INSURANCE AND MEMO
TO:
FROM:
COPIES:
I
Lucille Williams City Clerk
Ream Wilson, Director, Parks and Recreation
Cl1fY OF CLEARWATER
Interdepartment Correspondence Sheet
y
SUBJECT: Certificate of Insurance - st. Petersburg Junior College
DATE:
June 20, 1980
Attached is a certificate of insurance we recently received from
St. Petersburg Junior College. Please attach this certificate to
the lease between the City of Clearwater and the Junior College for
the joint use of facilities.
Please contact me if you have any questions.
RW:pp
Attachment
RECE\VED
JUN 23 1980
CITY CLERK
) C'
NAME AND ADDRESS OF AGENCY
Gallagher Bassett Insurance Service
3118 Gulf to Bay Blvd. Suite 120
Clearwater, Florida 33515
COMPANIES AFFORDING COVERAGES
NAME AND ADDRESS OF INSURED
St. Petersburg Junior College
Fla. Comm.' College Risk Management Consortium
Santa Fe Community College
P. O. Box 1530
Gainesville, FL 32602
COMPANY A
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY 0
LETTER
COMPANY E
LETTER
Qualified Self Insured
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, 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.
TYPE OF INSURANCE
POLICY NUMBER
POLICY
EXPIRATION DATE
GENERAL LIABILITY
BODILY INJURY $
[Ja COMPREHENSIVE FORM
[Ja PREMISES~OPERATIONS
o EXPLOSION AND COLLAPSE
HAZARD
o UNDERGROUND HAZARD
o PRODUCTS/COMPLETED
OPERATIONS HAZARD
[Ja CONTRACTUAL INSURANCE
o BROAD FORM PROPERTY
DAMAGE
o INDEPENDENT CONTRACTORS
Q PERSONAL INJURY
Self insurer as per State
of Florida Statute
Chapter 768.28 and 111.07
PROPERTY DAMAGE $
$
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BODIL Y INJURY AND
PROPERTY DAMAGE $
COMBINED
PERSONAL INJURY
$
AUTOMOBILE LIABILITY
o COMPREHENSIVE FORM
DOWNED
o HIRED
o NON,OWNED
BODILY INJURY
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT)
$
PROPERTY DAMAGE
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
$
EXCESS LIABILITY
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
o UMBRELLA FORM
o OTHER THAN UMBRELLA
FORM
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERATIONS/LOCATlONSNEHICLES
PURPOSE: Use of swimming pool for physical education program located at Morningside
Recreation Complex
Cancellation: Should any of the above described policies be cancelled before the expiration date thereof. the issuing com-
pany will endeavor to mail --3..Q.... days written notice to the below named certificate holder. but failure to
mail such notice shall impose no obligation or liability of any kind upon the company,
NAME AND ADDRESS OF CERTIFICATE HOLDER:
City of Clearwater
Parks and Recreation
P. O. Box 4748
Clearwater, Florida
ATTN: Mr. Ream
Department
Wilson
Director 'f)