CERTIFICATE OF LIABILITY INSURANCE (8)
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ACORQ,. CERTIFICATE OF LIABILITY INSURANCE CATE (MMlDDlYYYY)
06/02/2005
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. Coachman Rd, ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Clearwater, FL 33765-2616
INSURERS AFFORDING COVERAGE NAIC#
INSURED Patrlcia & Thomas Wolkowsky DBA Plrates Pantr INSURER A: Granada Insurance Company
25 Causeway Blvd INSURER B:
Suite 4 INSURER c:
Clearwater Beach, Fl 33767-2000 IIlSURER D:
INSURER E:
r.OVERAGE~
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 TERNS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~~: i..o.,~~ TYPE OF INSURANCE POLlC,", NUMBER POUCY EfFECTIVE POLICY ElWftATION LIMITS
GENERAL lIABILITY CP123519 06/01/2005 06/01/2006 EACH OCCURRENCE $ 1,000,000
7 COMMERCIAl. GENERAlllABIUTY DAMAGE TO RENTED $ 50,000
I CLAIMS MO.DE 00 OCCUR MED EXP (Any ona person) $ 1,000
A X PERSONAL & AOV INJURY $ 1,000,000
GENERAL AGGREGATE $ 1,000,OO(J
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ Incl uded
'I npRO- n
. POLICY JECT LOC
.~OMOBIlE UABILITY COMBIIlED SINGLE LIM!T $
At-N AUTO (Ea a:cident)
-
ALL OWNED AUTOS BODILY INJURV I
- (Per penon; i$
Sc:HEOUUOO AUTOS
-
HIRED AUTOS BODILY INJURY 1$
- (Per accident)
NON-OWNED AUTOS
-
- PROPERTY OAMAGE 5
(Per accldent)
GARAGE UABIUTY AUTO ONLY - EA ACCIDENT $
==i AN'( AUTO OTHER THAN EA ACe $
AUTO ONLY: AGG $
EXCESSIUUBRELLA LIABILITY EACH OCC~RRENCE $
tJ OCCUR 0 CLAIMS MADE AGGREGATE $
$
R DeDUCTIBLE I $
RETENTION S $
WORKERS COMPENSATION AND i I WC STATU.. I IO~-
EMPLOYERS' LIABILITY E.1., EACH ACCIDENT $
ANY PROPRIETOR/PARTNER'EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.l. DIS:=ASE - EA EMPlOYEE it
If yes. describe under EL DISEASE - POLICY LIMIT it
SPECIAL PROVISIONS below
O;rHER 'b 1 CP123519 06/01/2005 06/01/2006 Aggregate $500,000
l1quor lla i ity Each Common Cause $500,000
OESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXa.USIONS ACDED BY ENDORSEMENT I SPECIAL PROVISIONS
tertificate Holder ;s named as additional insured
CERTIFICATE HOLD
City of Clearwater
25 Causeway Blvd
Clearwater Beach, FL 33767
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, TliE ISSUING INSURER WILL ENDEAVOR TO MAIL
...!L DAYS WRITTEN NOTICE TO TIlE CERTIFICATE HOLDER NAMED TO THE LEfT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILrTY
Of K UPON THE INSUR ITS AGENTS OR REPRESENTATIVES,
AUTlIOR
@ACORDCORPORATION 1988
ACORD 25 (2001/08)