CERTIFICATE OF INSURANCE (6)
Roger Bcuchard I nsurance, Inc.
P. O. Box 6090
Clearwater, Florida 33518
COMPANIES AFFORDING COVERAGES
Decade, .Inc. d/b/a Ti II ie O'Toole's
519 Cleveland Street
C I ear w ate r, F lor i d a 33 5 I 6
COMPANY A
LETTER Travelers Insurance
COMPANY B
LETTER
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C .01" L_ ....4 i:.....
COMPANY
LETTER
COMPANY 0 \ i\c) r(' 1979
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LETTER
COMPANY E
LETTER GiTY CL~
NAME AND ADDRESS OF 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,
Limits of Liability in Thousands (000)
'~-EACIi_ n - AGGREGATE--
,- - OCCURRENCE
TYPE OF INSURANCE
POLICY NUMBER
POLICY
_ EXP!RATLON DATE
GENERAL LIABILITY
A
Q COMPREHENSIVE FORM
Q PREMISES-OPERATIONS
o EXPLOSION AND COLLAPSE
H AZA RD
o UNDERGROUND HAZARD
Q PRODUCTS/COMP1"ETEO
OPERATIONS HAZAReJ
o CONTRACTUAL INSlmANCE
o BROAD FORM PROPERTY
DAMAGE
Q INDEPENDENT CONTRACTORS
Q PERSONAL INJURY
BODILY INJURY
$
$
PROPERTY DAMAGE
$
650 725E005 A I NO 79
2-14-80
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
$500
$ 500
PERSONAL INJURY
AUTOMOBILE LIABILITY
o COMPREHENSIVE FORM
DOWNED
o HIRED
o NON.OWNED
BODILY INJURY
(EAC H PERSON)
BODILY INJURY
(EACH ACCIDENT)
$
EXCESS LIABILITY
PROPERTY DAMAGE
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
o UMBRELLA FORM
o OTHER THAN UMBRELLA
FORM
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
WORltERS'-CQMPENSi\IIOJ.jL
and
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERATlONS/LOCATIONSNEHICLES
City of Clearwater is an additional insured as respects the sidewalk
right-of-way on Cleveland Street.to the curb.
Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing com-
pany will endeavor to mail --1...0..- 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
Building Dept. City Hall Annex
10 South Missouri Avenue
Clearwater, Florida 33516
DATE ISSUED:
3-20-79
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