CERTIFICATE OF LIABILITY INSURANCE
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A CORD'M
CERTIFICATE OF LIABILITY INSURANCE
DATE IMM/DD/YYI
04/18/05
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 Southeast, Inc.
P,O. Box 31666
Tampa, FL 33631-3666
727-796-6666
INSURERS AFFORDING COVERAGE
INSURED
INSURER A:
INSURER B:
INSURER C:
INSURER D:
INSURER E:
ZURICH-AMERICAN-212-16535
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. NOTWITHSTANOING
ANY REOUIREMENT, 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 ~I;!~r..e:,~g~~~ PR~EY ~;m~~lJS!'l UM/TS
A ~NERAL LIABILITY CP03793718 2/01/05 2/01/06 EACH OCCURRENCE $ 1000000
..x SMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Any ono firol $ 1000000
- CLAIMS MADE W OCCUR MEO EXP (Anyone personl $ 5000
- PERSONAL & AOV INJURY $ 1000000
- GENERAL AGGREGATE $ 2000000
r;l'L AGGREA LIMIT APPl PER: PRODUCTS - COMP/OP AGG $ 2000000
X POLICY P,~,9;. LOC
~OMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO lEe ecoldonll
I--
i-'-- ALL OWNED AUTOS BOOIL V INJURY $
SCHEDULED AUTOS IPar person)
I--
I-- HIREO AUTOS BOOIL Y INJURY
$
NON-OWNED AUTOS IPer Decidenll
i-'--
PROPERTY DAMAGE $
tPer 8ccldent}
RAGE LIABIUTV AUTO ONL Y - EA ACCIOENT $
ANV AUTO OTHER THAN EA ACC t
, AUTO ONLY: AGG $
EXCESS UABIUTV EACH OCCURRENCE $
o OCCUR 0 CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I WC ST~~;,T TOJJl-
TORY L T
EMPLOYERS' UABILlTY
E,L EACH ACCIOENT $
E,L, DISEASE. EA EMPLOYEE $
E,L. DISEASE. POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSlONS 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 ADDITIONAL INSURED; INSURER LETTER: . CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED PDUCIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF CLEARWATER DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
AlT-LEO SCHRADER/RISK MGMT DIV NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
P.Q, BOX 4748 IMPOSE NO OBUGATION OR UABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
CLEARWATER, FL 33758 REPRESENTWlvES, ./J
AUT~",,~~~y/
I ,
ACORD 25-S (7/97) 46- 36 ~ 1./ V , @ ACORD CORPORATION 1988
lOO/IOO"d VS8# 99:01 900l/81/vO
LlI 9 66L aL
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