CERTIFICATE OF INSURANCE (046)
"1 ~rrtif::tr ~; ]n~:rant: J:~ise:' cer: of :;20/8~!l~i
THIS IS TO CERTIFY that the company indicated by an "X" has issued the policy or pOlicies described below, The insurance afforded is only with respect to the
coverages indicated by specific limits of liability and this certificate of insurance neither affirmatively nor negatively amends, extends nor alters the coverage
afforded by any policy described herein, ~
"This certificate or verification of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policies listed herein.
Notwithstanding any requirement, term, or condition of any contract or other document with respect to which this certificate or verification of insurance 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,"
NAMED INSURED and ADDRESS
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T.C. Structures Inc.
12405 - 49th St.
jGlearwater,Fl 33520
DESCRIPTION OF OPERATIONS
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~ WOHl"S' COM...SATIO'
~ OTHER.
KIND OF INSURANCE
GENERAL LIABILITY
o Comprehensive Form
o Premises-Operations
o Products/Completed
Operations
o Contractual
o Independent Contractors
o Personal Injury
AUTO L1AB I L1TY
o Comprehensive
DOwned
o Hired
o Non-Owned
~ Specified
UMBRELLA
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o THE OHIO CASUALTY INSURANCE COMPANY
o AMERICAN FIRE AND CASUALTY COMPANY
:KJ WEST AMERICAN INSURANCE COMPANY (PORTION ONLY)
CERTIFICATE ISSUED TO
NAME and ADDRESS
1
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City of Clearwater
P. O. Box 4748
~arwater, Fl 33518
LOCATION OF OPERATIONS
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LIMITS OF LIABILITY
EACH OCCURR.
000
$
AGGREGATE
000
COVERAGE
BODILY INJURY
$
000
PROPERTY DAMAGE
$
000
COMBINED SINGLE
LIMIT
$
000
000
$
4/2$/$4-85
Personal Injury
BODILY INJURY
,000 Each person
,000 Each accident
$
PROPERTY DAMAGE
,000 Each accident
ACW 9646349
,000,000 Single Limit
$
25
$
,000 Each accident
$
COMPENSATION -STATUTORY -STATE(S)
Employers' Liability - $
LIMITS OF LIABILITY
BODILY INJURY PROPERTY DAMAGE
In the event of cancellation of these policies written notice will be mailed to the party to whom this Certificate is issued but no responsibility is assumed by reason
of any failure to do so,
DATE: 21?5/R5/mp
7i Form L-604b Rev, 4-83
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ByCOmegys Insurance Agency
AUTHORIZED REPRESENTATIVE
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