CERTIFICATE OF LIABILITY INSURANCE (7)
~_Ma~' 03 05 03:07p
Sandbercen Ins, Inc.
7274469147
p.2
PRODUCER (727)442-0012
Sandbergen Insurance, Inc,
2121 N,E. Coachman Rd.
Clearwater, FL 33765-2616
FAX (727)446-9147
DATE IMMIODIYYYY)
05/03/2005
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.
ACORD
1M
CERTIFICATE OF LIABILITY INSURANCE
INSURED Patricia" Thomas Wol kowsky DBA Pi rates Pantr
25 Causeway Blvd
Suite 4
Clearwater Beach, Fl 33767-2000
INSURERS AFFORDING COVERAGE
INSlRER..: Maryland Casualty Company
INSLRER B:
INSLRER c:
INSLRER 0;
INSURER E:
NAIC t#
19356
COVERAGES
THE POLICIES OF INSURANCE LISTED BelOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT DR OTHER DOCUMENT WIT.H RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TER~S, EXClUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEt-.! REDUCED BY PAID CLAIMS,
I~: ~.R:~ TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY PAS4338Z895 06/01/Z004 06/01/2005 EACH OCCURRENCE $ 500,000
'-x CO "'MERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 500,000
- ~ CLAIIlASMAOE 00 OCCUR
IllEO ExP lAt'Y one person) $ 10.000
-
A X PERSONAL & NJV INJURY $ 500,000
-
GENERAL AGGREGATE S 1,000,000
- 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMPIOP AGG S
I n PRO. nLOC
PO.ICY JEeT
AUTOMOBILE LIABIUTY COMBINED SINGLE ~IMIT
- (E. accidenl) $
ANY AUTO
-
ALL OWIIlED AUTOS BODILY INJURY
- iPer person) $
SCHEDULED AUTOS
-
HIRED A.UTOS BODILY INJURY
- $
NON-OWNED A~TOS iPer accidenl\
-
PROPERlY DAMAGE S
{Per accldenl)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT S
R ANY AUTO OTHER THAN EAACC S
AUTO ONLY: AGG $
3ES5/UMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR 0 CLAIMS MADE AGGREGATE $
$
~ DEDUCTIBLE $
RETENTION $ S
WORKERS COMPENSATION AND I ~~,m~,Th!" 1 I OJ,!;!-
EMPLOYERS' LIABILITY
ANY PROPRIETORlPAR~NERfEXECUTIVE E,L, EACH ACCIDENT S
OFFICER/MEMBER EXCLU:)ED? E.L. DISEASE - EA EMPLOYEE S
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY L1Mrr S
OJHER PAS43382895 06/01/2004 06/01/2005 Aggregate $500,000
Llquor Liability Each Common Cause $500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
~ertificate Holder is named as additional insured as per policy wording
R
City of Clearwater
25 Causeway Blvd
Clearwater Beach, Fl 33767
SHOULD ANY OF niE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DAlE THEREOF, THE ISSUING INSURER lNlLL ENDEAVOR TO MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR UABIUTY
OF ANY PON THE INSUR TS AGENTS OR REPRESENTATIVES,
AUTHO RES TATIV
@ACORD CORPORATION 1988
ACORD 25 (2001/08)