CERTIFICATE OF LIABILITY INSURANCE
ACORD
TM
CERTIFICATE OF LIABILITY INSURANCE
PRODUCER (727)442-00-12
Sandbergen Insurance, Inc.
2121 N.E. Coachman Rd.
Clearwater, FL 33765-2616
FAX (727)446-9147
DATE (MMlDDNYYY)
04/25/2003
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 BELOW.
INSURERS AFFORDING COVERAGE
INSURED DENIS A. & CHERYL L. WHITE DBA PIRATES PANTRY INSURER A: Maryland Casualty Company
321 PALM ISLAND NE INSURERS:
CLEARWATER BEACH, FL H 767 INSURER c:
INSURER 0:
INSURER E:
NAIC#
19356
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDIN
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR" m~i TYPE OF INSURANCE POLICY NUMBER P8k+~~MMlDDIYY\ DATE IMMlDDIYYI LIMITS
LTR
GENERAL LIABILITY PAS042087867 04/28/2003 04/28/2004 EACH OCCURRENCE $ 500,000
e...-
X COMMERCIAL GENERAL LIABILITY ~~~~~~ YE~~~~~~ncel $ 500,000
.. I. CL~IMS MAD~... [Ilo~cUH - _.-- - - ---- - - ----'-,--- ~. --, ----- - ----- ,--" ,----- ---- ... i\<1EDJ=)(Pji\nLo!'e ~er]l.QQL_ -$ .' -le,GOO
_. ----
A PERSONAL & ADV INJURY $ 500,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/OP AGG $ 1,000,000
h 'nPRO- nLOC
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
I-- (Ea accident) $
ANY AUTO
I--
ALL OWNED AUTOS BODILY INJURY
- (Per person) $
SCHEDULED AUTOS
-
HIRED AUTOS BODILY INJURY
- (Per accident) $
NON-OWNED AUTOS
-
- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT $
~ ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
:=J OCCUR D CLAIMS MADE AGGREGATE $
-c- $
~ DEDUCTIBLE $
RETENTION $ $
.1.. - WORKERS COMPENSAIIONAIIID -'.-- -- - - -.- -- ... - I ',-1 lOTI'-
-- 'TORYlIMITSER
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE $
If yes. describe under E.L. DISEASE. POLICY LIMIT $
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERA nONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Re: 25 Causeway Blvd Clearwater Beach, FL 33767
ertificate holder is an additional insured as per the policy wording
CERTIFICATE HOLDER
City of Clearwater
Marine & Aviation Department
25 Causeway Boulevard
Clearwater Beach, FL 33767
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
~ DAYS WRITTEN NonCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
ACORD 25 (2001/08)
@ACORDCORPORATION 1988