CERTIFICATE OF INSURANCE
COMPANIES AFFORDING COVERAGES
Rodgers & Cummings, Inc.
P.O. Box 6600
Clearwater, Florida 33518
COMF,P;" A
LETHf'
Aetna Casualty & Surety
Ross Yacht Service, Inc.
279 Windward Passage
Clearwater, Florida 33515
i:::(iMPA~n B
LETeER
CO~PA}l'f C
LE nEP
COMPA,NY 0
LETTER
. OCT 1 1980
AND ADDRESS OF INSURED
COMPANY E
LETTER
CITY ~LERK
This is to certify that pOlicies of insurance listed below have been issued to the insured named above and are in force at this time,
------~-~_r__----.------ +'~ --~~-;~~~--~, -,--:--- limits of liability inJ",-hOU~~, ,.ndsjpOO)
TYPEOF INSURANCE I POLICY NUMBER EXPIRATION DAfE i . ~ EACH T AGGREGATE
1-.-; GENERAL LIABILITY I -- -----l-- BOD~NJURY--- I ;CC~R;E~CE I $ 500*
A KJ COMPREHENSIVE FORM ,. 23 GL 121121 ' 9/30/81 i ! i
KJ F'f'EMISES.-OPERATIONS f ['RO['ERn IJAMAGE+'. $.. 100 I,. 1; ,.100
o EXPLOSION AND COLLAPSE
HAZARD l
o UNDERGROUND HAZAHD
fJ PfiODUCTS/COMf'LEHD
. OPERATiONS HAZAHD I' -~:)DIL~:~JRY AND I ------ .--
jlkJ CONTRACTUAL INSURANCF PROPERTY DAMAGE I $ 1>
. 0 BROAD FORM PfWpmTY COMBINED I
O DAMAGE \ I I _I _ I
. [] ~::(~~~:~E~t:J~:~~TR,^CTORS I [I_ f------~:APPli::-;O prod-:~~~-;:~----t$--5 00-
+ ! Operatlon5 Hazard.
i
- AUTOMOBILE LIABiLITY --r.llODIL;;.'1JlmY---T;--------
I I . (EACH PERSON) I
O 'I ' PROPERTY DAMAGE $
HIRED I
O BODILY INJURY AND --~'---'-'--
. NON.OWNED i i PROPERTY DAMAGE $
I
rl----- ~:~::::;::::::: I~__n_
COMBINED
------~------
EXCESS LIABILITY
[J UMBRELL.~ FORM
o OTHLRTHAN UMEmELLA
FOfiM
________.----L-
WORKERS' COMPENSATlONI
and
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERA TIONS/LOC A TIONSNEHICLES
It is a condition of this certificate that the City of Clearwater lS
an Additional Insured per endorsement attached.
Cancellation: Should any of the above described policies be cancelled be~ore the expiration dafe thereof, the iSSUing com-
pany wlli endeavor to mail -4-0- days written notice to the below named certificate holder, but failure to
mail such notice s'lail impose no obligation or liability of any kind upon the company.
I NAME ,\ND ,\,'URc:,S CERTIFIC t, 1'. .,OLDER
I City Clerk's Office
! City of Clearwater
I P.O. Box 4748
I Cle arwa ter, Florida 33518
I
I 9/29/80
I DATE ISSUED__m___________.~______.___.__._____
i Rod rs & Cummin Inc.
I
I
I
!
I
_J
L____________________.
~, ';.-.~~~
~. 'I '.-....:'
lID I GllO
(Ed. 7-66)
..,
This endorsement forms a part of the policy to which attached, effective on the inception date of the policy unless otherwise stated herein.
(The following information is required only when this endorsement is is'Sued subsequent to preparation of policy.)
Endorsement effective Policy No. Endorsement No.
Nametllnsured
:~
,;;
..
Additional Premium $
Cou ntersigned by
(Authorized Representative)
'"
This endorsement modifies such insurance as is afforded by the provisions of the policy relating to the following:
COMPREHENSIVE GENERAL LIABILITY INSURANCE
MANUFACTURERS AND CONTRACTORS LIABILITY INSURANCE
OWNERS AND, CONTRACTORS PROTECTIVE LIABILITY INSURANCE
OWNERS, LANDLORDS AND TENANTS UABILlTYINSURANCE
ADDITIONAL INSURED
(State or Political Subdivisions-Permits)
It is agreed that the "Persons Insured" provision includes as an insured any state or political subdivision thereof designated in the schedule below, subject
tothefollowing additional provisions:
1. The insurance applies only with respect to operations performed by or on behalf of the named insured for which the state or political subdivision
has issued a permit. .
2. The insurance does not apply to bodily injury or property damage
(a) arising out of operations performed for the state or municipality, or
(b). included within the completed operations hazard,
- 3. If the Property Damage liability Coverage is not otherwise afforded, such insurance shall nevertheless apply with respect to operations performed
by or on behalf of the named insured for which such permit has been issued subject to the limits of liability stated herein.
SCHEDULE
Designalion of State or Political Subdivision:
C In Of CLEARWATER
. limits u'Property Damile liabllity-"'.
$100 . 000 each otturrence
$ 100 . 000 aggregate
Annual Premium $ -I NCl
GllO (Ed,7.66)
The IEtna Casualty and Surety Company- ------- ------Cauntersigned by
The Sla!1dard Fire Insurance Company
Hartford, Connecticut
(Authorized Representative)
'(CC-50351 3.74
cAr. 349321
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