CERTIFICATE OF INSURANCE
DATE IMMIDDIVY)
01/23/03
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.
~ACORD
TM
CERTIFICATE OF LIABILITY INSURANCE
PRODUCER
ACORDIA EAST - TAMPA BAY
P.O. Box 31666
Tampa, FL 33631-3666
727-796-6666
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LC"
CI-Qrk ~ tl.:Jk
INSURED
INSURERS AFFORDING COVERAGE
AMERICAN STATES INSCO-09084
Clearwater Historical
Society
P. O. Box 175
Clearwater FL 33757-0175
COVERAGES
INSURER A:
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
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.
I~~: TYPE OF INSURANCE POLICY NUMBER ~OllCY EFFECTIVE Pgk!fFY/~J)~~JJ$~ LIMITS
A ~NERAL LIABILITY 01 CG1164932
X COMMERCIAL GENERAL LIABILITY
I CLAIMS MADE W OCCUR
1/20/03
1/20/04
~'L AGGRE~ LIMIT AP~ PER:
I POLICY I I j~9.;. I I LOC
A ~TOMOBILE LIABILITY 01 CG 1164932
ANY AUTO
1/20/03
1/20/04
-
f-- ALL OWNED AUTOS
_ SCHEDULED AUTOS
-.X HIRED AUTOS
-.X NON-OWNED AUTOS
-
GARAGE LIABILITY
=l ANY AUTO
EXCESS LIABILITY
=:J OCCUR D CLAIMS MADE
RDEDUCTIBLE
RETENTION $
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
...
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS AODED BY ENDORSEMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER IS NAMED AS AND ADDITIONAL INSURED WITH RESPECTS
TO GENERAL LIABILITY.
CERTIFICATE HOLDER
I X I ADDITIONAL INSURED; INSURER LETTER:
CANCELLATION
EACH OCCURRENCE $ 500000
FIRE DAMAGE IAny one fire) $ 200000
MED EXP (Anyone person) $ 10000
PERSONAL & ADV INJURY $ 500000
GENERAL AGGREGATE $ 500000
PRODUCTS. COMPIOP AGG $ 500000
COMBINED SINGLE LIMIT $ 500000
lEa accident)
BODILY INJURY $
(Per person)
BODILY INJURY $
IPer accident)
PROPERTY DAMAGE $
(Per accident)
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACe $
AUTO ONLY: AGG $
EACH OCCURRENCE $
AGGREGATE $
$
$
$
I WC STATU-.I 10TH-
TnRY LIMITS ER
E.L. EACH ACCIDENT $
E.L. DISEASE. EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ........1Q.. DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
CITY OF CLEARWATER
PARKS AND RECREATION DEPT
100 S MYRTLE AVE
CLEARWATER, FL 33756
REPRESENTATIVES. A
AUTHORIZED REPRESENTATI'jf _"
jfYlfJJ IJ
(/
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
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@ACORD CORPORATION 1988
- I
ACORD 25-S (7/97)
46-40
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.
ACORD 25-5 (7/97)