CERTIFICATE OF LIABILITY INSURANCE (2)
ACORDTM
CERTIFICATE OF liABiliTY INSURANCE
DATE CMMIDDIYYI
03/26/01
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.
l'RODllCEN
ACaRDIA EAST - TAMPA BAY
P.O. Box 31666
Tampa, FL 33631-3666
727-796-6666
INSURERS AFFORDING COVERAGE
INSURED
INSURER A:
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
AMERICAN STATES INS CO-09084
Greenwood Comm. Health
Resource Ctr Inc
1108 N Greenwood Ave
Clearwater FL 33765
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 POUCY EFFECTIVE POLICY EXPIRATION LIMITS
A GENERAL L1ABIUTY 01CE2069375 411 6/01 4/16/02 EACH OCCURRENCE $ 1000000
-
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 200000
I CLAIMS MADE W OCCUR MED EXP (Anyone person) $ 10000
- PERSONAL & ADV INJURY $ 1000000
- GENERAL AGGREGATE $ 2000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000
I POLICY n P'~RT n LOC
~TOMOBILE LIABIUTY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
f--
f-- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Par person)
f--
f-- HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per accident)
f--
f-- PROPERTY DAMAGE $
(Per accident)
~RAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
~ OCCUR 0 CLAIMS MADE AGGREGATE $
$
~ DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I WC STATU- I 10:~-
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATlONSNEHICLES/EXCLUSIDNS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
CITY OF CLEARWATER IS LISTED AS ADDITIONAL INSURED
Attn: MLte.s BaLtogg
CERTIFICATE HOLDER I X I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFDRE THE EXPIRATION
CITY OF CLEARWATER DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
ECONOMIC DEVELOPMENT TEAM NOTICE TO THE CERTIFICATE HDLDER NAMED 'I'D THE LEFT, BUT FAILURE TO DO SO SHALL
POBOX 4748 IMPOSE ND OBLIGATION OR L1ABIUTY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
CLEARWATER, FL 33758-4748 REPRESENTATIVES.
7~HO);Z~ O;~em;;IVE-:) () t (/p A I
I
ACORD 25-S (7/97)
46-42
fS) ACORD CORPORATION 1988
"
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)
. 'nus IS EVIDENCE THAT INSURANCE AS IDENTIFIED BELOW HAS BEEN ISSUED, IS IN FORCE, AND CONVEYS -ALL THE
RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY.
PRDDUCER PHONE 727-796-6666 COMPANY
Acordia Southeast, Inc.
PO Box 31666
Tampa, FL 33631-3666
NATIONAL GRANGE MUTUAL
OLD DOMINION
SUB CDDE:
GRE41431
THIS REPLACES PRIOR EVIDENCE DATED:
3/26/01
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LOCATIONIDESCRIPTION
1108 N Greenwood Ave
Clearwater FL 33765
Greenwood Comm. Health
Resource Ctr Inc
1108 N Greenwood Ave
Clearwater FL 33765-
EFFECTIVE DATE
04/16101
CONTINUED UNTIL
TERMINATED IF CHECKED
LOAN NUMBER
POUCY NUMBER
FRG03313
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COVERAGElPERlLSIFORMS
AMDUNT OF INSURANCE
DEDUCTIBLE
BUILDING/SPECIAL FORM/REPLACEMENT COST
WIND & HAIL DEDUCTIBLE
290,000
500
2%
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Atin.: MUu Ba.U.ogg
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THE POLICY IS SUBJECT TO THE PREMIUMS, FORMS, AND RULES IN EFFECT FOR EACH POLICY PERIOD. SHOULD THE
POLICY BE TERMINATED, THE COMPANY WILL GIVE THE ADDITIONAL INTEREST IDENTIFIED BELOW 30 DA YS
WRITTEN NOTICE, AND WILL SEND NOTIFICATION OF ANY CHANGES TO THE POLICY THAT WOULD AFFECT THAT
INTEREST, IN ACCORDANCE WITH THE POLICY PROVISIONS OR AS REQUIRED BY LAW.
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NAME AND ADDRESS MORTGAGEE ADDITIONAL INSURED
CITY OF CLEARWATER
ECONOMIC DEVELOPMENT TEAM
POBOX 4748
CLEARWATER, FL 33758-4748
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LOSS PAYEE
LOAN I
AUTHORIZED REPRESENTATIVE