CERTIFICATE OF LIABILITY INSURANCE (97)Client#: 14106
AVRFCACRn
ACORD- CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DWYYY
n
01
/13109
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
WAUSAU SIGNATURE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PO BOX 8017 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
WAUSAU, WI 54402-8017
715 845-5211 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: Wausau Underwriters Insurance CO. 26042
AYRES ASSOCIATES INC INSURER B: Employers Insurance Company of Wausa 21458
PO BOX 1590
INSURER C:
EAU CLAIRE, WI 54702-1590
INSURER D:
INSURER E:
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.
LTR NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE
DATE (MMOD/YY) PODATE M PIRATION
MMD LIMITS
A GENERAL LIABILITY YYJY91503188069 01/01/09 01/01/10 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
Z&occurrence) $300,000
CLAIMS MADE F 7X OCCUR ..
MED EXP (Any one person) $5,000
PERSONAL & ADV INJURY $1.000.000
GENERAL AGGREGATE s2
000
000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG ,
,
$2 000 000
POLICY PRO-- LOC
AUTOMOBILE LIABILITY ASJY91603188029 01/01109 01/01/10
X ANY AUTO COMBINED SINGLE LIMIT
Ea accident)
$1,000,000
ALL OWNED AUTO S
J°
BODILY INJURY
$
SCHEDULED AUTOS (Per person)
X HIRED AUTOS X 2 O 2009
X
NON-OWNED AUTOS BODILY INJURY
(Per accident)
$
- 1
--_--. ---- - PROPERTY DAMAGE
(Per accident)
GAR AGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO EA ACC
OTHER THAN S
AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY THCY91503188039 01/01/09 01/01/10 EACH OCCURRENCE $5 000 000
X OCCUR FICLAIMS MADE AGGREGATE $5,000,000
DEDUCTIBLE $
X RETENTION $ 10000 $
A WORKERS COMPENSATION AND
' WCJY91503188049 01/01/09 01/01/10 X I TORY WC LIMIT FR
EMPLOYERS
LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E.L. EACH ACCIDENT
$100000
OFFICERIMEMBER EXCLUDED7
If
d
ib
d E.L. DISEASE - EA EMPLOYEE $100,000
yes,
escr
e un
er
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
$500,000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
PROJECT: CITY OF CLEARWATER, 2003 ENGINEER OF RECORD CONTACT.
CITY OF CLEARWATER IS INCLUDED AS ADDITIONAL INSURED UNDER THE GENERAL
LIABILITY POLICY PER GLO566 AND AS LIMITED INSURED UNDER THE AUTO PER
CA2048.
1..1411114CLLA I Ium
CITY OF CLEARWATER
PO BOX 4748
CLEARWATER, FL 33758-4748
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL %Q_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Aa, %jnu ca k4vv Irwi) 1 OT Z #5541112/M538061 ME1 O 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-S (2001/08) 2 012 #S541112/M538081