CERTIFICATE OF LIABILITY INSURANCE (9)
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SANDBERGEN INSURANCE
727-446-9147
p, 1
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CERTIFICATE OF LIABILITY INSURANCE
(727)446-9147
DATE (MMIOD/YYYYl
04/05/2005
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.
PRODUCER (721)442-0012 FAX
Sandbergen Insurance, Inc.
2121 N.E. Coachman Rd.
Clearwater, FL 33765-2616
INSURED Marlna Restaurant" Coffee Shop
Thomas & Patr;c;a Wolkow~ky
25 Causeway Boulevard
Clearwater Beach, FL 33767-2064
INSURERS AFFORDING COVERAGE
INSURER/\: Capac;ty Insurance Co,
INSURER B:
INSURER C:
INSURER D:
INSURER E:
NAlC #
COVERAGES
THE POUCIES OF INSURANCE LISTED BEl.OW 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POUCIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR '-DD'l 'TYPe OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY CLP009277 04/01/2005 04/01/2006 EACH OCCURRENCE: $ 1,000,000
~MERCIAL GENERAL LABlUTY DAMAGE TO RENTED $ 100,000
CLAIMS MADE [!J OCCI.R r.EO EX!" (Anyone person) $ 5,000
A X PE:RSONII1. & AD\lINJURY S 1,000,000
RECEIV ~D GENERAL AGGREGATE $ 2,000.000
GEtJ'L ...GGREGATE LIMIT APPLES PER PRODUCTS.COMP~PAC~ $ 1,000,000
I POLICY n ~fr n lOC !
AUTOMOBILE LIABILIlY API-< U 5 Ll 'U~ COM3INEDSlr,GlE LIMIT
- $
ANY AUTO (Ea accident)
-
ALL OWNED AUTOS OFFICIAL RECOR[ SAND BODILY INJURY
- S
SCHEDULED J>UTOS LEGISLATIVE SRVC (Per person:
- ~ DEPT
HIRED AUTOS
- BODILY INJURY $
NON-OWNED AUTOS (pe, accident)
-
- PROPERTY D".MAGE $
(Per ec:cfdent)
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT S
~ ANY AUTO OTHER'TH"N EAAC;C $
AUTC DNl Y: AGG $
EXCESSlUMSRa.t..A LIABILITY e.a.CH OCCURRENCE $
~ OCCLR C CLAIMS MADE AGGREGATE $
$
~ DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I WCSiATU. I IOJ~.
EMPLOYERS' LIABILITY
ANY PROPRIETORIPARTN:RiEXEC'JTIVE E:,l. EACH "CCrDEN'I $
OFFICERlNEMBER EXCLUDED? E,L. DISEAse. EA E~'PlOYE $
~~I~~~~~~~jS below E.L. DISEASE - POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS r lOCATIONS / VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT / SpeCIAL PROVISIONS
ertificate Holder ;s Landlord Additional Insured
CERTIFIC TE HOLDER
City of Clearwater
Mar;ne & Av;at;on D;v;son
Cathedne
25 Causeway Boulevard
Clearwater Beach, FL 33767
ACORD 25 (2001/08) FAX: (727)462-6957
Apr- os. 05 08: 44a
SANDBERGEN INSURANCE
727-446-9147
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy{ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
requ ire an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s),
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative 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)