CERTIFICATE OF LIABILITY INSURANCE (2)
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ACORD CERTIFICATE OF LIABILITY INSURANCE
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DATE (MMlDDIYY)
05/01/2001
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 (7 2 7) 44 2 - 0 0 1 2 FAX (7 2 7) 44 6 - 9 14 7
Sandbergen Insurance, Inc.
2121 N.E. Coachman Rd.
Clearwater, FL 33765-2616
INSURERS AFFORDING COVERAGE
INSURED P i rat e sPa n try
Thomas & Patricia Wolkowsky dba
25 Causeway Boulevard, '4
Clearwater Beach, FL 33767-2000
INSURER A:
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
Zurich Insurance Co.
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.
'L'TR TYPE OF INSURANCE POLICY NUMBER rOATE (MMlDDiYY) -DATE (MM/DDIYY) LIMITS
GENERAL LIABILITY PPS37785020 04/28/2001 04/28/2002 EACH OCCURRENCE $ 500,000
-
X COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 500,000
I CLAIMS MADE 0 OCCUR MED EXP (Anyone person) $ 10,000
A PERSONAL & ADV INJURY $ 500,000
GENERAL AGGREGATE $ 1,000,000
GEN'lAGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/OP AGG $ 1,000,000
11 nPRO. n
POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
f- (Ea accident) $
ANY AUTO
f-
ALL OWNED AUTOS BODilY INJURY
f- $
SCHEDULED AUTOS (Per person)
I--
HIRED AUTOS BODilY INJURY
f- $
NON-<lWNED AUTOS (Per accident)
f-
f- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC S
AUTO ONLY: AGG S
EXCESS LIABILITY EACH OCCURRENCE S
tJ OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION AND I TORY LIMITS IVER'
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT S
E.L. DISEASE - EA EMPLOYEE S
E.L. DISEASE. POLICY LIMIT $
OTHER
OESCRIPTlON OF OPERATIONS/LOCATlONSNEHICLESlEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER I X I ADDITIONAL INSURED; INSURER LETTER A CANCELLATION
SHOULD ANY OF THE ABOVE DES~~GPOLICIES BE CANCELLED BEFORE THE
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City of Clearwater _ DAYS WRITTEN NEE CER CATE DER AMED TO THE LEFT,
Marine & Aviation Department ,m '.cu",o ':'X2'5 j'tl,no, 0","",""
25 Causeway Boulevard OF ANY KIND UPON T CO'l!'P I E S R P~ I'lTATIVES. __
Clearwater Beach, FL 33 767 AUTHORIZED REPRESENTA~ ~':'JI .. V
Steven SandberQen ~ ~,w
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