CERTIFICATE OF INSURANCE (6)
~rom-John L Wortha" & Son LP
7135211951
T-269
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_RTIFICATE: OF LIABILITY INSURANCE ~w.u;{MtoIIIlDlt'(J . -'--' "1.,-..
Ci1I'OO~G3r' T f?
TIiIS CER"nFlCATf IS ISSUED AS A MATT In.'';i\!.o~ ~A
N, L.P. ONlY AND CONFERS NO RIGHTS UPON THE CERTII=IGATE
HOLDER. THIS CERTIFICATE OOES NOT AMEND, EXTEND OR
.1386 ALTi.:R THE COVERAGE AFFORDED BY neE POUCIES BELOW.
gwP _ cdeJker INSURERS AFFORDING COVERAGe
Ie LLC INS~ A:. ^rneMcan Home A$&urance COrtlpany
:; 500 INSURER 9:
INSORIOR C:
INSURER rr
INSURIOR E:
1,: i
i'I' l.i i
JU
'iiCF:HAM & SC
~
riOU5TON, 'rE;XAS 77251
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C'~0\tf"! C.A,STLEAiLANi
:e,C:::;,,::: ['~IV~, SUiT
066386-99-763
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.- :'." Q" INSURANC ; LISTeD I;lELOW HAVE BIi SN ISSUED TO THE INSURED NAMED ABOV!! FOR 'TtiE POUCY PEklOD INDICATED_ NOTWITHSTANDING ANY
. .,,,~' H,RM OR co \IDrrJON OF ANY CONTRAc:"r OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEJ{flfICA TE MA, Y ElE ISSUED OR MAY PERTAIN,
;.,.;"~;I'OROEO 3Y THE POLICIES DESCRIEED HeREIN IS SUBJECT TO l\LL THE TERMS. EXCLUSIONS AND CONDmONS OF SUCH POlICIES_
'\ e. . SHOWN lIIAY HAVE 8EeN REDUCEr) BY PAlO Cl.AJM5.
T'l'E 01" INSURAN':I; POliCY NUMIilER PQUCY EFFECTIVE PQLJCY EXPlRATlON UMrTS
ERAL UABILIl'Y GL45704S~ 01101/2004 01/01/2005 EACH OCClJRRENCE $ 1,000.000
COMMERCIAL GeNER.A L UAIlII.ITY AReDAMA~E(~on.ft~1 $ 100,000
ClAIMS IVIAtlE G ~ OCCUI'l MeO EXP (Anv ono Defeon) $ 5.000
, PERSONAL & ADV INJtI~y $ 1,000,000
-
~~ERAL AGG~liiGATE $ 2,000,000
<-'.--- -
:-:,: ..:.:-:: :':,.:'~ Ml PL.ES PER PRODUCT" - COMP/OP AGG $ ~,OOO,OOO
",-' ~, ,....; "RO- . ~-LOC
.. ,,"~~
T,". ,. :. ::.;C :'JAI!IUl'!' CA4575579 (AO:;) 0110112004 01/0112005 .
C~INED SINGLE UIIIIT 1,000,000
CA1468Ei05 (MA 0110112004 01/01/2005 (E;> :JCcldo.,ll $
,,,".:""A'J"TQ CA14B834!il Cl/A) 01101/~004 01/01/2005
~'YNEJ AUTOS CA4575580 (IX) 01/01/2004 01/0112005 8ODIL'r ~JURY
$
"'"'~!'-~:~D1..."~;=, N..rros (P&f ..,,",on)
",'1';:1: AVTOS IiIOOII. Y INJURY
(Por ~Clllenl) $
,()'~.cWNE[] AUTOS
PROPERTY DAMAGI; $
(per ilccldant)
GE UABIUTY AUTOONf.Y-EAACCIDENT $
, ANY A\JTO OTHliiR 1HAN EA ACC $
AUTDONLY: AGG i
,--"
_"T> ._- I;ACH OCCURRENCE $
.-. ~tA MS MADE AGGREGATE $
-
S
-~'=:::, ~:C7.'5t.E S
.~--~~~~~~~~ $
";::C~l:j=-~:;~0ON ~ III~ WC4SS1696 {CA; 01/0112004 01/01/2005 .,. WCSTAru- I IO.ll,l- $
"_::~':'=3 W.;I3I:"'1Y WC45S0237 (AO: .) 01/0112004 01/01/2005 EL EACH ACCIDEN'I' 1.000,000
$
E.L.. DISEASE - EA, EI\IPLOYJ;J $ 1,000,000
E.L DISEA.5E - POUCY UMIT $ 1.000,000
ER
T:, ;" CPE:RA11ONSlLQC ATIONSIVEHlC~CLUSlO~ S MlOEO BY ENDORSEMeNTJSPEClAl PROvISIONS
"r= :-C:'DER IS iNCLUDED AS AN ADDIT IONAL INSURED UNDER GENERAL AND AUTOMOBII.E LIABILITY POUCIIES WHI;;N REQUIREO 8Y
.-'".:-?i\CT SUT ONLY WITH Ri.:SPECT lO: COUNTRYSIOEJSUII814424
_.----
I ADDlllONALIP48UREO; I oIS~ LETTER:
CANCELLAlION
SHOUt.O PJ./Y OF THE ABOVE DESCRIBED POLICf5S SE CANCEl.1.5 D BEFORE
THE EXl'IRATION DATE THEReOF, THE ISSUING INSURER WII.L ENDEAVOR TO_
MAIL 30 DAYS WRITT!';N 1Il0TICE TO THIS CERTIFICATIi HOLDER Nf.MED TO THE
L.EFT, SUT FAILURe TO DO SO SHAl.llMf'OSE NO OBLIGATION OR LIABiliTY OF
ANY KIND UPON TH~ ISSUER. ITS AG~NTS OR R~PRESENTATrVe~,
AS5
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:.'>\"'S '-:OLDl;R
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CITY OF CLEARWATER
ATTN:EARL6ARRETT
! GENERAl. SERVICES DE~I RTMENT
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At1IllORlZI;D REPRESENT"'lTYE
JOHN L. WORTHAM & SON, L.P.
@ACORDCORPORATION 1988
DIIIH9-03
12 :42pm
From-John L Wortharr & Son LP
7135211951
T-269 P.002/002 F-964
c;"' ,," 068386-9 ~.763
CITY :JF CLEARWATER
IMPORTANT
:f the ce: tificete holder is an ~ OOITIONAL INSUREO, the policy{les) must be endorsed. A statement
:, ~~.;::; t :::rtificate does not confer rights to the cartlflcate holder in lieu of such endorsement(s).
If SUBROGA nON IS WAIVED, subject to the tenns and conditions of the policy, certain policies may
require ~ n endorscRU!nt. A st Itement on this ceJ1ifleate does not confer rights to the certificate
holder ir lieu of such endorse mentIs).
DISCLAIMER
T:~,~ Cert ficate of Insurance 011 the reverse side of this fonn does not constitute a contract between
the issui '9 insurer(s), authori;:ed representative or producer, and the certificate holder, nor does it
"fl'jrmatl' rely or negatively amI !nd. extend, or alter the coverage afforded by the policies listed thereon.
ACORD 2S..s (7197)