CERTIFICATE OF LIABILITY INSURANCE (5)
ACORD.M CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIYY)
04/02/2003
PRODUCER (727)442-0012 FAX (727)446-9147 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Sandbergen Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
2121 N.E. toachman Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Clear\vater, Fl 33765-2616
INSURERS AFFORDING COVERAGE
INSURED Marina Restaurant INSURER A: Service Insurance Company
Thomas & Patricia Wolkowsky INSURER B:
25 Causeway Bouevard INSURER c:
Clearwater Beach, Fl 33767 INSURER 0:
I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
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.
'~f~ TYPE OF INSURANCE POLICY NUMBER P~l-+~~~:=gg,w\E
GENERAL LIABILITY 5MP501339 04/01/2003
-
X COMMERCIAL GENERAL LIABILITY
I CLAIMS MADE 00 OCCUR
Pgi!fI{~~~M:N
04/01/2004
LIMITS
EACH OCCURRENCE
500,00
500 , OOl
I,OOl
500,OOCl
1,500,000
1,500,OOCl
-
$
$
$
$
$
PRODUCTS - COMP/OP AGG $
FIRE DAMAGE (Anyone fire)
MED EXP (Anyone person)
A
PERSONAL & ADV INJURY
-
GEN'L AGGRE nGATE- LIMIT APPLIES PER:
r----, PRO- n
I I POLICY JECT LOC
AUTOMOBILE LIABILITY
'--
GENERAL AGGREGATE
ANY AUTO
c--
COMBINED SINGLE LIMIT
(Ea accident)
$
ALL OWNED AUTOS
I--
_ SCHEDULED AUTOS
HIRED AUTOS
-
BODILY INJURY
(Per person)
$
-
NON-OWNED AUTOS
BODtL Y INJURY
(Per accident)
$
-
PROPERTY DAMAGE
(Per accident)
$
nRAGE LIABILITY
11 ANY AUTO
OTHER THAN
AUTO ONLY:
AUTO ONLY" EA ACCIDENT $
EA ACC $
AGG $
EXCESS LIABILITY
=:j"OCCUR 0 C~AIMS MADE
II DEDUCTIBLE
I RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
--~.
EACH OCCURRENCE $
AGGREGATE $
$
$
$
OTHER
.
I T~~~mlNs IOl~'
E.L. EACH ACCIDENT $
E.L. DISEASE" EA EMPLOYEE $
E.L. DISEASE" POLICY LIMIT $
.
DESCRIPTION OF OPERATIONSlLOCATIONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER
I X I ADDITIONAl INSURED; INSURER LETTER: A
CANCELLATION
ACORD 25-S (7/97)
FAX: 462-6957
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUA COMPANiEWILL. END. OR TO MAIL
~ DAYS WRITTEN NOTICE T~ THr yERTIFICATE HOL trJT, THE LEFT,
BUT FAILURE TO MAIL SUCH ?f'C I ~ 'f'LL IMPOS OB GATI LIABILITY
OF ANY KIND UPON THE C~PAN): ~ ~GENTS 0 P SENT"~' .
AUTHORIZED REPRESENTATI'"\ .":)/ '/Jj ~.... ", I A. Jut '1' rA...
Steven Sandbergen ~ ~ll ~ - ...p-"
<&\ACORD CORJt(lRATION 1988
City of Clearwater
Marine & Aviation Department
25 Causeway Boulevard
Clearwater Beach, Fl 33767