CERTIFICATE OF LIABILITY INSURANCE (5)
From: AMna Davis At: Roe Insurance FaxID: 727-376-2262 To: Marie O.
Date: 10/10103 09:58 AM Page: 2 of 3
A~t}RD:.
CERTIFICATE OF LIABILITY INSURANCE
OP ID AD
FOUNVIL 10
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
Greg Roe Insurance, Inc.
9851 State Road 54
New Port Richey FL 34655
Phone: 727-376-0030 Fax: 727-376-2262
INSURERS AFFORDING COVERAGE
INSURED
Ir~SuREp. A:.
Nonprofits Ins. Association
Underwriters at Llo d's
Foundation Village
Neighborhood Fam1ly Center,Ine
Fam1ly CenterL Inc.
918 Woodlawn :st.
Clearwater FL 33756
INSURER B
INSURER C
INSURER 0
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 TYPE OF INSuRANCE POUCvNUMElER ~~C~~ Pg;i~Y~~,?N UMlTS
LTR
~NERAI. LIABILITY EACH OCCLRRENCE <1,000,000
A ~ t5MERCIAl. GENERAL UABIUTY NIA1810764 10/01/03 10/01/04 FIRE DAMAGE (.Any one fire) $ 100, 000
e-- CLAIMS MADE ~ OCCUR MEO EXP (Airy one person) $ 5,000
e-- PERSONAL e. ADV INJVR\i $1,000,000
>--- GENERAL AGGREGATE $ 3, 000, 000
GEN'lfo.GGREGATE LIMIT APPUES PER PRODUCTS ~ COMP!OP AGG $ 3. 000, 000
h POLICY n ~6 n LOC
~OMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
A ANV AUTO NIA1810764 10/01/03 10/01/04 (Ea accident)
e--
- AlL OV'l".JED AI.ITOS SOD1L Y INJURY
$
~ SCHEDULED AUTOS .;r'Crpcf:Jon)
~ HIRED AUTOS BODILY Ir.J,JuRY
$
~ NCN-CI,.l\JNEO AUTOS (Per accIdent)
PROPERTY DAMAGE <
(Per accident)
GAIWOE LIABILITY AUTO ONLY. EA, ,~CCIDENT $
~ ANY A.LITO OTHER: THAN EA ACe $
AUTO ONLY .A.GG $
SiCS LIAIIILITY Ei'.CH OCCLPPEI'lCE <
D Cl...A.lMS M:DE --
OCCUR ,A,GGREG,A.TE $
$
~ DEDUCTIBLE <
RETENTION $ $
WORKERS COMPENSATION AND I ~R~T~~S I 10TH-
ER
EMPLOYERS' LIABILITY
E_L- EACH ACCIDENT -- ~~---
E.L DISEASE ~ EA EMPLOYEE- $
EL DISEASE - POLICY LIMIT $
OTHER
A Sexual/Prof Liab NIA1810764 10/01/03 10/01/04 Sxl/Prof 1,000.000
B Buildina Cova 190539 02/22/03 02/22/04 Bldq Covq 303 000
DESCRIPTION OF OPERATIONSlL.OCATIONlllWHlCLeSj&XCLUSIONS ADDED BY ENIIORUM&NTISPIiCIAI. PRO\IJlIIONS
FAXED TO 727 562 4037.
CERTIFICATE HOLDER I N I ADDITIONAl. lNSUREO; INSURER LETTER CANCELLATION
CITYCLE SHOULD ANY OF THE A8QVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSUMIlt WILL IiNllEAVCR TO MAIL ~ DAYS WRITTEN
CITY OF CLEARWATER Nonc.. TO THIi CIiRTfFlCATe HOt.D&R NAMED TO THE LEFT, IBUT FAILURE TO DO SO $HALt.
ATTN: MARIE ORSELLO
112 SO. OSCEOLA AVENUE tMPO&li. NO 08LICATK)N OR LlABILlTY OF ANY I(INQ UPON THE INSUReR, ITS-AQENTS OR
CLEARWATER FL 33756 REPREB&NTATMlS.
IWm~ RSPrva,SENTATr>I& ~ .
I . I. _.. ~ . I . .. . _
ACORD 25-8 (7/97)
@ ACORD CORPORATION 1988
From: Alvina Davis AI: Roe Insurance FaxID: 727-376-2262 To: Marie O.
Dale: 10/10103 09:58 AM Page: 3 of 3
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer. and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 250$ (7/97)