CERTIFICATE OF LIABILITY INSURANCE
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All Lines Insurance Group Inc
1345 S Missouri Ave
Clearwater FL 33756
Phone 727-446-5721 Fax 727-298-8850
mclarkson@insuranceagentfl.com
May 19, 2005
Insured: 688 SKATE SHOP II
Company: Burns & Wilcox
. Policy #: TBA
Policy Period: MAY 18 05 To: MAY 18 06
Total Number of Pages: 4
688 Skate Park
Phone:
Fax: 727-562-4825
Debbie ~eid
Re: Certificate
Per your request, attached is evidence of insurance for the above captioned account.
Should yciu have any questions, please feel free to telephone.
Sincerely
Laura C Johnston
Commercial Lines CSR
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PAGE 1212
DATE (MM/DDIYY)
MAY 18 OS
TtllS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERT/FICA re
HOl-tlER. TtllS CERTIFICATE tlOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
ACORD
TM,
PRODUCER
ALL LINES INSURANCE GR.OUP INC
1345 S MISSOURI AVE
CLEARWATER FL 33756
PHONE: 727-448.5721
FAX: 727-298-8850
CERTIFICATE OF LIABILITY INSURANCE
INSURERS AFFORDING COVERAGE
NA.lC#
INSUReo
688 SKATE PRO SHOP /I
6140 ULMERTON RD
CLEARWATER FL 33760
INSURER A:
INSUR:I!R B:
-.-
INSURER c:
. INSURER 0:
INSUFtER 5:
Burns & Wilcox
COVERAGES
THE POLICIES OF INSURANCF. I.ISTE;D E!ElOW HAVE BEEN ISsueo TO THE INSURED NAMED ABOVI:; I=OR THIi POLICY PI!R10D INOICATIill, NOlWlTHSTANDING
ANY REQUIREMENT, TeRM OR CONDITION 01= ANY CONTRACT OR OTHER OOCU~ENT WrrH ReSPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OF!
MAY PERTAIN. THE INSURANce AFFORDED BY THI:; POLICIIiS DESCRIBED HEREIN 18 SUBJIiCT TO AI.I. THI:; TERMS, EXCLUSIONS MID CONDITIONS OF SUCH
POI.,ICII:;S. AGGREGATE LIMITS SHOWN MAY llAVE BEEN RI:DUCED BY PAID CLAIMS.
. ..- ..... . .nO --.-----.., .. .
INSf TYPE OF INSURANce POLICY NUMBER POUCV EFFECT1VE poucy ':M'::'~N I I.lMITS
LTR DA.n;................. DATE M DD
GENERAL UABILllY TbA MAY 18 05 MAY 18 08 EACH OCCURRENCE $ . 1,tJOO.,P~.~.
-- DAMAGETGRENTEL'J "OM'
X COMMERCIAL Ge"'E~AL J.IA$II.ITY _P'~MISESJEo'p.cc(I"'ncQI__ .!.___. . .3.0~~O~O_.
--.. I CLAIMS MADE I~ OCCUFt
: MEa. EXP (Any OM P.",,,n, $ SD,OOO
- ...
A Pl;FlSONAl, /!. AI:IV IN,IUFW $ 1,OOQ,OOO
- -.. - .. _'__M_ 0" .R'." _ _,
GENERAL AGGREGATE $ 2.0D~,.~o.~_
- ...--.. .... , .. .-. ..--. '" ,. .. '.'-'.'--'
GEN'L AGGREGATe LIMIT APPLIE;:S PER: PRODUCTS-COMP/OP AGG, $ 1,000,000
I POLICy n non.e~ r . I,n,... ...- '" '.... . . . .. --- --.. " .....,,-
AUTOMOBILE L1ABILllY COMBINED SINGLE! LIMIT
..... (5:lcc<ldenl) 5:
ANY AUTO
... --.---..
ALL OWNED AUTOS 8ODIl.Y INJURY
"-- (Par person) $
SCHEDULED AUTOS
,,---
HIRE;:D AlITOS , BODILY INJURY
, $
NON.OWNED AUTOS I (Per aa:idM I)
..--. i .-...--.... .
-. --.. ..- - P~PE~ DAMAGe: $
GARAGE UABILI"N AUTO ONLY - EA ACCIDENT $
../ ANY AUTO OTHEIHHAN EA ACC $
..
AlITO ONLY: AGG :0
EXCESS' UMBERELLA UABllllY EACH oeCUFl~Nce $
-=:1 occU~ [..-..., CLAIMS MADE AGGREGA"TE $
$
-. I DEDUCTIBLE
$
RETENTION $ $
WO~I(ERS COMPENSATION AND I I ~~rCr~YT$ I ...1. <:,Tl1ER
EMPLOYERS' L1ABILllY '-'p~--" ..-.-. "_OM'.. ..._
ANY I'I'lOI''''ISTO'''IF'^QTN~M!l!~CU11VE e,l., eACH ACCIDENT S
... ,......-- ------. .-...-....---
O~"ICI!IWIII.MBI!R El(CWDED? E.L. DISEASE-EA EMPLOYEE $
Ir y", 11&.0'11.. UK"'" - ----
SPECIAL PReVIBIONS bol... E.L, DISEASE-POLICY LIMIT $
OTHF.R:
I
DESCRIPTION OF OPERATIONS/LOCATIONNEHICLES/EXCLUSIONS ADDED EN DORSEMENTI SPECIAL PROVISIONS
Ct;RTIFICAT~ HOLDE~ I X I ADDmONAlINSURED: INSURER lETTER: CANCELlATION
CITY OF CLEARWATER SHOULD ANY OF TJotE ABOVE: DF.SCR1l:IEO POLICIES BE CANCI:LLED BEFORE THe
1426 MARTIN LUTHER KING JR AVE EXPIRATION DATI: THEREOF, TI-lE ISSUING COM~A"Jv wiLL F.;NDFAVQR TO MAIL 10
DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLOG:R NAMED TO Tl-II:; LEFT, SUT
CLEARWATER, FL 33758 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR llA!lILl1Y OF ANY KIND UPDN THI:;
INSURfR, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRF.SeNTATIVe .~'
Att@ntion: ~~
~.~ - -.,.
ACORD 25 (2001/D8)
Certificat~ ~ 41236
Michael B_ Clarkson
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J-'AC::i1::. 1::13
POLICY NUMBER: TBA
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED.OWNERS) LESSEES OR
CONTRACTORS (Form B)
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL L1ABILllY
Name of Person or Organization;
SCHEDULE
CITY OF CLEARWATER
1426 MARTIN LUTHER KING JR AVE
CLEARWATER. Fl 33756
(If no entry appears above. information required to complete this endorsement will be shown in the
Declarations as applicable to this endorsement.)
WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization
shown in the Schedule. but only with respect to liabilitY arising out of "your work' for that insured by
or for you
CG 20 10 11 85
Copyright Insurance Services Office, Inc., 1984
C~rlifir::at~# 41236
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PAGE t14
. POLICY NUMBER: TBA
COMMERCIAL GENERAL L1ABILIl'(
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ THIS CAREFULLY
ADDITIONAL INSURED PRIMARY COVERAGE
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
ThIs insurance Is primary for the person or organization shown in the schedule, but only with respect to liability arising out of your
work or that insured by or for you. Other insurance afforded to that Insured will apply as excess and not contribute as primary to 'the
insurance afforded by this endorsement
All other endorsement provisions, conditions and exclusions of this insurance shall remain unchanged and apply to the additional
insured and described below.
SCHEDULE
ADDITIONAL INSURED
CITY OF CLEARWATER
1426 MARTIN LUTHER KING JR AVE
CLEARWATER, FL 33756
CONTRACT/PROJECT
NAMED INSURED 688 SKATE PRO SHOP II
6140 UlMERTON RD
CLEARWATER FL 33760
Certificate # 41236