CERTIFICATE OF INSURANCE # WC 0099333-01- CPP 0118962
~-
~
CERTIFICATE OF INSURANCE
TO
CITY OF
CLEARWATER
FLORIDA ("the City")
A Municipal Corporation
J
Only This Certificate
Of Insurance form
will be accepted.
12/23/87
Return Completed Certificate To:
CITY OF CLEARWATER
. p.O. Box 4748
Clearwater, FL 34618.4748
Attn: RISK MANAGEMENT
Issue Date
This certifies. to the City that the following described insurance has been issued to the Insured named below and is in force at this time:
Description of what is Insured:
Business Personal property
Business- Income
Legal Liab.
Insured:
Address:
Colony Marine Restaurant, Inc.
71-75 Causeway Blvd.
Clearwater, fl. 34615
Contract/Purchase Order/Lease Applicable:
TYPE AND FORM LIMITS/COVERAGE POLICY EXPIRATION
INSURER NAME AND RATING NUMBER DATE
Worker's Compensation
and Employer's Liability Worker's Compensation - Statutory Florida
General Accident Ins. Co Employer's Liability:
(Name of Insurer) Each Accident 100,000. WC 0099333-01 12/28/88
Best's Rating A+ Each Employee. Disease 008 800.
All Claims - Disease 50 , 0 .
GENERAL LIABILITY "Claims-Made"_ "Occurrence"~
(CG 0002 2/86) (CG 0001 11/85)
Comprehensive Occurrence Limit
$ 100,000.
Scheduled Aggregate Limit
CPP 0118962 12/28/88
Multiple Peril Pkg. po li c y CP003 $ lnn , nnn
(;pnpr",l Arrir1pnr Tn~ Co Fire Damage Limit
(Name of Insurer) $ 50.000.
Med. Exp. Limit
Best's Rating A+ $
AUTOMOBILE LIABILITY Business Auto Symbol(s):
Basic Each Accident
Comprehensive $
Garage
Garage Auto Symbol(s)
(Name of Insurer) Each Accident
Best's Rating __ $
EXCESS LIABILITY "Claims-Made"_ "Occurrence"_
Umbrella Occurrence/Aggregate $
Other
Self-Insured Retentior: $
(Name of Insurer)
Best's Rating
The following coverages or conditions are in effect and policies endorsed accordingly:: Yes No N/A
The City, its officials, and employees are named on all liability policies described above as insureds as respects: (a) activities
performed for the City by or on behalf of the named insured, (b) products and completed operations of the Named Insured,
and (c) premises owned, leased or used bv the Named Insured. "
Products and Completed Operations Aggreaate -(Enter Limit Here: "TUV, vvv ) v
The undersigned will mail to the City 30 days written notice of cancellation: reduction of coverage or limits; aggregate erosion; x
advance of the Retroactive Date; and/or renewal.
Separation of Insureds I x
Personal and AdvertisinQ Iniury (Enter Limit Here: ) I X
All Risk Prooerty Damaoe (see Prooerty Schedule - Attachment 1) X
Premises and Operations Aaareaate (Enter Limit Here: 300.000 ) X I
Contractual Liability Coverag~ applying to this Contract/Lease/Agreement Aggregate (Enter Limit Here: jUU, UUU ) X
X
Owners and Contractors Protective:
Coverage afforded the City, its officials, employees and volunteers as an insured applies as primary and not excess or con-
tributing to any insurance issued in the name of the City. X
Waiver of subro ation from Workers' Com ensation insurer. I X I
This certificate is issued as a matter of information. This certificate is not an insurance policy and does' not amend, extend or alter the coverage afforded by
the policies listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance
maybe issued or may pertain, the insurance afforded by the policies described herein is subject to all the terms, exclusions and conditions of such policies.
Rhodes Insurance Agency, Inc. General Accident Insurance Co.
Agency or Brokerage Insurance Company
P. O.Box 5164, Clearwater. Fl. 34618 Maitland, Ga. r
AddrBj\l Rhodes !)ome Office //2./(
L.... //~ - -
Name of Person to be Contacted Auth6rized Signature " Date
(813) 442-2137 N.:>te: Authorized signature may be the agent's if agent has placed insurance
Telephone Number D j. through an agency agreement with the insurer. If insurance is brokered,
U : re.- ",-,,~ <, ,~ authorized signature must be that of official of insurer.
10.16.87
Dc.,
D,'I!
c,
!-/~ / d.
c J. ./..
..
'"/
.,. .
A TT A(';~MENT I TO CERTIFICATE OF INSURANfE
Dated:
12/23/87
Issued by (Agency/Brokeragellnsurance Co.): Rhodes Insurance Agency, Inc.
Issued For (Contract/Lease/Aggreement): City of (;1 PRrw",rpr
PROPERTY SCHEDULE (Use Additional Pages As Necessary)
BUILDING %OF
OR AMOUNT OF INSURANCE COINS- DESCRIPTION AND ADDRESS OF PROPERTY COVERED
PROPERTY NO. URANCE
1 $25,000 80% Business personal property located at 71-75 Causeway Blv
Clearwater, Fl.
16,000 Business Income
5,000 Fire Legal Liab.
-
d. ,
DEDUCTIBlES APPLICABLE (SPECIFY)
$250.00
50. ded' Glass
CP0030(11~85) CP1020(ll-85) CPl050(11-85) L2709(1-86) CG0037(11-85)CP0015(11-85) P0006(1-87)
SUBJECT TO THE FOllOWING ENDORSEMENTS ATTACHED HERETO:
10-16-87