CERTIFICATE OF LIABILITY INSURANCE
A CORaM CERTIFICATEtOF LIABILITY INSURANc(E I DATE (MM/DDNY)
1011 9/00
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ACaRDIA EAST - TAMPA BAY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.o. Box 31666 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tampa, FL 33631-3666
727-796-6666 INSURERS AFFORDING COVERAGE
INSURED INSURER A: AMERICAN STATES INSURANCE CO
Greenwood Comm. Health
Resource Ctr Inc INSURER B:
1001 Greenwood Av#22-1 &2 INSURER c:
,Clearwater FL 33755 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 SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
1~.;>,lI TYPE OF INSURANCE POLICY NUMBER POLICY EFFE~~y'~ Pgk!f~Y/~JJ~~lJS~ LIMITS
A ~ERAL L1ABIIJTY, .. ", 01CE2069374 4/16/00 4/16/01 EACH OCCURRENCE $ ,500000
- .- -' "- -- --~-- - . -- ..
e-X 3MMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 200000
f--- CLAIMS MADE W OCCUR MED EXP (Anyone person) $ 10000
PERSONAL & ADV INJURY $ 500000
f--- GENERAL AGGREGATE $ 1000000
n'L AGGREA LIMIT APn PER: PRODUCTS - COMP/OP AGG $ 1000000
POLICY ~~9T LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO lEa accidentl
-
- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
-
- HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per accident)
~AGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
D' OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ - $
WORKERS COMPENSATION AND .Ht: (";i::1 I WC STATU- I TOTH-
, ~U TORY LIMITS
'Ie -~ ER
-- EM PLOYERS' 'L1ABllITY-- '- -- -- . '-.,
E.L. EACH ACCIDENT $
OCT 2 4 000 E.L. DISEASE - EA EMPLOYEE $
E.L. DiSEASE - POLICY LIMIT $
OTHER
CITY CLERK DEP ~RTMENT
DESCRIPTION OF OPERATIONS/LOCATlONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS RECEIVED
OCT 2 3 2000
RISK MANAGEMENT
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF CLEARWATER DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~
DAYS WRITTEN
100 MYRTLE A VENUE NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
CLEARWTER, FL 33758 IMPOSE NO OBLIGATION 0 LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENT A TlVES.
, AUTHORIZED REP~ WiIY/ 4~j(JtlA
ACORD 25-S (7/97) 7- 14 @AC'ORD CORPORATION 1988
Cc~ ~W B~ J&tr-..- C>€f
R-\ 5fL
I'
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-S (7/97)