CERTIFICATE OF LIABILITY INSURANCE (8)
I-rom: ::iHAt-<UN U'Nl::IL At: ljUUCHAt-<U IN::iUt-<ANCl:: l-aXIU: ljoucharCl Insurance 10: UeOOle
Uate: 4111LUU4 11 :40 AM I-'age: 1 01
ACORD.. CERTIFICATE OF LIABILITY INSURANCE OP ID s9 DATE (MMlDDIYYYY)
PJ:CKL-l 04/07/04
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Bouchard-Starcrest ONL Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
101 Starcrest Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
POBox 6090 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
C1earwater FL 33758-6090
Phone: 727-447-6481 Fax: 727-449-1267 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: THE TRAVELERS J:NSURANCE CO 3
INSURER B
Pick1es P1us Too INSURER c:
Kim
320 C1eve1and street INSURER D
C1earwater FL 33755
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED, NOlWlTHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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,
LTR NSRD TYPE OF INSURANCE POLICY NUMBER II"D'1o.~ (MMlODIYY) DATE (MMIDDIYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1000000
- 03/23/04 03/23/05 PRE~ISES (Ea occurence)
A X COMMERCIAL GENERAL LIABILITY J:6804638A922-TCT $ 300000
I CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 5000
PERSONAL & ADV INJURY $ 1000000 ,,'
-
GENERAL AGGREGATE $ 2000000
-
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2000000
Xl n PRO- nLOC
X POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
f-- $
ANY AUTO (Ea accident)
f--
ALL OWNED AUTOS BODIL Y INJURY
f-- (Per person) $
SCHEDULED AUTOS
r---
HIRED AUTOS BODiL Y INJURY
- (Per accident) $
NON-OWNED AUTOS
f--
f-- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILI1Y AUTO ONLY - EA ACCIDENT $
~ ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
CJ OCCUR D CLAIMS MADE AGGREGATE $
$
==], DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND ITORY L1Mm; I IU~~
EMPLOYERS' L1ABILI1Y
ANY PROPRIETOR/PARTNER/EXECUTIVE E,L, EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? EL DISEASE - EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below E,L, DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Restaurant * Fami1y style
FAX: 727-562-4825
CERTIFICATE HOLDER CANCELLATION
CJ:TCLEA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10
DAYS WRITTEN
CITY OF CLEARWATER
ATTN: DEBBIE REJ:D
100 SOUTH MYRTLE AVE
CLEARWATER FL 33756
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR L1ABILI1Y OF ANY KINO UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES,
AUTHORI ~ PR SENTA~
rrom: ::;HAKVI'J V'I'J~IL At: I:lVUL;HAKU II'J::;UI"<AI\jL;~ raXIU: I:loucnara Insurance 10: ueoole
Uate: 41 IILUU4 11 :'1b AIVI t-'age: LOT;
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 I nsurance 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,