CERTIFICATE OF INSURANCE
.
c.. / e_ ,~ k
FERTIFICATEOF I,NSURANC;,
[X] ALLSTATE INSURANCE COMPANY HOME OFFICE-NORTHBROOK, ILLINOIS
o ALLSTATE INDEMNITY COMPANY
Name and Address of Party to
Whom this Certificate is Issued
""
Name and Address of Insured
City of Clearwater
Donald J. Petersen, Risk Mgr.
P.O. Box 4748
Clearwater, FL 33518
Pinellas County Arts Council
400 Pierce Blvd.
Clearwater, FL 33516
INSURANCE
IN FORCE
TYPE OF INSURANCE
AND HAZARDS
POLICY FORMS
LIMITS OF LIABILITY
POLICY NUMBER
EXPIRATION
DATE
Workmen's Compensation
STATUTORY *
Employers' Liability
STANDARD
$ See Be low PER ACCIDENT (Employer's Liability only)
*Applies only in following state(s): FL
49 649 517 ~JC
10-1-87
10-1-88
Automobile liability Bodily Injury Each
o OWNED ONLY o BASIC PERSON
$
o NON-OWNED ONLY o COMPRE- $ ACCI DENT $
HENSIVE
o HIRED ONLY o GARAGE $ OCCURRENCE $
o OWNED, NON-OWNED 0 Bodily Injury and Property Damage (Single limit)
$ EACH ACCIDENT
AND HIRED $ EACH OCCURRENCE
General Liability Bodily Injury
[]] PREMISES-O.L&T. D SCHEDULE EACH
$ PERSON
[j] OPERATlONS-M.&C. EACH
$ ACCIDENT $
[X] Esca 1 a tor [XJ COMPRE- EACH
~W~1j( $ OCCURRENCE $
HENSIVE AGGREG. PROD,
[X] PRODUCTS/ COMP, OPTNS, $
COMPLETED OPERATIONS AGGREGATE
o PROTECTIVE (Inde- D SPECIAL OPERATIONS $
pendent Contractors) MULTI-PERIL AGGREGATE
o Endorsed to cover D PROTECTIVE $
contract between AGGREGATE
insured and CONTRACTUAL $ 49 649 518 BPP
Bodily Injury and Property Damage (Single limit) 10-1-87 10-1-88
$ EACH ACCI DENT
$ 300,000 EACH OCCURRENCE
dated $ 600,000 AGGREGATE
Employers Bodily Injury by accident $100,000 e ch accident
Li abil ity Bod il y Injury by disease $100,000 e ch employee
Bodily Injury by disease $500,000 p 1 i cy 1 i mit
0/<"'/ pfEIL J>c>~ /0 ~7
The policies identified above by number are in force on the date indicated below. With respect to a number entered under policy number, the type of insurance shown at its left is in
force, but only with respect to such of the hazards, and under such policy forms, for which an "X" is entered, subject, however, to all the terms of the policy having reference
thereto. The limits of liability for such insurance are only as shown above. This Certificate of Insurance neither affirmatively nor negatively amends, extends. nor alters the
coverage afforded by the policy or policies numbered in this Certificate.
In the event of reduction of coverage or cancellation of said policies, the company indicated by lEI will make all reasonable effort to send notice of such reduction or
cancellation to the certificate holder at the address shown above.
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
,19~ By 4/1J-'1~4.. ma4~jlA>>
Authorized RepresentatIve
/
Date
U454A
10-9
,./~
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Allstate~
HOME OFFICE. NORTH BROOK, ILLINOIS
CHANGE ENDORSEMENT
Effective Date of Change
10-1-87
v
Change Endorsement No.
1
1, Policy Number
THIS ENDORSEMENT FORMS A PART OF THE POLICY NUMBERED BELOW:
49 649 518 BP
2. Named Insured
Pinellas County Arts Council
3. Changes:
It is agreed that City of Clearwater has been added as additional insured
per attached CG2013.
4. Changes in Premium:
The above amendments result in a change in the premium as follows:
NO
[X] CHANGE
TO BE
D ADJU~;rED
AT AUDIT
ADDITIONAL
PREMIUM $
RETURN
PREMIUM $
IN WITNESS WHEREOF, Allstate has caused this endorsement to be signed by its Secretary and its President at
Northbrook, Illinois.
~t~
Secretary
GL.-J-?:. ~
President
Countersigned By
<~b~~
/~..AY
, Authorized Agent
BU9301
(Ed.l-BB)