CERTIFICATE OF LIABILITY INSURANCE (2)
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ACORD..
CERTIFICATE OF LIABILITY INSURANCE
OP 10 SE
TARPO-8 05/10/04
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.
DATE (MM/DD/YYYY)
p"~ODUCER
~rown & Brown Insurance
17757 US Highway 19 N, Ste 660
P.O. Box 2456
Clearwater FL 33757-2456
Phone: 727-461-6044 Fax: 727-442-7695
INSURERS AFFORDING COVERAGE
INSURED
H&M Investments of Clearwater
dba Tarpon Woods Country Club
Clearwater Golf Assoc Inc.,
dba Clearwater Exec Golf Course
H&M Investment of Clw Inc dba
1100 Tarpon Woods Blvd
Palm Harbor FL 34685
INSURER A
American States Insurance
Associated Industries
NAIC#
19704
23140
INSURER B:
INSURER C
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 SHO\I\IN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION
LTR NSRD TYPE OF INSURANCE POLICY NUMBER DATE (MMIODlYYI DATE (MMlDDIYYI LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
'-- DAt\-1AGE TO RENTED
A ~ COMMERCIAL GENERAL LIABILITY 02CE05657401 01/10/04 01/10/05 $ 100,000
~ CLAIMS MADE [!] OCCUR PREMISES (Ec. occurence)
MED EXP (Any one person) $ 5,000
-
X Liquor Liab 1mi1/ PERSONAL & MN INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $ 2,000,000
I n PRO- nLOC
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $ 1000000
A X ANY AUTO 01CG48439901 01/10/04 01/10/05 (Ea accident)
-
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
-
HIRED AUTOS BODILY INJURY
- $
NON-OWNED AUTOS (Per accident)
-
X Comp $250 PROPERTY DAM'.GE
- $
X ColI $500 (Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
=1 ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
~ OCCUR D CLAIMS MADE AGGREGATE $
$
=1 DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I. WC STATU- I IDTH-
,ORY LIMITS ER
B EMPLOYERS' LIABILITY 2003331926 03/17/04 03/17/05
ANY PROPRIETOR/PARTNER/EXECUTIVE EL EACH ACCIDENT $ 100000
OFFICER/MEMBER EXCLUDED? EL DISEASE, EA EMPLOYEE $ 100000
If yes, describe under $ 500000
SPECIAL PROVISIONS below EL DISEASE - POLICY LIMIT
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS/ VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS cl~
City of Clearwater is listed as additional insured with respect to the
following location: 1875 Airport Drive, Clearwater, FL 33755. R, s k-
File
CERTIFICATE HOLDER CANCELLATION
CI TYOFC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAlL
30
DAYS WRITTEN
City of Clearwater
Attn: Mark Gohim
P.O. Box 4748
Clearwater FL 33758-4748
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAlLURE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHO~aVE _
'-/~ I_
@ ACORD CORPORATION 1988
ACORD 25 (2001/08)