CERTIFICATE OF LIABILITY INSURANCE (2)
A CORaM
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CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIODIYYI
03/02/05
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
Clearwater Country Club
Management, Inc.
525 North Betty Lane
Clearwater FL 33755
INSURER A:
INSURER B:
INSURER C;
INSURER 0:
INSURERS AFFORDING COVERAGE
FIREMAN'S FUND INSURANCE CO
AUTO DWNERS-09703
BRIDGEFIELD EMPLOYERS INS CO
INSURED
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.
INSR TVPE OF INSURANCE POUCV NUMBER ~OLlCY EFFE~~~~ POLICY EXPIRATION LIMITS
LTR 0
A ~ERAL L1ABIUTY MZX80838084 1/01/05 1/01/06 EACH OCCURRENCE $ 1000000
r-X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE IAny one flrel $ 100000
~ CLAIMS MADE W OCCUR MED EXP IAny one pe,son' $ 5000
[-
PERSONAL & ADV INJURY $ 1000000
GENERAL AGGREGATE $ 2000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000
nnPRO- n
POLICY JECT LOC
B AUTOMOBILE LIABILITY 9562406000 1/01/05 1/01106 COMBINED SINGLE LIMIT
r-- (Es sccldent) . 1000000
L ANY AUTO
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS IPsr person)
c--
L HIRED AUTOS BODILY INJURY
$
..x NON-OWNED AUTOS IPsr accident}
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
==1 ANY AUTO OTHER THAN EA ACC $
AUTO ONL V: AGG $
A EXCESS LIABILITY XYM97715874 1/01105 1/01/06 EACH OCCURRENCE $ 5000000
Q OCCUR 0 CLAIMS MAOE AGGREGATE $ 5000000
$
RDEDUCTIBLE $
RETENTION $ $
C WORKERS COMPENSATION AND 83028251 1/01/05 1/01/06 I /6~.;r~~;" I IOlt.
EMPLOYERS' LIABILITY
E.L, EACH ACCIDENT $ 500000
E.L. DISEASE. EA EMPLOYEE $ 500000
E.L, DISEASE. POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
FAX: 562-4825
CERTIFICATE HOLDER IS ADDITIONAL INSURED RE:GENERAlllABIUTY ONLY
CERTIFICATE HOLDER I X I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
CITY OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAlL ---1.Q.. DAYS WRITTEN
P.O. BOX 4748 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUl' FAILURE TO DO SO SHALL
CLEARWATER, FL 33758-4748 IMPOSE NO OBLIGATION OR L1ABIUTY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES. /1
AUT~R~TATIVE
I rT
ACORD 25-5 797 II
( /
46- 36
€l ACORD CORPORATION 1988
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