CERTIFICATE OF INSURANCE (10)
A80RDN
CERTIFICATE OF LIABILITY INSURANCE
OP ID C1 DATE (MMlDDIYYYY)
LANE-01 01 25 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
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 Indus tries, Inc.
Lane Hospitality, Inc.
Hospital1ty Investment Assoc.
Lane Hotel Investments II, L.P
One Lane Center
1200 Shermer Road
Northbrook, IL 60062
INSURERS AFFORDING COVERAGE
St. Paul Fire and Marine
NAIC#
40142
26247
24767
INSURER A:
INSURER B:
INSURER C:
INSURER D:
INSURER E:
American Zurich Insurance Co.
American Guarantee & Liability
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 NSR[ TYPE OF INSURANCE POLICY NUMBER DATE iriM/68,wj" I ,]lTE (MMlDDIVVj" LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
~
A X COMMERCIAL GENERAL LIABILITY GL06847039 03/01/05 03/01/06 PREMISES YE~~~~~~nce) $ 500,000
, ", , " --tCLAfMSMADE" ~'OCCUR- 1--,- .---,,--- ---,-. .- -- -. --,- ------- MEt} !:XP tp.nyone-person)'- -$ 10,000 ,
~ EMP BENEFITS PERSONAL & ADV INJURY $ 1,000 r 000
~ LIQUOR LIAB GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000 r 000
"I n PRO- rxl
POLICY JECT X LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
~ $1,000,000
B ~ ANY AUTO BAP6847041 03/01/05 03/01/06 (Ea accident)
~ ALL OWNED AUTOS BODILY INJURY
$
~ SCHEDULED AUTOS (Per person)
~ HIRED AUTOS BODILY INJURY
$
~ NON-OWNED AUTOS (Per accident)
~ PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
~ ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $25,000,000
C ~ OCCUR D CLAIMS MADE QK09000414 03/01/05 03/01/06 AGGREGATE $25,000,000
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND X ITO~Y"LI~:+'S I IO_TH-
ER
Ae, _~I'L.()'(ERS' L~E1IL~T!..._ - -,----,------ WCfr6S 4 7i14iT------ -'6'3jVl/05- - 03iO~- EL EACH ACCIDENT-'c:" Tl;'Oo-O rO 0 0
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERlMEMBER EXCLUDED? E,L. DISEASE - EA EMPLOYEE $ 1,000 r 000
If yes, describe under E.L DISEASE - POLICY LIMIT $lrOOO,OOO
SPECIAL PROVISIONS below
OTHER
B Automobile BAP6847041 03/01/05 03/01/06 Comp Oed: $250
Physical Damaqe ColI Oed: $500
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
For operations and activities of the licensee DBA Holiday Inn Sun Spree
located upon the property more fully described in the license agreement
effective 10/1/96. Certificate Holder is recognized as additional insured.
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 MAIL ~ 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~~EN2.5E. c-J ~
@ACORD CORPORATION 1988
ACORD 25 (2001/08)