CERTIFICATE OF INSURANCE (7)
A COR~M
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDNY)
12129/2003
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
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
JOHN L. WORTHAM & SON, L.P.
P.O. BOX 1388
HOUSTON, TEXAS 77251-1388
068386-99-441
gwp - cdelker
INSURERS AFFORDING COVERAGE
INSURED
CROWN CASTLE ATLANTIC LLC
510 BERING DRIVE, SUITE 500
HOUSTON, TX 77057
INSURER A: American Home Assurance Company
INSURER B:
INSURER C:
INSURER D:
INSURER E:
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 MAYBE 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.
I~fl: TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
. -A.' . ~RAL'LIABILIT'/-"~ .. . .{iL4570453 . ... 01/0112004. ....... 01/01/20Q5- ., EACH OCCURRENCE $, 1 .000,000
tI COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anv one firel $ 100,000
I CLAIMS MADE W OCCUR MED EXP (Anv one Derson) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2 000,000
n'L AGGRnE LIMIT APnS PER: PRODUCTS. COMP/OP AGG $ 2,000,000
POLICY ~~1!T LOC
A ~TOMOBILE LIABILITY CA4575579 (AOS) 01/01/2004 01/01/2005 COMBINED SINGLE LIMIT $ 1,000,000
ANY AUTO CA 1468605 (MA) 01/01/2004 01/01/2005 (Ee accident)
A r-- CA 1468349 (VA) 01/01/2004 01/01/2005
A ~ ALL OWNED AUTOS CA4575580 (TX) 01/01/2004 01/01/2005 BODILY INJURY
$
A SCHEDULED AUTOS (Per person)
r--
..L HIRED AUTOS BODILY INJURY
$
~ NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
~GE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
~ESS LIABILITY EACH OCCURRENCE $
OCCUR D CLAIMS MADE AGGREGATE $
$
==J DEDUCTIBLE $
RETENTION $ $
A' f-woRKERS COMPENSATION AND WC4551896 (CA) ---, --'- ------ 01101/2004 .. OUOl/2005 " "J ~~!:,~!~T,l!.;.1 JOJ~' $.
EMPLOYERS' LIABILITY WC4550237 (AOS) 01/01/2004 01/01/2005 $ 1,000,000
A E.L. EACH ACCIDENT
E.L DISEASE. EA EMPLOYE $ 1,000,000
E.L. DISEASE. POLICY LIMIT $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER IS INCLUDED AS AN ADDITIONAL INSURED UNDER GENERAL AND AUTOMM" ... ..-...-, -~... UIRED BY
WRITTEN CONTRACT BUT ONLY WITH RESPECT TO: SITE: COUNTRYSIDE 1 BU#814424 'w ~ ~ ~ a w .~ ~
JAN I 2 2004
'-'
CERTIFICATE HOLDER I I ADDITIONAL INSURED' INSURER LETTER: CANCELLATION _
SHOULD ANY OF THE ABOV~~Idl!hYd)t~ EFORE
THE EXPIRATION DATE THE EO~l AVOR TO
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
THE CITY OF CLEARWATER FLORIDA ANY KIND UPON THE ISSUER, ITS AGENTS OR REPRESENTATIVES.
ATTN: EARL BARRETT, ENGINEERING DEPT.
P.O. BOX 4748 AUTHORIZED REPRESENTATIVE
CLEARWATIER, FL 33758-4748 JOHN L. WORTHAM & SON, L.P.
ACORD 25-S (7/97)
@ACORDCORPORATlON 1988
ACORD 25-5 (7/97)
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend, or alter the coverage afforded by the policies listed thereon.
RECEIVED
JAN J 3 2DD4
OFFICIAL RE
LEGISLATIVE CORDS AND
SRVCS DEPT