CERTIFICATE OF INSURANCE (220)
This is to Ce .
~ I ca eo nsurance
THIS CERTIFICATE IS ISSUED AS A MATTER OF I . ORMATION ONLY AND CONFERS NO RIGHTS UPON yeJ THE CERTIFICATE HOLDER. THIS
CERTIFICATE IS NOT AN INSURANCE POLICY A. DOES NOT AMEND, EXTEND, OR ALTER THE COVERAtE AFFORDED BY THE POLICIES LISTED
BELOW,
EIVED
Name and OCT" 2 -- 11
address of ~LIBER1Y.
Insured arr GII&' Ir8'IMUfUAL"
that
THE SALVA nON ARMY
1424 NORTHEAST EXPRESSWAY
ATLANTA, GA 30329
is, at the issue date of this certificate, insured by the Company under the policy(ies) listed below. The insurance afforded by the
listed policy(ies) is subject to all their terms, exclusions and conditions and is not altered by any requirement, term or condition of
. h f b' d
any contract or other document with resoect to whlc this certi Icate mav e Issue
ERTIFlCATE EXP. DATE
TYPE OF POLICY * 0 CONTINUOUS POLICY NUMBER LIMIT OF LIABILITY
o EXTENDED
m POLICY TERM
Coverage Afforded Under we EMPLOYERS LIABILITY
law of the FollowinQ States:
10/01/96 WA 1-65D-004052-275 AL AR DC FL GA Bodily Injury By Accident Each
- ..- WORKERS--- .. --- - -.------ --f---- --- - KY LA MDMSNC- $1,000,000 _ .__.. ....._. ~ccident_
1-
COMPENSATION OKSCTNTXVA Bodily Injury By Disease Policy
$1,000,000 Limit
Bodily Injury By Disease Each
$1,000,000 Person
GENERAL LIABILITY General Aggregate-Other than Prod/Completed Operations
$5,000,000
o CLAIMS MADE Products/Completed Operations Aggregate
$500,000
I RETRO DATE t 10/01/96 RG2-651-004052-285 Bodily Injury and Property Damage Liability Per
$500,000 Occurrence
Personal and Advertising Injury Per Person!
IKI OCCURRENCE Organization
, Other: I Other:
AUTOMOBILE 10/01/96 AS2-651-004052-295 $500,000 Each Accident - Single Limit -
LIABILITY B. I. and P. D, Combined
IKI OWNED Each Person
IKI NON-0WNED Each Accident or Occurrence
IKI HIRED Each Accident or Occurrenc'e
OTHER
.... .. . .. -- 1<- -~---,-- -- --
ADDITIONAL COMMENTS
The Salvation Army Clearwater I FL - Temporary Overnight Shelter At: 1120 N. Betty
Lane
I.....
I,
:1
I'
*IF THE CERTIFICATE EXPIRATION DATE IS CONTINUOUS OR EXTENDED TERM, YOU Will BE NOTIFIED IF COVERAGE IS TERMINATED OR REDUCED
BEFORE THE CERTIFICATE EXPIRATION DATE, HOWEVER, YOU WILL NOT BE NOTIFIED ANNUALLY OF THE CONTINUATION OF COVERAGE,
SPECIAL NOTICE - OHIO: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER,
SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD,
NOTICE OF CANCELLATION: (NOT APPLICABLE UNLESS A NUMBER OF DAYS IS liberty Mutual
ENTERED BelOW,) BEFORE THE STATED EXPIRATION DATE THE COMPANY WILL NOT Insurance Group
CANCEL OR REDUCE THE INSURANCE AFFORDED UNDER THE ABOVE POLICIES UNTIL ~
UNTIL AT LEAST 30 DAYS NOTICE OF SUCH CANCELLATION HAS BEEN MAILED TO:
- . .~
CERTIFICATE City Of Clearwater AUTHOR~ REPRESENTATIVE
HOLDER 112 South Osceola Avenue LINDA F, CHILDS
Clearwater, Florida 10/1/95
DATE ISSUED
NORCROSS
OFFICE
This certificate is executed by LIBERTY MUTUAL INSURANCE GROUP as respects such ipsurance as is afforded by Those Companies
BS 772R6