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VARIOUS CERTIFICATES OF INSURANCE AND CORRESPONDENCE (3) Rodgers & Cummings Insurance, Inc. P.O. Box 5148 Clearwater, FL 34618 South Carolina Insurance Co. Effective 12: 01 am 1/01 ,19 88 Expires D 12:01 am D Noon 1/01 ,19 89 ~ This binder is issued to extend coverage in the above named company per expiring policy 1/ SMP4488l49 (exceot as noted below) -D NAME AND MAILING ADDRESS OF INSURED Description 01 Operation/Vehicles/Property Head Start Child Development & Family Service Inc. 12351 l34th Ave. N. Largo, FL 33540 S..::-s""" $.Tt;"~tn"'sC',,: -~ g fY J, n") 5Ht::C:Li= tL , I ~ Type and Location 01 Property Coverage/ Perils/ Forms Amt of Insurance Oed. Coins. % 701 N. MIssouri, Clearwater Building Fire/E.C./& U&MM 75,000 250 80 P R o P E R T Y Type 01 Insurance Coverage I Forms Limits of Liability Each Occurrence Bodily Injury $ Aggregate $ L I A B I L I T Y D Scheduled Form [iJ Comprehensive Form [X) Premises/Operations [Xl Products/Completed Operations D Contractual Other (specify below) Med. Pay. $ 500 Personal Injury [X) GJ D D D D D D D D D Fire Legal Per $ 1,000 Person Per Accident '. Property Damage $ $ Bodily Injury & 300,000 Property Damage $ $ 300,000 Combined DA DB Dc Personal Injury $ Limits of Liability Bodily Injury (Each Person) $ . Bodily Injury (Each Accident) $ Property Damage $ A U T o M o B I L E Liability 0 Non.owned Comprehensive-Oed uct i ble Collision-Deductible Medical Payments Uninsured Motorist No Fault (specify): Other (specify): o Hired $ $ $ $ Bodily Injury & Property Damage Combined $ WORKERS' COM PENSA TION - Statutory Limits (specify state&- belowf .0 EMPLOYERS' LIABILITY - Limit $ SPECIAL CONDITIONS/OTHER COVERAGES DEe R E C E ~, ~.7 r. D 4 \. "\(1 ,1,,3. ,J NAME AND ADDRESS OF 0 MORTGAGEE o LOSS PAYEE 5U ADD'L INSURED Attn: Donald J. Petersen LOAN NUMBER Department of Planning & Urban Development City of Clearwater P.O. Box 4748 Clearwater, FL 34618-4748 ACORD 75 (1 ,m-c) - .".r,.. TO: FROM: COPIES: I CITy'OF CLEARWATER Interdepartment Correspondence Sheet -" ~i' "---- ' Susan Stephenson, Documents & Records Manager Elizabeth S. Haeseker, Assistant City Manager SUBJECT: Insurance - Head Start Pre-School Program DATE: Apri 1 29, 1986 In accordance with the City's lease with Head Start (March 21, 1983), e' "ead Start is to give us certificates of insurance to cover fire and liability. Enclosed are copies of those certificates. , . ce the insurance binder for fire is to extend the coverage in the liability policy, I have no concern that the City is not listed as additional insured. RECEIVED APR 30 1986 Enclosures CITY CLERK ? ;' HL ~ & OJ.!<fllCS INS. mJ P.O. BOX 5148 ~TER, FL 33S1S PHONE: (813) .61-6111 THIS CERT/FlCA H IS ISSUED AS A "'.&. ITER OF "-II'ORJ.lA TION ONL Y AND CC";FERS NO RIGHTS Ur'ON THE CERT""Ct, [ HOLDER. THIS CERTlFICA TE DOES NOT AMEND, EXTEND OR AL TER THE COVEF.....E AFFORDED BY THE POLICIES BELOW" COMPANIES AFFORDING COVERAGE GENERAl.. L1ABIUTY COMPREHENSIVE FORM PRfMISESJOPERA TIONS UNDERGROUND EXPlOSION & COLlAPSE HAZARD PROOUCTSICOMPlETED OPERATDlS COtiTRACTUAl INDEPENDENT CONTRACTORS BROAD fORM PROPERTY DAMAGE PH1SONAl INJURY COMPANY A lETTER COMPANY B lETTER COMPANY C lETTER COMPANY D lETTER COMPANY E lETTER OOOIH CAIaJNA INSURAN:E CCMPAHY INSURED IlNId Start. OUld Dew lopaent and Family Seorvice, Irx:. 12351 134th J.venue North Ll1r9o, P'L 33540 . THIS IS TO CERTIFY THAT POUCIES OF INSURAN~ LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWr~HSTANDING ANY REQUIREMENT, TERM OR CONDrT/ON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISS~TO OR MAY PERTAIN, THE INSURAN~ AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDI- TIONS OF SUCH POUCIES. ..~_ CO LT TYPE Of INSURANCE POUCY NUMBER POl ICY EFFfCIM POlICY EXPlRA TQ llA TE (MWllOIYY) llA TE (MINro'YY) SMP4488149 1/1/86 1/1/87 $ PROPERlY $ $ DAMAGE Bl&PO $300 $ ..300 COMBINED I PERSONAL INJURY 1$ flU. y fU1lY $ I1'ER P9mI) !UU lUll' $ ~RAanNl) I PROPERTY $ DAMAGE BI & PO I I COMBINED $ BI & PO $ COMBINED AUTOMOBILE L1ABIUTY ANY AUTO All OWNED AUTOS (PRlV. PASS.) AU OWNED AUTOS (OTHfR THAN) PRJ\. P~. HIRED AUTOS NON{)WNED AUTOS GARAGE llABIUTY ------- EXCESS UABIUTY lJM!lREUA FORM 0TliER THAN UMBREllA RB.4 WORKERS' COMPENSAT1ON AND EMPLOYERS' UABILITY piA -fJJJf m.~"\. . ;:~~" .~,'~ I' c;.;; -r .~-,ii't'-;'.:? i '~', , . . .. ,.~ T- (L,--.! 1 i . t to .: ~ \ 4 ~, _::..1'.... _ ...~~ 4, ~ ~ ,; 1'1: .-.' "",.-.,,, ...----._:~j ! ~ :: l . 6' i~ 1 ! ~; , '. ^i,n IOQr' d l, . \ ..~t-( . h.... ," ,; i \ \ ,., . ! -...... ,- . '. OTHER I DESCRIPTION OF OPERATIONSILOCATlONSlVEHICLESlSPECIAl ITEMS ! 701 N. Kissouri AW'nUe, Clearwater, FL and Adiit.1ona.l Insured City of Clearwater P.O. ~ 4748 Clearwater, P'L 335~ " SHOULD ANY OF THE ABOVE DESCRIBED POUCIES BE CANCEu.EO BEFORE THE EX- PIRATlO~ DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAll~DAYS WRfTTEN NOTl~ TO THE CERTIFICATE HOLDER NAMED TO THE lEFT. BUT FAILURE TO MAIl SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABILJTY OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE .... - . . - . ~--' -- "")J "c No ":i :......-... . ",'. a ML ROIx;ERS & CUMMINGS INSUIWK::E INC. P.O. BOX 5148 Clearwater, FL 33518 Insurance Company NAME AND MAILING ADDRESS OF INSURED Effective Expires KJ 12:01 am 0 Noon g This binder is issued to extend company per expiring policy # Description of Operation/Vehicles/Prop r ,19 1/1/87,19 HEAD START CHIlD DEVELOPMENT & FAMILY SERVICE, INC. l2351 134th Avenue North Largo, FL 33540 Building Type and location of Property Coverage/ Perils/ Forms Amt of Insurance Ded" Coins. % Building - 701 N. Missouri, Clearwater Fire/OC/V&MM 75,000 250 80 ~ i ~ ..~. ; l' i- L . I t A .; ,. B -; t I . L f I \. T t y " J s. A ;'. ~ 'I U f.' T , 0 1~ M r 0 ~ B , l E Type of Insurance Coverage/Forms limits of Liability Each Occurrence Bodily Injury $ Aggregate 1$ o Scheduled Form 0 Comprehensive Form o Premises/Operations o Products/Completed Operations D Contractual Other (specify below) Med. Pay. $ Per Person $ Per Accident DAD B Dc Property Damage $ Bodily Injury & Property Damage $ Combined Personal Injury Limits of Liability I Bodily Injury (Each Person) Bodily Injury (Each Accident: o Liability 0 Non.owned C Hired o Comprehensive.Deductible 5- o Collision"Deductible $ o Medical Payments S- O Uninsured Moforist $ o No Fault (specify): o Of her (specify): o WORKERS' COMPENSATION - Statutory Limits (s Property Damage $ I 1$ $ $ $ $ ., . I I ID o o Personal Injury Bodily Injury & Property Damage Combined $ SPECIAL CONDITIONS/OTHER COVERAGES $ .. APR 2 2 19[(, p~Jf ~ "i NAME AND ADDRESS OF 0 MORTGAGEE D LOSS PAYEE g ~D~~~I~~~~;D Attn: Jim Sheeler Departnent of Planning City of Clearwater P.O. Box 4748 Clearwater, FL 33518 LOAN NUMBER & Urban Developrrent 4/21/86 IOC. Dale .' ACORD 75 (11m<) ift~il$ ,~,:.~- '_>......~:-'~:c .;.c, '. ' ....:.i~..~~. ',' -:-......~~" .~.~...~:.~;. ,;.0.,," " ~~t1.l: '';;-;'" ' "'~" ~"''''''''"''::~ 1'\'.........::.._"'.~~n..:.". ,.__~>~~",...t- ..--. ~ ,;." ~~"". .-,", .,-~..- ' , ~~'-;I'.~~:"~~~~~~~~.~';~'..~'>... .;';~ir - -.-~ ~_.:~.----~~4~~-~':__.;.":-~';.: ":" :;~~.-~~~~i1:.;~' M[' ROD3ERS & CUMMINGS INS. INC. P.O. BOX 5148 CLEAFWATER, FL 33518 PHONE: (813) 46l-Glll INSURED Head Start Child Development and Family Service, Inc. l2351 l34th Avenue Nortll Larqo, FL 33540 TYPE OF INSURANCE POLICY NUMBER GENERAL LIABILITY COMPREHENSIVE FORM PREMISES/OPERA nONS UNDERGROUND EXPLOSION & COLLAPSE HAZARD PRODUCTs/COMPLETED OPERATIONS CONTRACTUAL INDEPENDENT CONTRACTORS BROAD FORM PROPERTY DAMAGE PERSONAL INJURY SMP4488149 AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS (PRIV, PASS.) ALL OWNED AUTOS (OTHER THAN) PRIV, PASS. HIRED AUTOS NON.OWNED AUTOS GARAGE LIABILITY EXCESS LIABILITY__ UMBRELLA FORM OTHER THAN UMBRELLA FORM WORKERS' COMPENSATION AND EMPLOYERS' LIABILITY OTHER DESCRIPTION OF OPERA TIONS/LOCA TIONSlVEHICLESlSPECIAL ITEMS Missouri Avenue, Clean.7ater, FL and Additional Insured City of Clearwater P.O. Box 4748 Clearwater, FL 33517 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 BEl-OW. COMPANY A LETTER COMPANY B LETTER COMPANY C LETTER COMPANY D LETTER E COMPANIES AFFORDING COVERAGE SOUTH CAROLINA INSURANCE COMPANY RECEIVED AM POLICY EFFECTIVE POLICY EXPIRATION DATE (MMIDDIYY) DATE (MMlDDIYY) 1/1/86 1/1/87 :;~~~~~TY $ BI&PD $ COMBINED 300 $ $ 300 PERSONAL INJURY $ SOOllY $ INJURY (PER PERSON) SOOllY INJURY $ (PER ACCIDENT) PROPERTY $ DAMAGE BI & PD $ COMBINED BI & PD $ COMBINED STATUTORY (EACH ACCIDENT) (DISEASE"POLlCY LIMIT) (DISEASE.EACH EMPLOYEE) --. ., -'. - TO: FROM: COPIES: SUBJECT: DATE: '1 Lucille Williams - City Clerk Joseph R. McFate - Community Development ~ (~Ji3Lf tlTY OF CLEARWATER Interdepartment Correspondence Sheet DirectOptrn~ "'" RECEIVED Head Start Child Development & Family Service Ins. Cert. February 28, 1984 FEB 28 1984 CITY CLFRK Enclosed is a copy of the Certificate of Insurance for the Head Start property on North Missouri Avenue as required by the lease. We have retained a copy for our files and have furnished the Assistant City Manager with a copy. JRM: nt Enc. ML Rodgers & Cummings Insurance P.O. Box 5148 Clearwater, FL 33518 Inc COMPANIES AFFORDING COVERAGES NAME AND ADDRESS OF INSURED COMPANY A LETTER COMPANY B LETTER COMPANY C LETTER COMPANY 0 LETTER COMPANY E LETTER This is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time. 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. South Carolina Insurance Co. Head Stprt Child Development & Family Service % Wm. Fillmore 12351 134th Avenue North Largo, FL 33540 TYPE OF INSURANCE POLICY NUMBER POLICY EXPIRATION DATE limits of liability in Thousands ( OCC~~~NCE AGGREGATE GENERAL LIABILITY x o COMPREHENSIVE FORM o PREMISES-OPERATIONS o EXPLOSION AND COLLAPSE HAZARD o UNDERGROUND HAZARD o PRODUCTS/COMPLETED OPERATIONS HAZARD o CONTRACTUAL INSURANCE o BROAD FORM PROPERTY DAMAGE o INDEPENDENT CONTRACTORS o PERSONAL INJURY SMP9966259 01/01/85 BODILY INJURY $ 300 $ 100 $100 PROPERTY DAMAGE BODILY INJURY AND PROPERTY DAMAGE COMBINED $ $ PERSONAL INJURY $ AUTOMOBILE LIABILITY o COMPREHENSIVE FORM DOWNED o HIRED o NON.OWNED EXCESS LIABILITY BODILY INJURY $ (EAC H PERSON) BODILY INJURY $ (EACH ACCIDENT) PROPERTY DAMAGE $ BODIL Y INJURY AND PROPERTY DAMAGE $ COMBINED BODILY INJURY AND PROPERTY DAMAGE $ COMBINED o UMBRELLA FORM o OTHER THAN UMBRELLA FORM WORKERS' COMPENSATION and EMPLOYERS' LIABILITY OTHER Property A SMP9966259 DESCRIPTION OF OPERATlONS/LOCATIONSNEHICLES Additional Named Insured: City of Clearwater Attn: Joseph McFate P.O. Box 4748 Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the iSSUing com. pany will endeavor to mail ---3....0..- days written notice to the below named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the company. NAME AND ADDRESS OF CERTIFICATE HOLDER DATE ISSUED 2/27/84 City of Clearwater Attn: Joseph McFate P.O. Box 4748 I / INS. INC. Clearwater, FL 33517 ML RODGERS & y ~ , C I Jf 0 F C LEA R W ATE R Interdepartment Correspondence Sheet '- TO: Lucille Williams - City Clerk FROM: ~v~1J' Joseph R. McFate - Community Development Director ! COPIES: SUBJECT: Head Start Insurance Certificate DATE: March 30, 1983 Enclosed is the original Certificate of Insurance for Head Start's Liability Policy as required by our lease with them for the North Missouri Avenue site. We have retained a copy for our files. JRM:nt Enc. {!c '. &tij 1-1 ~ ML Rodger$ & Cummings Insurance, Inc. P. O. Box 6600, Clearwater, Florida 33518 COMPANIES AFFORDING COVERAGES NAME AND ADDRESS OF INSURED COMPANY A LETTER COMPANY B LETTER COMPANY C LETTER COMPANY D LETTER COMPANY E LETTER This is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time. 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. South Carolina Insurance Co. Head Start Child Development & Family Service, Inc. 12351 134th Avenue North, Largo, Florida 33540 TYPE OF INSURANCE POLICY NUMBER POLICY EXPIRATION DATE Limits of Liability in Thousands ( EACH OCCURRENCE GENERAL LIABILITY WJDIL Y 1NJURY 300 300 A o COMPREHENSIVE FORM [X] PREMISES-OPERATIONS o EXPLOSION AND COLLAPSE HAZARD o UNDERGROUND HAZARD o PRODUCTS/COMPLETED OPERATIONS HAZARD o CONTRACTUAL INSURANCE o BROAD FORM PROPERTY DAMAGE o INDEPENDENT CONTRACTORS o PERSONAL INJURY S~~P 996 62 59 1-1-84 PROPERTY DAMAGE 100 100 BODILY INJURY AND PROPERTY DAMAGE COMBINED $ $ PERSONAL INJURY $ AUTOMOBILE LIABILITY o COMPREHENSIVE FORM DOWNED o HIRED o NON.OWNED BODIL Y INJURY (EACH PERSON) BODILY INJURY (EACH ACCIDENT) $ PROPERTY DAMAGE BODIL Y INJURY AND PROPERTY DAMAGE COMBINED EXCESS LIABILITY BODILY INJURY AND PROPERTY DAMAGE COMBINED o UMBRELLA FORM o OTHER THAN UMBRELLA FORM WORKERS' COMPENSATION and EMPLOYERS' LIABILITY OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES t~~:~"~~~~.::"..~_.(..':::~:~~:. ; : Cancellation: Should any of the above described policies be cancelled before the expiration date thereof. the issuing com- pany will endeavor to mail --1.0. days written notice to the below named certificate holder, but failure to mail such notice shall impose no obligation or liability of any kind upon the company, NAME AND ADDRESS Of CERTIFICATE HOLDER City of Clearwater Community Development Dept. P. O. Box 4748, Clearwater, Florida 33518 DATE ISSUED ~. I C I Jy 0 F C LEA R W ATE R Interdepartment Correspondence Sheet TO: Lucille Williams - City Clerk FROM: Joseph R. McFate - Community Development Direc#hJttftz = COPIES: SUBJECT: Head Start Lease DATE: March 29, 1983 Please find a copy of the Head Start Lease for your files. A copy has been retained for our files. JRM:nt RECEIVED MAR 30 1983 CITY CLERK