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CERTIFICATE OF LIABILITY INSURANCE (9)ACOPDCERTIFICATE OF LIABILITY INSURANCE °ATE,MMIDD/YYY"' z/9/aoo9 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Wells Fargo Ins Services Southeast, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Po Sox 31666 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Tampa FL 33631-3666 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. (727) 796-6666 _ INSURERS AFFORDING COVERAGE NAIC # INSURED INSURERA: Zurich American Insurance Comp 16535 Chi Chi Rodriguez Youth Foundation, Inc. INSURER B: Zenith insurance Com an 13269 3030 McMullen Booth Road INSURER C: Clearwater FL 33761 INSURER D: INSURER E: CnVFRAnFR 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. - - TN $ R LTR DD'L INSRD TYPE OE ItIAMANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY CP03793718-06 f j9 F.2`/,1/2010 PREMISES Ea occurenc $ 11000,000 F 7 :. ' GLAIMS.MADE. OCCUR X . MEDEXP(Any Oneperson) $ 5.,.0.00 - ? PERSONAL BADV INJURY $ 11000,000 f 20 - . GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000 PRO OFFI 1;iL RECORd AND LOC POLICY EMPICYSS Benefits a 2,000,000 AUT OMOBILE LIABILITY LEGI SLATIVE SRVCS DFPI COMBINED IN S GLE LIMIT $ A X ANY AUTO BAP299722107 2/1/2009 2/1/2010 (Ea accident) 1,000,000 ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS B I Y IN OD L JURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAM GE A $ (Per accident) GAR AGE LIABILITY AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ 1,000,000 A X OCCUR CLAIMS MADE UMB931027905 2/1/2009 2/1/2010 AGGREGATE $ 1,0°0,000 DEDUCTIBLE X RETENTION $ 10,000 $ B WORKERS COMPENSATION AND Z836521209 2/1/2009 2/1/2010 X WCSTATU- OTH- TORY I I EMPLOYERS' LIABILITY ..v ...- ..---_' ---... - -.-..-?--. - __ _ VJV PRbI''t11=TOR/PARTNER/EXECUTIVE l E.L. EACH ACCIDENT $ 11000, 0 00 OFFICER/MEMBEREXCLUDED? E-L- DISEASE - EA EMPLOYE $ 1,0001000 If yyes, describe under SPECIALPROVISIONS below E.L. DISEASE - POLICVLIMIT $ 1,000,000 OTHER I I DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS FL statute mandates 10 days notice of cancellation for nonpayment of premium. CERTIFICATE HOLDER IS NAMED AS ADDITIONAL INSURED RE: GENERAL LIABILTY ONLY. FAX 727-562-4825 BC (9 C LER K L,IMM I IrIL.A I r- MULL11t11 I:ANC:tLLAI IUN 5 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN CITY OF CLEARWATER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL PO BOX 4748 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. CLEARWATER FL 33758 AUTHORIZED REPRESENTATIVE AL;UKU L5 (LUU11U8) © ACORD CORPORATION 1988 n- I ,.F % 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). 2/9/2009 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 (2001/08)