CERTIFICATE OF INSURANCE (9)
A CORD_
CERTIFICATE OF LIABILITY INSURANCE
OPID K
LANE-01 01 28
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.
04
PROo-.kER
The Addis Group, Inc.
2500 Renaissance Blvd. Ste 100
King of Prussia PA 19406-2772
Phone: 610-279-8550 Fax:610-279-8543
INSURED Lane Industries, Inc.
Lane Hospitality, Inc.
Hospita11ty Investment Assoc.
Lane Hotel Investments II, L.P
One Lane Center
1200 Shermer Road
Northbrook, IL 60062
INSURERS AFFORDING COVERAGE
INSURER A:
INSURER B:
INSURER C:
INSURER D:
INSURER E:
American Zurich Insurance Co.
NAIC#
40142
26247
24767
American Guarantee & Liability
St. Paul Fire and Marine
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,
LTR NSRt TYPE OF INSURANCE POLICY NUMBER PD~';!~jJ~rJ5,w;E P~k~CEY(~~b~~~N LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,'000,000
r--
A X COMMERCIAL GENERAL LIABILITY GL06847038 03/01/04 03/01/05 ~~E\G;S~S (Ea occurence) $ 500,000
r-- :=J CLAIMS MADE [!] OCCUR
MED EXP (Anyone person) $ 10,000
r--
X EMP BENEFITS PERSONAL & ADV INJURY $1,000,000
r--
~ LIQUOR LIAB GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000
n n PRO- !Xl LOC
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
r-- $1,000,000
B X ANY AUTO BAP6847040 03/01/04 03/01/05 (Ea accident)
r--
~ ALL OWNED AUTOS BODILY INJURY
$
X SCHEDULED AUTOS (Per person)
r--
~ HIRED AUTOS BODILY INJURY
$
X NON-OWNED AUTOS (Per aceldent)
r--
I-- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
q ANY ~UTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $25,000,000
C ~ OCCUR D CLAIMS MADE QK09000414 03/01/04 03/01/05 AGGREGATE $25,000,000
$
=] DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X TS'~/~I~:f'S I IU~~-
A EMPLOYERS' LIABILITY WC06847039 03/01/04 03/01/05
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1,000,000
-- If yes, describe under -- --- -- ~,.- -.-..,---- --, "',' -- --- ~-~"- ECUlSEASE':~ODCYllMIT ' $I;-OUO ,000 u', u
SPECIAL'PROVlSlONS below
OTHER
B Automobile BAP6847040 03/01/04 03/01/05 ~-Lre-d: $250
Physical Damage i r-~o~). 'Ded: ' ,.. $500
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS \' " ) r
For operations and activities of the licensee DBA Holiday Inn Sun Sp~ ~~,\ ,
,
located upon the property more fully described in the license agreeme 1" '~- 9 i
effective 10/1/96. Certificate Holder is recognized as additional in ~\uJl d. \
J
- J
- f.~\"'T[R
"\lBlI~I~OWK~\,D~\;NISTRATI( '.
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Real Estate Services
ATT: Earl Barrett
P.O. Box 4748
Clearwater, FL 33758-4748
CLEAR -1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAlL 30 DAYS WRITTEN
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.
AU~~EN~E. (.,J ~
@ACORD CORPORATION 1988
ACORD 25 (2001/08)