CERTIFICATE OF INSURANCE (4)
rC
Return Completed Certificate To:
CITY OF CLEARWATER
P.O. Box 4748 I
Cleerwater. FL 34618-4748 _
Altn: RISK MANAGEMENT
CERTIFICA TE OF INSURANCE
TO
CITY OF
CLEARWATER
FLORIDA ("the City")
A Municipal Corporation
I
Only This Certificate
Of Insurance form
will be accepted.
Insured:
Address;
This certifies to the City that the following d~scribed policies have been issued to the Insured named below and ar8 in force at this time.
Howard G. Hamilton c/o Palm Pavilion
10 Bay Esplanade
Clearwater, FL 34615
As fled in lease dated OctOD2r 28, 1985, between
Description of operations/locations/products insured; speci'
City of Clearwater and Howard G. Hamllton
ContracVPurchase Order No. (if any);
POLICIES
AND INSURERS
Bodily Injury
LIMITS
Property Damage
POLlCY
NUMBER
EXPIRA nON
DATE
Worker's Compensallon
Roval Ins. Co.
(Name of Insurer)
E I '" "I' $ 500.000
mp oyer s LlaOI Ity
ACS2s1283
4-1-88
Best's Rating
A
"Claims.Made"_
X
"Occurrence"_
Check polley type:
Comprehensive General Liability~
or
Commercial General Liability_
Royal Ins. Co.
(Name of Insurer)
Each Occu rrence
S
Aggregate
S
PYAK08760
4-1-88
Each Occurrence
S
Aggregate
$
or
Best's Rating
A
Combined Single Limit $ 500.000
Aggregate $ 500.000
Business Auto Polley
Liability Coverage Symbol ....L-
Royal Ins. Co.
(Name of Insurer)
Each Person
$
Each Accident
$
Each Accident
$
PYAK08760
4-1-88
or
Best's Rating
A
Combined Single Lir-'t $ 500,000
"Claims.Made"_
"Occurrence"~
Umbrella Liability
Roval Ins. Co.
(Name of Insured)
Occurrence/Aggregate $ 2,000,000
PLA217398
4-1-88
Self.lnsured Retention $
10,000
Best's Rating
A
The following coverages or condition. are In efleet: Yea No
The City, its officials, and employees are named on all liability policies describe<l above as insureds as respects: (a) aClivities
perlorrred for the City by or on behalf at the named insured, (b) products and completed operations of the Named Insured,
and (cl premises owned, leased or used b the Named Insured. X
Products and ComoleteJ Ooeratlons X
The undersigned will mail to the City days written' notice of cancellation; reduct,,," of coverage or limits: aggregate erosion;
ad'iance oflhe Retroactive Date: and/or renewal.
Cross liabili Clause or eou'valent wordin
Personal Iniury, perils ~: 3 and C
Sroed Form Pro Dc "'. e X
X, (;, U HazardS InCluOed
ContraClual liabili C<lvera e a
liouor liab,li
Coverage aHorded the City, its oHicials, emlO'oyees and volunteer as an in
tributin to an Insurance ISSUed in the name of the Ci .
Waiver of .ubrogalton from Workers' Compensation insurer. I X I
This cenificale i. issued as a matter 01 ,nformation. This cenificate IS not an insurance policy and does not amend, extend or alter the coverage a~Jrded by
the policies listed herein. Notwithstanding any reqUirement, term or condition of any contract or other document With respect to whiCh thiS cenlficate of insurance
may be issued or may penain, the insurance aHordee by the policies described herein is subjeCl to all the terms, exclusions and condItions of such policies.
Veghte Insurance
Agency 0' Sroke'.oe Insurance Company
PO Box 17305, Clearwater, FL 34622
Address Home OHice
Carol Kaley
Name 01 Person to De Contacted
813-579-0055
Telephone Number
7.21-87
AuthOrized Sfin ure ~ Date
Note: AU!h",iilJ signature may be t r'~ent's if, agent has placed insurance
through a,ri ;tg:ency agreement n lhe Insurer. It insurance is brOker""
autnorizeVignature must be th t of oHicial of ,nsurer. I q _ OD~ _ J q
C;~:-;~,C~
ATTfHMENT I TO CERTIFICATE OF INSURtNCE
Dated:
Issued by
PROPERTY SCHEDULE (Use Additional Pages As Necessary)
BUILDING I % OF
OR AMOUNT OF INSURANCE COINS- DESCRIPTION AND ADDRESS OF PROPERTY COVERED
PROPERTY NO. URANCE
002-01 125,000 90 Building - 332 S. Gulfvie1-J Blvd.
Cleanvater Beach
Clean-Ja ter, Florida
Occupied as Gift Shop & Refreshment Stand
003-01 50,000 90 Building - 330 s. Gulfview Blvd.
Cleanvater Beach
Clearwater, FL
Occu]Jied as Bath House
I .
!
DEDUCTIBLES APPLICABLE (SPECIFY)
$1,000 Deductible
SUBJECT TO THE FOllOWING ENDORSEMENTS ATTACHED HERETO:
7.21.87