CERTIFICATE OF INSURANCE (3)
ACORD",
CERTIFICATE OF LIABILITY INSURANCE
DATE IMMIDDIYYI
04/05/04
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
INSURED
INSURER A:
INSURER B;
INSURER c:
INSURER 0:
INSURER E:
INSURERS AFFORDING COVERAGE
FIREMAN'S FUND INSURANCE CO
Clearwater Country Club
Management, Inc.
525 North Betty Lane
Clearwater FL 33755
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERMOR 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 ~~~!.W~~~'{.~ "gk!fEY'~'2')~~~~ UMITS
A ~NERAL UABILITY MZX80823685 1/01/04 1/01106 EACH DCCURAENCE . 1000000
..x 3MERCIAL GENERAL LIABILITY FIRE DAMAGE (AnV one firel . 100000
- CLAIMS MADE W OCCUR MED EXP IAnv one person) . 5000
PERSONAL & ADV INJURY . 1000000
GENERAL AGGREGATE . 2000000
n'L AGGREn UMIT APn PER: PRODUCTS - COMP/OP AGG . 2000000
POLICY ~~g;. lOC
~TOMOBILE LIABILITY COMltlNED SINGLE LIMIT $
ANY AUTO lEa accident)
~
I-- All OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per peraonl
I--
'-- HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per acclden"
'--
PROPERTY DAMAGE $
{Per accident!
RRAGE LIABILITY AUTO ONLY - EA ACCIDENT .
ANY AUTO OTHER THAN EA ACC .
AUTO ONLY; AGG .
EXCESS LIABILITY EACH OCCURRENCE $
t:lOCCUR 0 CLAIMS MADE AGGREGATE .
.
RDEDUCTIBLE .
RETENTION $ $
WORKERS COMPENSATION AND I T~~;r~~;, I IOJ.tl-
EMPLOVORS' LIABILITY
E.L EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
OTHER
,
DESCRIPTION OF OPERATIONS/lDCATIONSNEMICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
FAX: 562-4825
CERTIFICATE HOLDER I I ADDITIONAl. INSURED; INSURER LETTER: CANCELLATION
CITY OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIB.ED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
ATTN: DEBBIE REID NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
P.O. BOX 4748 IMPOSE NO OBLIGATION OR llABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
CLEARWATER. FL 33758-4748 REPRESEIQ' A TIVES. .
AUTH A~ ttlt A
I WVI''''
ACORD 25-S (7/971
46- 36
(1) ACORD CORPORATION 1988
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), 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 25-8 (7/97)
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