CERTIFICATE OF LIABILITY INSURANCE (14)From: SANDRA VOSS At: BOUCHARD INSURANCE, INC FaxID: To: Attu Earl Barrett
Date 2/3/2009 11:49 AM Page: 2 of 3
E VE $ DATE(MMlDDO1 02/03/09
OP ID ?
ACORD CERTIFICATE OF LIABILITY INSURANCE srLV
/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Bouchard-Clearwater ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
101 Starcrest Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P O Box 6090 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Clearwater FL 33758-6090
Phone:727-447-6481 Fax:727-449-1267 INSURERS AFFORDING COVERAGE NAIC#
INSURED m_ ',IJ._,IFEP H. auto-owners Insurance Company 18988
INS JF ER B. .__......,.._?
Silver Dollar Trap Club Inc rsJJRER
16316 Patterson Rd
.r„r. „ ------ -- - _?_.. - -- -
Odessa FL 33556 _-
IrJSJF'EP. E
OVERAGES
THE POLICIE^ OF II1ISQRANCE LISTED BELOW HAVE BEEN ISSUED TO THE IN.SL IRED NAMED ABC,VE FF?P `IE P'OLIC'Y PERIOD INDICATED NOTWITHISTAIJDI IG
AMY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT Tn ?:HI _-1 I HIS CkkI IFICATE MAY BE ISSUED OR
MAY PEK'LnIN, THE INSURANCE AFFORDED 9Y THE POLICIES DESCRIBED HEREIN 18 SUBJECT T(-- ALL THE TERMS, E)ICLL l SIONS AND CONDITIONS -,F SUCH
POLICIES AGGREGATE LIMITS SM=IWH MA'f HAVE BEEN RFDLJCFD nY PAID CLAIMS
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDIYY) DATE (MM/DDIYY) LIMITS
GENERAL LIABILITY EACH CA. CU; PENCE :F 1000000
A X X COMMERCIAL GENERALLIABIL11Y 20693662 01/29/09 01/29/10 PR'.=MI3[SfC?oc.r.,i1r?nte) F 300000
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CLAIMS MADE ? OCCUR
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MED E-'.P (An I r,,ne peg 3,1n)
t 10000
PERS_
AL aov u.,'uR'r F 1000000
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Hired/nonowned au I CEPIEF'ALAGC,PEGATE :f3000000
GEI`I'L A.GC RELATE LIMIT APPLIEc PER.
i
PROD_ICTS - COMI?IOP Al I
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:6 3000 000
PRO-
X POLICY JECT LOC _ ._.
AUT OMOBILE LIABILITY
rOMFINED 1,6,-,LE DIAT
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r) 'F1000000
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------ ANYAUTIJ 4703500300 11/19/08 11/19/09 ,
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ALL OVVIVED HIS 102 - -- -------- --
BODILY INJIIFY
SCHEDULED AUTOS IPer;:;rsco)
I IIR'CD AUT05
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NON-OVVIdEGAUTO:Z (Pei a_cidenl) {
PROPERTY GIf?JGE
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GAR AGE LIABILITY
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EXCESS/UMBRELLA LIABILITY FACIIOCCI1FR'I-7NCE :F
OCCUR CL41`AS MALE AG?F9 ,A E :f
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WORKERS COMPENSATION AND
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DESCRIPTION OF OPERATIONS I LOCATIONS 'VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
re: vacant land - part of the Southeast 1/4 of Section 19, Township 27
south, Range 17 East Hillsborough County, FL.
CERTIFICATE HOLDER IS ADDITIONAL INSURED WITH RESPECTS GENERAL LIABILITY
SUBJECT TO THE TERMS, CONDITIONS AND EXCLUSIONS OF THE POLICY.
Fax: 727-562-4755
CERTIFICATE HOLDER CANCELLATION
City of Clearwater
Attn Earl Barrett
Engineering Department
PO Box 4748
Clearwater FL 33758-4748
CITYCLW SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $O SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
+wnv cu I/Vu IJUC( O ACORD CORPORATION 1988
From, SANDRA VOSS At. BOUCHARD INSURANCE, INC FaXID: To: Ath Earl Barrett Date: 2!3/2009 11:49 AM Page: 3 of 3
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 riot confer I ights 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 (200110U`