CERTIFICATE OF LIABILITY INSURANCE (70)
ACORD
CERTIFICATE OF LIABILITY INSURANCE
F DATE(MMI°DIY
YYY)
12/12/2008
08
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Wells Fargo Ina Services Southeast, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P O Box 31666 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
TampaFL 33631-3666 -
(727) 7.96-6666,
INSURERS AFFORDING COVERAGE
NAIC #
INSURED -- - INSURERA: Hartford Fire Insurance Com an 19682
Image One Corp dba INSURER B:
INSURER C:
6206 Benjamin Rd #301
INSURER D:
Tampa FL 33634
INSURER E:
L;UV tKAIaC,
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT
,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
MAY PERTAIN
,
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
TR DD'
?n
TYPE OF INAI)RANCF POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMIDDIYYI LIMITS
IABILITY EACH OCCURRENCE $ 1,000,000
GEN ERAL L
RCIAL GENERAL LIABILITY
21SBALI1614
1/1/2009
1/1/2010 DAMA E O RENTED
PREWSIES Eaoocurence
$ 300,000
A X COMME
?X OCCUR MED EXP (Any one person) $ 10,000
CLAIMS MADE
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
MIT APPLIES PER:
' PRODUCTS - COMP/OP AGG $ 2,000,000
L AGGREGATE LI
GEN
1 7 POLICY PRO- LOC
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $
2JUECLI4905 20QI9
/
'
l 1
-/1 2010 (Ea accident) 1,000,000
A X ANY AUTO L? I
?
1
'r
l ?
?
ALL OWNED AUTOS S r.r .._...._....?,a ---- BODILY INJURY $
AUTOS (Per Person)
SCHEDULED
X HIRED AUTOS I _ 200 .? j BODILY INJURY $
UTOS (Per accident)
X NON-OWNEDA
PROPERTY DAMAGE $
D (Per accident)
LEGI LATIV - AUTO ONLY - EA ACCIDENT $
- GA RAGE LIABILITY
OTHER THAN EA ACC $
ANY AUTO AUTO ONLY: AGG $
ILITY EACH OCCURRENCE $ 3,000,000
EXCESS/UMBRELLA LIAB
CLAIMS MADE 21SEALI1614 1/1/2009 1/1/2010 AGGREGATE $ 3,000,000
A X OCCUR
$
$
DEDUCTIBLE
X RETENTION $ 10,000
STATU- OTH- $
ND
TION 21WEQDII9811 1/1/2009 1/1/2010 X
ITS ER
WRY
-
A_ A
WORKERS COMPENSA
-
PLOYERS'-LIABILITY _
E.L. EACH ACCIDENT -
$ 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
E. L. DISEASE - EA EMPLOYE
$ 1,000,000
Ifyes,des-be under E. L. DISEASE-POLICY LIMIT $ 1,000,000
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS/ LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Florida statute mandates 10 day cancellation notice for nonpayment of premium.
CERTIFICATE HOLDER IS ADDITIONAL INSURED AS RESPECTS GENERAL LIABILITY
GtK I Wlt.A 1 r- 1'1ULUCR
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
CITY OF CLEARWATER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
ATTN: CITY CLERK
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
P O BOX 4748
REPRESENTATIVES.
CLEARWATER FL 33758 AUTHORIZED REPRESENTATIVE O?
A-^kI deoo
ACORD 25 (200910B)
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12/12/2006
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 (2001108)
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