CERTIFICATE OF INSURANCE (4)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDDIYY)
12/01/2004 12/01/2003
PRODUCER LOCKTON COMPANIES OF DALLAS, INC. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
717 N. HARWOOD, LB#27 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
DALLAS TX 75201 ALTER THE COVERAGl= BY THE POLICIES BELOW~
214-969-6700 INSURERS AFFORDING COVERAGE
INSURED Cingular Wireless, LLC INSURER A : ACE American Insurance Comnanv
1024339 5565 Glenridge Connector, Suite 1800 INSURER B : National Union Fire Insurance Co.
Atlanta GA 30342 INSURER C :
INSIIRFR D .
I IN!,;IIRFR F .
COVERAGES CINWIOI GO
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
c--- .~~THF IN~IIRANr.F AI="ORnFn Ry', THE P.OLlCIES. rn;sr.RIBE~EREIN IS SUBJECT-TO ALL.THE TERMS. EXClJ.lSlONS..AND COIllQITIONS OF~UCH
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAl CLAIMS.
INSR ~~Tri:J6~ ~~T"r~~N
LTR TYPE OF INSURANCE POLICY NUMBER LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1 000 000
-
A X COMMERCIAL GENERAL LIABILITY HDOG 19905020 12/01/2003 12/01/2004 FIRE DAMAGE IAnv one fire) $ XXXXXXX
I CLAIMS MADE [X] OCCUR MED EXP IAnv one oerson) $ Excluded
PERSONAL & ADV INJURY $ 1 000 000
- GENERAL AGGREGATE $ 10,000,000
~'L AGGREn LIMIT APn PER: PRODUCTS - COMP/OP AGG $ 1 000 000
PRO-
POLICY JECT LOC
AUTOMOBILE LIABILITY
- COMBINED SINGLE LIMIT $ 2,000,000
A X ANY AUTO ISAH08004225 ALL STATES 12/01/2003 12/01/2004 (Ea accident)
-
- ALL OWNED AUTOS BODILY INJURY
$ XXXXXXX
SCHEDULED AUTOS (Per person)
-
- HIRED AUTOS BODILY INJURY
$ XXXXXXX
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $ XXXXXXX
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $ XXXXXXX
=1 ANY AUTO NOT APPLICABLE OTHER THAN EA ACC $ XXXXXXX
AUTO ONLY: AGG $ XXXXXXX
EXCESS LIABILITY EACH OCCURRENCE $ 5,000,000
B ::=J OCCUR D CLAIMS MADE TBD 12/01/2003 12/01/2004 AGGREGATE $ 5 000 000
l W UMBRELLA $ XXXXXXX
~XXXXXX
. _u ~_ ........ _ DE[)UCTI~~_ FORM ... --~---- _'n"______ _._~-_. "------- ~---,--, - .-------,-- -- . .~--'-- -'--~~ -~ -~~.~_._-~~ -.-"
RETENTION $ $ XXXXXXX
A WORKERS COMPENSATION AND WLRC43533083 AOS 12/01/2003 12/01/2004 X l~cfR~~~~YT!'; I I~~H'
A EMPLOYERS' LIABILITY SCFC43533046 WI 12/01/2003 12/01/2004 1 000 000
E.L EACH ACCIDENT $
E.L DISEASE - EA EMPLOYEE $ 1 000 000
E.L DISEASE - POLICY LIMIT $ 1 000 000
OTHER
DESCRIPTION OF OPERATIONSlLOCATIONSlVEHICLESlEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
GROUND CELL SITE NAME: TAM 440-062.1 LOCATION: 3290SR 580 AT MCMULLEN BOOTH ROAD, CLEARWATER, FLORIDA CERTIFICATE
HOLDER IS INCLUDED AS ADDITIONAL INSURED AS RESPECTS TO GENERAL LIABILITY
CERTIFICATE HOLDER I. I ADDITIONAL INSURED" INSURER LETTER: CANCELLATION
1402769 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF CLEARWATER-CITY MANAGER DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
PO BOX 4548
CLEARWATER FL 34618-4748 NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT .FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE '-\> n n ~ .
I '5 If')
ACORD 25-5 (7/97) For questions regarding this certificate, contact the number listed In the 'Producer' section above and specify the client code 'CINWI01'. @ACORDCORPORATION 1988
."....