
Chi Chi Rodriguez Financial Report (
November 2, 1995
As required by the agreement between the City of Clearwater and the Chi Chi Rodriguez
Foundation, the attached financial statement for this past fiscal year is being forwarded
for your information and files.
Please contact me if you have any questions.
RW /deb
Attachment
H:\DAT A \ WPFILES\DEBBIE\MEMO\CHICHI.DOC
_rCYCl[O a PAP!:R
lIECEIVED
NOV 0 6 1995
Clly CLERIC DEPT.
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:;:;:;:::::~:: .:t::::-: -: .:::.:.:.:-:::-:.:-: -:::.' -:':.,::..... _-:-:.'..,:-'.' -:. .,. -:.:.','.' -:.; .,' -:.' . -:,'. :,'.''', - -,' . -.', ' '. : "'. -:.;.' -'" ,-.' . -: -' -. _:- -- .- -:- : -' '. '.: - - - ,-: - -:. ':-:-,' '. -: -: -: -: -' -' .: -: " - ,-: -:'. -:. -:......:-'.
(:.CI- /2-1 :') IL /VI.
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ODUCER
TillS CERTlJi1CATE IS ISSUED AS A ~IATTER OF INFOR..\lATlO:'l O:'lLY AND
CONITRS SO RIGIIT'S UPON TilE CERTIJi1CATE HOLDER. TillS CERTIJi1CATE
DOES NOT AMEND, EXTEND OR ALTER TilE COVERAGE AFTORDED BY TIlE
rOLlCIF.s BELOW
INQUIRIES: 813-796-6666
Acordia of Central Florida
COMPANIES AFFORDING COVERAGE
P,O, Box 31666
w~~~~
Travelers Indemnity Co,
T'.-I> #,
Travele~ Indemnity Co,
Tampa, FL 33631-3666
'StiRED
Chi Chi Rodriguez Youth
Fbundation, Inc,
3030 McMullen Booth RoR IS K
Clearwater FL 34621
Riscorp Insurance Compa
ns IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW lIA VE BEEN ISSUED TO TIlE INSURED NAMED ABOVE FOR TIlE POLICY PERtOD
ICATED, NOTWITIISTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUME.'fT WITH RESPECT TO wmCH Tins
ERTlJi1CATE MA Y BE ISSUED OR MA Y PERTAIN, THE INSURANCE AFTORDED BY TIlE POLICIES DESCRIBED IIEREIN IS SUBJECT TO ALL THE TERMS,
XCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MA Y IIA VE BEEN REDUCED BY PAID CLAIMS,
POLICY EFT, POLICY EXP,
DATE (MMIDDIYY) DATE (MMIDDIYYl
TYPE OF INSURANCE
POLICY NUMBER
66060705167
2/01/95
2/01/96
GENERAL AGeREGA TE
PROIJ..COMP/OP AGe,
PERS, & ADV.IN1URY
EACH OCCURRENCE
F1RE DAMAGE(Oue n...)
MED. EXP, (Oue Per)
COMBINED SINGLE
LIMIT
COMM, GENERAL LIABILITY
CLAIMS MADE [iJOCC,
OWNER'S II< CONTRACT'S PROT
810290K0652
2/01/95
2/01/96
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
X SCHEDULED AUTOS
X lURED AUTOS
BODILY IN1URY
(Por ,,""0111
BODILY IN1URY
(por occldool)
PROPERTY DAMAGE
EACH OCCURRENCE
AGGREGATE
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
J...../t
ISSUE DATE (~IMIDDIYYl
2/13/95
.. ... ~ ~ .'
LL\IITS
1000ooo
1000ooo
1000ooo
1000ooo
5000
50??oo
01646
2/20/95
2120/96
')).C~'fi6N((:: ,...........,.........:}........::}:;.:.....f::{:.::.:.::'" .:\.:...:.:'.:.:.....:.':'..:..:':::.:::;...~..:::::.::...,
SIIOULD ANY OF TIlE ABOVE DESCRIBED POLICIES BE CANCELLED BEFOIlE TIlE
EXPIRATION DATE TlIEIlEOF, TIlE ISSUING COMPANY WILL E.'iDEAVOR TO
MAIL ....1lL- DAYS WIUTTEN NOTICE TO TIlE CUTlnCA TE !I0LDER NAMED TO TIlE
LEFT, BUT FAILURE TO MAIL SUC!I NOTICE SllALL L'dPOSE NO OBLIGATION OR
LIABIUTY OF ANY KIND UPON TIlE COMPANY, ITS AGENTS OR IlEPRE5ENT A TTVES.
EACH ACCIDENT
DISEASE-POLICY LIMIT
DISEASE-EACH EMP,
WORKERS' COMPENSATION
AND
EMPLOYER'S LIABILITY
OTIIER
DESCRlMlON OF OPERATIONSILOCA TlONSNEIIICLESISPEClAL ITEMS
CERTIFCATE HOLDER IS AN ADDmONAL INSURED IN RESPECTS TO AUTO, AND
GENERAL LIABILITY,
"CERTIFICATE:HOLDER\\.......:.:::..
..,................
:.:.:.:......................::::::::.:~?:::~jr~f~rtt?(;:;::.:::.
.:.:.::;:::;:::::::.'
.:::::;:;:::::;:::::
CITY OF CLEARWATER
A TIN: REAM WILSON
P,O, BOX 4748
CLEARWATER, FL 34618-4748
10??oo
50??oo
10??oo
...:-:....-:......:->-........,-.
. ~ x...........;....
~ ~~~~~-~-~-~ -~~~~~--~---~;~~;~~~-~
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
Rodgers & Cummings Insurance,
P.O. BOx 10000
Clearwater, F1 34617
Inc.
COMPANIES AFFORDING COVERAGE
f~~NY A
Travelers Insurance Company
INSURED
COMPANY B
LETTER
Chi Chi Rodriguez Youth Foundation,
3030 McMullen Booth Road
Clearwater, F1 34621
Inc f~~~NY C
COMPANY D
LETTER
C ~~.J./
,_~__~___~~.~~~~~,~~~"C~..'.' "_'~""_'~'_~""_
COMPANY E
LETTER
COVERAGES
"'ff
i.j>"
THIS IS TO CERTIFY THAT 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, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
CO
LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DDIYY) DATE (MMIDD/YY)
LIMITS
___...__.._."r....~<-.,.--"""'.<--<._~,<<_....,.......,..,---.._._-""-'_...'--'-~---..,-""""'~~,~., ,...- ."~".~".-.".---
GENERAL LIABILITY
A X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE X OCCUR. 660607G5l67COF
OWNER'S & CONTRACTOR'S PROTo
2/1/92
GENERAL AGGREGATE $1,000,000
PRODUCTS-COMP/OP AGG. $1,000,000
PERSONAL & ADV. INJURY $1,000,000.
EACH OCCURRENCE $1,000,000
FIRE DAMAGE (Anyone fire) $ 50 ,000
~.._...,,_.,_,.,..,.,_,..____...._~~~.~~,!~y,~~~~~,_~_.........",5~O.o.Q"-..,....
COMBINED SINGLE
LIMIT
2/1/93
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
$
_ BODILY INJURY
(Per person)
$
BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE $
----..,...,..--.-,......-..-..'
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBBELLlLFORM __ ..
~.,---,-_.__.,.__......"......,_.....~..,....~-_.
..,.,."..-..._""_...._..,...~~_'__._r~.,.~"""'..................<......,__~.a._,u.......cn"""'.....,......~.,."-',' ,." ,'.',,,..'.,.. .".. c.....,... ,"r' ~~,,"~-"~,.,. ,,,.,,,",,,--,,,.,-'."'-"P"
EACH OCCURRENCE
AGGREGATE
$
$
,
........_.~.......~.........,.,.....-.C"'~,~~::.::=:~_,;:::;,..~,...,~;::.---...,_~".....,~.,__--....-;;:.:;;.:.:.:..::;:;:;~:i
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STATUTORY LIMITS
WORKER'S COMPENSATION
AND
EMPLOYERS' LIABILITY
EACH ACCIDENT
$
$
DISEASE-POLICY LIMIT
DISEASE-EACH EMPLOYEE $
OTHER
1
I
,,,.... ,,--,----,-.---.-.-,~,,~.. ,.." ,....._.._...._..m"_'..._~_, .__1
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_"~..__,.....-~...~...~.,_...,......_.._....".n__n.." -...,.............-".. . .,-,., .~"'.'-'.... ...~,.", .-~"' ."0" .......,. ",' .,~,,,.,", ,,,..~-=..,,~.','..<I>-'..,"',"',.., f
CANCELLATION I
I
1
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAIL 3&- 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 COMPANY, ITS AGENTS OR REPRESENTATIVES,
..,.~,,,.,.me )~~~. ~~~_.-
@ACORD CORPORATION 1990
r DESCRIPTION OF OPERATIONS/LOCATIONS/VEHiCLEs;S;ECIAL-ITE;s-~._-'_m_____'._..__u.._,...
I
Glen Oaks Golf Course 3030 McMullen Booth Road, Clearwater, ;1
Certificate holder is additional insured
CERTIFICATE HOLDER
City of Clearwater
P.O. Box 4748
Clearwater, f1 34618-4748
I
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