CERTIFICATE OF LIABILITY INSURANCE (83)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYYYY)
09/24/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Suncoast Insurance Associates ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 22668 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tampa, FL 33622-2668
813 289-5200 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Phoenix Insurance Company 25623
Advanced Systems Engineering, Inc. INSURER B: Travelers Indemnity Company 25658
13555 Automobile Blvd. INSURER c: Travelers Casualty and Surety Co 19038
Suite 330 INSURER D: XL Specialty Insurance Company 37885
Clearwater, FL 33762 INSURER E:
Client#. 5955
ADVASYS3
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 TYPE OF INSURANCE POLICY NUMBER PJ>..t~~~9~~~8mIE P~~i:/~~~N LIMITS
A ~NERAL LIABILITY 6606851L26A 10102/08 1 0/02/09 EACH OCCURRENCE $1.000 000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1.000.000
I CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $10000
PERSONAL & ADV INJURY $1 000.000
GENERAL AGGREGATE $2 000 000
n'L AGGREffl LIMIT APPlS PER: PRODUCTS-COM~OPAGG $2 000 000
POLICY X jr8;: LOC
B ~OMOBILE LIABILITY BA4883L691 08/17/08 08/17/09 COMBINED SINGLE LIMIT
ANY AUTO ~ECEIVI 0 (Ea accident) $1,000,000
I--
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS r-r-"') ').... 200 (Per person)
-
!.- HIRED AUTOS '-_I """....., BODILY INJURY
$
1L NON-OWNED AUTOS (Per accidenl)
- OFFI( IAL RECORm AND PROPERTY DAMAGE $
1"-" . -.. .- CD\/f""C I"\I::DT (Per accident)
I ",r..I'
~AGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B :i]ESS/UMBRELLA LIABILITY CUP6849Y191 08/17/08 08/17/09 EACH OCCURRENCE $5 000 000
X OCCUR D CLAIMS MADE AGGREGATE $5 000 000
$
:;:1 DEDUCTIBLE $
X RETENTION $ 10000 $
C WORKERS COMPENSATION AND .. - UB6848Y20108 08/17/08 08/17/09 X I T~~\~:r~;,~~ I IOJ~-
EMPLOYERS' LIABILITY $500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $500 000
If yes, describe under $500,000
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT
D OTHER Professional DPR9611360 03/10/08 03/10/09 $2,000,000 per claim
Liability $2,000,000 annl aggr.
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Professional Liability is claims made and reported.
Certificate holder is listed as an additional insured with respects to
General Liability, Auto Liability and Excess Liability policies on a
primary and non-contributory basis. Waiver of Subrogation in favor of the
(See Attached Descriptions)
CERTIFICATE HOLDER
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 -30...- DAYS WRITTEN
Attn: City Clerk NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
PO Box 4748 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Clearwater, FL 33758-4748 REPRESENTATIVES.
A~ED REPRESENTATIVE
. ~ ~Ql..A -
ACORD 25 (2001/08) 1 of 3
#M172586
KEB
@ ACORD CORPORATION 1988
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(s), 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 25-5 (2001/08) 2 of 3
#M172586
aSSORI
additional insured applies to the General Liability, Auto Liability,
Excess
Liability and Workers Compensation policies.
AMS 25.3 (2001/08)
3 of3
#M172586
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