CERTIFICATE OF INSURANCE ADDITIONAL INSURED ENDORSEMENT TO CITY
Lancaster Insurance Inc
POBox 2856
Clearwater, FL 33517
THIS CERTFlCATE IS ISSUED AS A MAtTER OF INFOMIATION ONLY AND CONFERS
NO NGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND,
EXTEND OR Al TEA TIE COVERAGE AFFORDED BY THE POlICIES BELOW.
COMPANIES AFFORDING COVERAGE
COMPANY A
~R Hartford Ins Co of the Southeast
INSURED
Robert J Burnside CLU & Assoc Inc
319 South Garden Ave
Clearwater, FL 33516
COMPANY.
lETTER
lJ""
COMPANY C
lETTER
COMPANY D
lETTER
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/lJO/YY) DATE (MMlDD/YY)
GENERAL LIABILITY
X COMPREHENSIVE FORM
PREMISEs/OPERATIONS
UNDERGROUND
EXPLOSION & COLLAPSE HAZARD
PRODUCTs/COMPLETED OPERA liONS
CONTRACTUAL
INDEPENDENT CONTRACTORS
BROAD FORM PROPERTY DAMAGE
PERSONAL INJURY
2lSBAPH1587
12/25/84 12/25/85
~~~:~~TY $
$
AUTOMOBILE liABILITY
ANY AUTO
ALL OWNED AUTOS (PRIV PASS.)
ALL OWNED AUTOS (OTHER THAN)
PRIV. PASS.
HIRED AUTOS
NON-OWNED AUTOS
GARAGE LIABILITY
BI & PD $1-,000, $ 1,000 ,
COMBINED PERSONAL INJURY $
BOIJIlY $
INJURY
(Pl'R Pl'RSON)
OCXJllY
INJURY $
(Pl'R ACCIDENT)
PROPERTY $
DAMAGE
BI & PD $
COMBINED
BI & PD $
COMBINED
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS' COMPENSATION
AND
EMPLOYERS'LIABlLlTY
(EACH ACCIDENT)
(DISEASE-POLICY LIMIT)
(DISEASE-EACH EMPLOYEE)
OTHER
DESCRIPTION OF OPERA TIONSllOCA TIONSlVEHIClESlSPECIAl ITEMS
Additional Insured endorsement to: City of Clearwater
City of Clearwater
POBox 4748
Clearwater, FL 33518