CETIFICATE OF INSURANCE
COMPANIES AffOROtHG COVERAGES
Rodgers & Cummings, Inc.
P.O. Box 6600
Clearwater, Florida 33518
N"ME '-NO ADDRESS OF INSUMD
COtM'1>NY A
LETTER
COMI''''~Y B
LETTER
COMf'''NY C
LETTER
COMPANY 0
LETTER
COMPANY E
LETTER
Aetna Casualty & Surety
Ross Yacht Service, Inc.
279 Windward Passage
Clearwater, Florida 33515
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.
Limits of liability in Thousands ( 00)
OCC~~~NCE AGGREGATE
TYPE OF INSURANCE
GENERAL LIABILITY
A KJ COMI'REHENSIVE FORM
~ PREMISES-.-OPERATIONS
o EXI'LOSION AND COLLAf'SE
HAZARD
o UNDERGROUND HAZARD
[J PflODUCTS/COMPLETED
OPERATIONS HAZARD
KJ CONTRACTUAL INSURANCE
o Bf,OAD FORM PROPER:;YI
DAMAGE
o INDEPENDENT. CONT.RACTORS
KJ PERSONAL INJURY ,
AUTOMOBILE LIABILITY
o COMPREHENSIVE FOPM I
, [] OWNED
10 I
HIRED I
[J NONOWNEr;
, '
..-..-t-=-EX-CESSLTABiliTY~-I-
I L_j I}MBRELiA i
'.'[] "-.), r, 1-11 1'1 II'",," I'
! r':'?M
.-..".-"...------.--."'.- -..........-"-...-)
iWORKIERS' ':" OM f'EI\ISP,TION
,,;
. _ r__~iIfl!'~~:~~-':I.:>~..!..J{l)iUn_....L
, OTHER :
POLICY
EXPIRATION DATE
POLICY NUMBER
BODILY INJURY
$500
50
$ 500
50
*
PROPERlY DAMAGE
. $
23 AL 203679
9/30/78
BODILY INJURY AND
PROPERTY DAMAGE ~
I COM""," .
I ~ .Applles to Products/Completed
i-------i~-- fJODIl~IO:J~:~O:-~:d
I lEACH PERSUN) , $$
BODILY INJURY
,TACH OCCURRENCE)
--~~--------
I
"T - _n .-------
I
$
WER;-~(JN,.'\1.. INJURY)
_.__________-----1_________
1
I
Pl10PERTY DAMAGE $
r------- --- ------~-
I BODILY INJURY ANO '
I PROFERTY DAMAGE j $
L- --"--s.Q!~BINEQ __ _
I BODIlY'NJllf(l,r" I
I $
i
PliOc'IYTY
-
i . RECEIVED~
- _lIillWlllfi!ilillfiIlllilllMlilillil/lll!iiil~liIitillf~!!iililillJ4l1ll1ijjl!l!lltiff:!~iliRitHH"Hfi' iU~'HiHlll,mflli~~~~f~.i.
1~!liIttIBllhN'liIlDlIIJiIl!II_@lYillrllill_IIIII".UIII""---T
;.., ,< r nN<.: f ~~
DEe
1 1971
Additional Named Insured: City of Clearwater
Endorsement attached.
Cancellation'
;~T:Y:-~':
.U'CI any of '.h: JIJo','e described P:)!:Ci-2:, IHI cnlle')! !)E,fore q:'lla'i~11 <.I,d: (:-"II'I'::f !h':i n,
will ende:lVoI to maill.L cayo, wlltten IL'jl,cc :c:he belc\I, nm'Hl .::wl("cate h:,ldH, ()ut to
J ! such notice shalllmpOSEI:10 obllgatlo!\ or Ilabil'ty' cf ,my i(ln:j ucon IIle C'::mpany.
1N!,MG~~;,-,~:ODREs-sorCf_f~;r~(;j~- E HOt D[ R
City Clerk's Office
City of Clearwater
P.O. Box 4748
Clearwater, Florida
3351Fr
I' ~
fit;
'.1.11
.'1
~-
GllO
(Ed. ]-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 issued subsequent to preparation of policy.)
Endorsement effective 9/30/77 Policy No, 23 AL203679 Endorsement No.
~m~lmured Ross Yacht Service, Inc.
Additional Premium $
( U horized Representative)
ROOGERS & CUMMINGS, INC. AGENTS
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 LIABILITY INSURANCE
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
to the following additional provisiom:
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 damaee
(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.
Designation of State or Political Subdivision:
SCHEDULE
CITY Of CUMWATU
limits of Property Damage liability
$ JOG,OOO each occurrence
$ )00,000 aurecate
Annual Premium $
llECEIVE'O
DEe 1 1977
,~n CLERK
GllO (Ed, ]-66)
~
..