CERTIFICATE OF LIABILITY INSURANCE (2)
Apr 15 04 11:40a
SANDBERGEN INSURANCE, INC
p. 1
727-446-9147
CEIRTIFICATE elF LIABILITY INSURANCE
FA'/.. (727)4. .6-9147
DATE (NMlDllIVYYY)
04/15/2004
THIS ER TE IS ISSUED AS A MAnER OF IN
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
ACOR[t
PRODUCER (727)442-0012
Sandbergen InsurancE:, Ine
2121 N.E. Coachman I~d,
Clearwater, FL 3376:)-2616
INSURED DENIS A. a CHERYL L. ,,"ITE DBA P: :RATES PANTRY
321 PALM ISLAND NE
CLEARWATER BUGI, FL 33767
COVERAGES
INSURERS AFFORDING COVERAGE
INSURER A: Maryland Casualty COlq)any
INSURER B:
INSURER C:
INSURER D:
INS~ER E:
NAIe #
19356
THE POLICIES OF INSURANCE USTED BELOW HAVE BEE ...ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. N01WITHSTANDIN
AN'( REQUIREMENT, TERM OR CONDITION OF ANY CON'" RACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURA~ICE AFFORDED BY THE POL :IES 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 NSRJ: n'PE OF INSU~:ANCE POLI( V NUMBER DATi'IMMID"'iiIm~ DATE lilMlOiIiWi UMITS
GENERAL LIABIUTY PAS042087867 04/28/2004 04/28/2005 EAOl OCCURRENCE $ 500,000
X COLlMERCIAL GENG;RAL LIABILITY ::'~~ n::... _neel $ _ 500.000
- =:J CI.AIMS UAOE [!] OCCUR MEn EX? (Anyone person) $ 10, 00(]
."
- PERSONAL&AC:N INJURY $ ., 500,00(1
A X
- GENERAL AGGREGATE $ 1. 000,00(1
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ 1,000,000
I nPRO- n
POLICY JEC': LOC
AUTOMOBILE LIABlUTV COMBINED SINGLE LIMIT
- (Ea accident) S
ANY AUTO
-
ALL OWNEO AUTO!; BODILY INJURY
- (Per peosonl S
SCHEDlILED AUTOS
-
HIRED AUTOS BODILY INJURY
- (p.., acOdent) $
NOfII-OWNED AUTC'S
I-----
I----- PROPERTY DAMAGE $
(per accident)
GARAGE UA81L1TY AUTO ONLY - EA ACCIDENT $
=l ANi AUTO OTHER THAN EAACC $
AUTO ONL V: AGG $
EXCESSIUMBRELLA LlABIUTY EACH OCCURRENCE $
=:J OCCUR o CLAlNS MADE AGGREGATE $
$
=l DEDUCTIBLE $ -
RETENTION $ $ .r
WORKERS COMPENSATION P.ND I TORYLIMITS I IU~- :
EMPLOYERS' lIABILITY E.L. EACH ACCIDENT $ '.
NoIY PROPRIETORlPARTNER.~.xECUTIVE
OFFICER1MENBER EXCLUD8:11 E.L DISEASE - EA EMPLOYEE $
~' describe under E.L. DISEASE - POLICY LIMIT $
ECIAL PROVISIONS below
ClTHI!R PAS04Z087867 04/28/2003 04/28/2004 Each Occurrence $500,000
~iquor Liability DESCRIPTION OF opeRATIONS I LCICATIONS IIIEHIClES I EXCWSIO oIS ADDED BY ENDORSEMENT 1 SPECIAl PROVIS10NS
Re: 25 Causeway Blvd Clearwater Beach, FL 33767
ertificate holder is an additional iniured as per the policy wording
CERTIFICATE HOLDER
City of Clearwater
Marine " Aviation Department
25 Causeway &lulevard
Clearwater Beach, FL 33767
ACORD 25 (2001/08)
CANCELLATION
SHOULD ANY OF T1lE ABOVE DESCRIBED POLICIES BE CANCELLED BB'ORE THE
EXPIRATION D~TE T1lEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
-AS...- DAYS WRJTTaI NonCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHAU INPOSE NO OBUGA1l0N DR LIABIUTY
OF ANY KINO U N E INSURER, ITS AGENTS OR RS'RIiSEHTATIVES.
AUTHORIZED REP ATlVE
@ACORDCORPORATlON 1988
Apr 15 04 11:40a
SANDBERGEN INSURANCE, INC 727-446-9147
'"-
IMPORTANT
If the cert:ficate holder is an ADDr "IONAL INSURED, the policy(ies) must be endorsed, A statement
on this certificate does not confer I ights to the certificate holder in lieu of such endorsement(s).
If SUBRGGA liON IS WAIVED, su Jject to the terms and conditions of the policy, certain policies may
require an endorsement A statem mt on this certificate does not confer rights to the certificate
holder in ieu of such endorsemen (s).
DISCLAIMER
The Certificate of Insurance on thl' reverse side of this fonn does not constitute a contract between
the issuir.g insurer(s), authorized J apresentative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
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