WARREN CLAY WITHERS / CERTIFICATE OF INSURANCE
C,~'_ ~ I Q,l--~{~ "'- K./s /<
PRODUCER
Mutual Insurance Agency
at Clearwater, Inc.
P .0. Box 177 9
Clearwater PL 33757-1779
:CE:RtH~~lCATE::Or::1JAEnLJTy::nslSURAN:c:a~:iti:~:;:::::::::::::: DATE (MM/DDIYY)
::-:...:......:.::::.::..:::.:. :::::':::'.::': :::::::.: ::.... .': ::-:-. ::::-::-:-::-:-.:.:.::: :-:.:.:.:-:-....:-:: :--:::: .::::::.::' ::-.:.....:::...::..:::.:-:::-:.:::.:::..::.:-.::. :";I;;iEQ::~:iL::::::::::-:: 0 9 /19 / 0 2
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
A CORD_
John Gay
Phone No. 727 -446 - 6064 Fax No. 727 -442-9751
INSURED
COMPANY
A OWners Insurance Company
COMPANY
B
COMPANY
C
Warren Clay Withers
805 Bruce Avenue OOMPANY
Clearwater PL 33767 D
:~~~M$~$::::::::::::::::::::::::::::::::::::::::::::::::::;:;:::;:::;:::::::;:::::::;:::::::::::::::::::::::;:::::::::::::::;:::::::::::::::::::::::::::::;:::::;:::::;:::::::::;:::::::::::::::::;:::::::::::::;;::::::::::::::::::;:::::::::;:::::;:::;:::::::::::::::::;:;:::;::::::
THIS IS TO CERTIFY THAT 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 OONTRACT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAlO CLAIMS. .
EACH ACCIDENT $
$
$
$
$
IOl~-:::::::::::::::::-::;::::::::'::::::;:::
$
$
$
CO
LTR
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MMIOOIYY) DATE (MMIODIYV)
TYPE OF INSURANCE
POLICY NUMBER
GENERAL LIABILITY
r--
A X COMMERCIAL GENERAL LIABILITY
:.:.: I CLAIMS MADE [!] OCCUR
OWNER'S & CONTRACTOR'S PROT
10/30/02
10/30/03
GENERAL AGGREGATE
PRODUCTS-COM~OPAGG
PERSONAL & ADV INJURY
EACH OCCURRENCE
FIRE DAMAGE (Anyone lire)
MED EXP (Anyone person)
23 20567442
-
AUTOMOBILE LIABILITY
-
-
COMBINED SINGLE LIMIT
ANY AUTO
ALL OWNED AUTOS
BODILY INJURY
(Per person)
-
-
SCHEDULED AUTOS
HIRED AUTOS
BODILY INJURY
(Per accident)
-
-
-
NON-OWNED AUTOS
PROPERTY DAMAGE
GARAGE LIABILITY
-
_ ANY AUTO
-
AUTO ONLY - EA ACCIDENT $
OTHER THAN AUTO ONLY:
EXCESS LIABILITY
I UMBRELLA FORM
'I OTHER THAN UMBRELLA FORM
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
AGGREGATE
EACH OCCURRENCE
AGGREGATE
THE PROPRIETORl
PARTNERs/EXECUTIVE
OFFICERS ARE:
OTHER
RINCL
EXCL
I WC STATU- I
I TORY LIMITS
EL EACH ACCIDENT
EL DISEASE - POLICY LIMIT
EL DISEASE - EA EMPLOYEE
DESCRIPTION OF OPERA TIONS/LOCATIONSlVEHICLES/SPECIAL ITEMS
Landscape Gard,ning (Acacia ROUDdabo~t). City of Clearwater & Clearwater
Beach Associat1on are named as addit10nal insureds.
LIMITS
$ 1000000
$ 1000000
$ 1000000
$ 1000000
$ 50000
$ 5000
$
$
s
$
. . . . . . . . . . . . . .
. . . . . . . . . . . .
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C:IT10 0 2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
Ci ty of Clearwa ter ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
c/o Parks & Rec. Dept.
Mi 11 i e McP adden BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
P . o. Box 4748 OF ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES.
Clearwater PL 33718-4748 AUTHORIZED REPRESENTATIVE
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