CERTIFICATE OF LIABILITY INSURANCE (2)
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CERTIFICATE OF LIABILITY INSURANCE
DATE IMMIDDNY)
03/28/05
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
Acordia Southeast, Inc.
P.O. Box 31666
Tampa, FL 33631-3666
727-796-6666
INSURERS AFFORDING COVERAGE
INSURED
INSURER A:
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
AMERICAN STATES INS CO-09084
Clearwater Historical
Society
P. O. Box 175
Clearwater FL 33757-0175
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 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~i': TYPE OF INSURANCE POLICY NUMBER ~<i~~r.J~5~'R.~~ PgklfFY EXPIRATION LIMITS
A ~NERAL LIABILITY 01 CG 1164934 1/20/05 1/20/06 EACH OCCURRENCE $ 500000
~ 3MMERCiAL GENERAL LIABILITY FIRE DAMAGE (Anyone fire) $ 200000
f-- CLAIMS MADE W.oCCUR MED EXP (Anyone person) $ 1 0000
PERSONAL & ADV INJURY $ 500000
GENERAL AGGREGATE $ 500000
,
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 500000
h POLICY -h ~~9~ n LOC
A ~TOMOBILE LIABILITY 01CG1164934 1/20/05 1/20/06 COMBINED SINGLE LIMIT
(Ea accident) $ 500000
f-- ANY AUTO
f-- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
f--
~ HIRED AUTOS BODILY INJURY
$
~ NON.OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
RRAGE LIABILITY AUTO ONLY, EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
O'OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I T"'6~;I~Ns I 10TH.
ER
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
E.L. DISEASE - POLICY LIMIT $
OTHER
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DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS .
CERTIFICATE HOLDER IS NAMED AS AN ADDITIONAL INSURED WITH RESPECT
TO GENERAL LIABILITY. \<\ ~j< ).'ij \J ~~J
CERTIFICATE HOLDER I X I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF CLEARWATER DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL -1.Q.. DAYS WRITTEN
PARKS AND RECREATION DEPT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
100 S MYRTLE AVE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
CLEARWA TER, FL 33756 REPRE4ENTATIVES. ^
AUT~D 1nlVE .IL
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ACORD 25-S (7/97) 46- 56 \ @ACORD CORPORATION 1988
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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(sl, 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-S (7/97)