CERTIFICATE OF LIABILITY INSURANCE (9)
ACV1MT. J I, Lvv)~LI: VnIVI:IC~UVl"Hf\KU j~~ABILITY INSURANCE NU. J.I ~J J~ r, 1/ LIN/l:Itll't"'t'Y"l?
r -. ._", otJf. ... I II I _ _I PICKI,-l 05/31/05
PRQDUCER THIS CERTIFICATE IS ISSUED AS A. MATTER OFINFORMATION
BouCha~d-C1earwater ONLY AND CONFERS NO RIGHTSUPON THE CERTIFCATE
r..:31 Sta~c'-Elst Dri.ve HOL.DER. THIS CERTIFICATE DOESNOT AMEND, EXTEND OR
POBox 6090 ALTER THE COVERAGE AFfORDED BY THE POLCIES BELOW.
C~earwater FL 33758-6090
Phona:727-447-6481 Fax: 727-449-1267 INSURERS AFFORDING COVERAGE NAlC#
INSURED INSURER A; ST PAUL/~RAVELERS
INSURER B:
P.ickles Plus Inc (Ii Pickles INSUReR C;
P1W!l !roo
PO Box 308 60021 INSUReR D;
Fox Riyer Grova IL
INSU~ E;
COVERAGES
TliE POLICIES OF INSURANCE USTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMeD AElOVi: FOR THE POucy PeRIOD INOtCATeD. NOTwITHSTANDING
ANY REQUIREMENT. TERM OR COlllDITION OF A~ CONTRACT OR OlliER DOCUMENT WITH ~SPECT TO WliICH lli.s CERTIFICATE MAY BE ISSUED OR
MAY l'eRTAl~, "..5INSUAANCE AFFORDED ElYTHE POLICIES DESCRIBED H~IN IS SUBJECT TO ALl THE TERMS, EXCLUSIONS ANO CONDITIONS OF SUCH
POLICIES. AGGREGATE UMIiS SHOWN MAY HAve BEeN REOUCED BY PAID ClAIMS.
Lom NSRt TYPe OF INSURANCE POUCY' NUMBER DATE MMlDDrrn- ~1YYl UMrrs
GE~E<lU.1. LIABILITY EACH OCCURRENCE $ 1000000
-
A X COMMERCIAL GENeRAL UASlLlTY 16804638A922TCT05 03/23/05 03/23/06 pReMiSes IEm gCJ;l,lI13'1ll1ill $ 300000
, Cl.AIMS MAOE ~ OCCUR MED EXP (Any one pel'$on) IS 5000
1D ~ NOna FOR lfCl4PM PE~SONAL & Atw INJURY S 1000000
l- S 2000000
GENeRAL AGGREGATE
GEN'LAGGREGA,TE UMIT APPLIES PER: PRODUCTS - COMPJOP AGG S 2000000
Xl POUCY n f~8i n LOO
AIITOMOBtLE LIABILn"( COMBINED SINGLE LIMIT
- (Ea aCcident) :I
ANY AUTO
-
AIJ.OWNED AUTOS BODILY INJURY
- :$
SCHEDULED AUTOS (Per plltSO")
'--
- HIRED AUTOS BODILY INJURY
(Per accident) $
- NON-OWNED AUTOS
- PROPERlY DAMAGE IS
(Per Beckiei'll
~AAG" LlA81UlY AIJTO OtllL Y . EA AOOlDeN,. $
AI'('(AUTO OTHER THAN EAACC $
AUTO ONL~ AGG $
EXCESSIllM5RELLA LIABILITY EACH OCCURReNCE $
~ OCCUR o CLAIMS MACE '. . ,...... AOOREGATE
$
,
=j DEDUCTIBLE M~ $
RETeNTION $ If 3 1 2005 is
WORkERS COMPENSA110N AND ITOR.Y LIMITS I 'u~~.
ENPLOl'1ORS' LIABILITY .-. .-' E.L. IOACH ACCIDENT
ANY PROPRJETDR/F'AATNERlEXECUTlVE PARK~ & RECMEATIO~ s
OFFlCERlM5MElER EXCLUDED? E.L DISEASE - EA EMPLOYEE S
If 1:.8, describe Llndl!lr
S C1AL PROVISIONS belgw E.L DISCAsE. POUCY LIMIT $
OlHER
DESCRlroON OF OPERATIONS I LOCA1"IONS [VEHICLES I EXCl.USIONS ADPED BY ENDORsa4E1\lT I SPECIAL PROVISIONS
Restau.-ant * Fami~y Style
FAx: 727-562-4825
CERTIFICATE HOLDER
cr~Y OF CLE~~R
ATTN: DEBBrm REm
100 SOU!l'H MYRTUl AVE
CLEARWATER FL 33756
CANCELLATION
cr~CLEA SHOULD AN'( OF THE AeoVE DSSCRfBED I'OUCI!;S BE CANCELLED BEFO~E Tl-lE EXPI~TlO
DATE llfEREOF. THE ISSUING INSURER WILL ENDEAlfoR TO NAIl. ~ DAYS WRITTE"
NOnce TO 11iE c:ERlIFlCATE HOLDeR NAMEtl .0 TJoIE LEFT, BUT FAILURE TO DO so SHALL
IMPOSI!! NO OllUGAlIoN OR UAIlIUTY OF AMY KIND UPON TH~ INSURER, ITS AGENTS OR
f{EPRESE 'TlVES.
AUTHOR P SENTA
ACORD 25 (2001/08)
@ACORDCORPOAATION1988