CERTIFICATE OF LIABILITY INSURANCE (100)MAR. 20. 2009 8:32AM 'CUMBEY & FAIR, INC N0. 6P) 9 F. 2
6
AC4RR CERTIFICATE OF LIABILITY INSURANCE OP ID A= DATE(MMIDA/YWY)
CUM&F?1 03/16/09
PRODUCER
Wallace Welch & Willingham Inc
300 First Avenue South, 5th Fl
P.O. Box 33020 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.
St. Petersburg FL 33733
phone:727--522-7777 Fax-727-521-2902
INSURERS AFFORDING COVERAGE
NAIC#
INSURED INSURERA: XMVI plan moo co p! r..aplerd 01505
INSURER S: Ake it9hetib 6 E[wivwero rn. Co 44148
Inc.
C13IDb8 & Fair INSURER C. TraYl rtation Ina. Co. 20494
,
2463 Xntorpr±ze Rd.
33763 INSURER IX ri.Lda Roea1.1 a?d?ataon axr
Clearwater FL INSURER E:
rr.?Trr-Y.Tra3y
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INWARD NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CRRTIPICATR MAY PE ISSU3D OR
MAY PERTAIN- THE INSURANCE AFFORDEb BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONOITIONE OF SUCH
POLICIES, AGGREGATE LIMITS s}IgWN MAY NAVE BEEN REDUCED BY PAID CLAIMS.
LTR NS TYPI: Or INSURANCE POLICY NUMBER MT5 MID OATS A LIMOS
A i CENERALLIABILITY
x COMMERCIAL GENERAL LIABILITY
2086949437
03/16/09 EA;NOCCVRRENCE
03/16/10 PaEMIsES??urence &1 000 000
s300,000
I CLAIMS MAO& a OCCUR IVIED EXP Any one Parrs) $10,000
PEQSONAL &AOV INJURY S110000000
GENERAL AGGREGATE S 2 000 000
GEWLAGGREGATE LIMII'APPUESPER: PRODUCTS -COMP/OP AGO 82,000,000
POLICY X JER? LOC Em Hg11. 11000,000
AUTOMOBRE LIABILITY
^OA9EINED5ING_ELIMIT
S1,000,000
A X ANY AUTO 2068208793 03/16/09 03/16/10 (Ee90Cltlent)
I ALLOWNE0AUTO6 d BODILVnJ,IURV
P $
SCHEDULED AUTOS er peraor)
(
HIREDAUTOS BODILY NJURY $
NON-OWNED AUTOS t
E'
r't? d r,
are
1 200
(Perarddenl)
I -
PR7PERTY DAMAGE
(Por aGClaenq
GARAGBLIABILITY ' A AUTO ONLY - EA ACCIDENT s
LEGISLATI E SRVCS DE T
ANY AUTO
EAACC
OT1ERTHAN
S
AUTOONLY; AQG S
EXCESSAIMBREL ALIABXJTY EA;NOCCURRENCE $2,000,000
C OCCUR D GI.aMSMAOC 2086949471 03/16/09 03/16/10 AG^t,REGATE s2,000,000
s
j DEDUCTIBLE S
X RETENTION $10,000 a
WORKERS COMPENSATION AND X TORY LIMITS ER
D EMPLOYIMRS' LIABI ITY
PARTN°R/EXECUI7VE
NY PROPRIETOR 052024691 03/16/09 03/16/10 C.L. CACH ACCIDENT $1,000,000
I
A
OFFICERIMEMBER EXCLUDED7 E,I,. DISEASE. EA EMPLOYEE S 1 x000 000
IT yes dasallbounder
.SPJf JAL PROVISIONS below
E.L. DISEASE-POLICY LIMIT
S 1 000 000
1
OTHER
* Frofessional Liab AEICPG09 03116108 03/16/11 Ea Claim 11000,000
$2t,000 Deductible CLADO MADE Aggregate 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDIED BY ENDOR9EMLNTI SPECIAL- PROVISIONS
RE: Job 1Qo: 7128 Project Name= Corti-fleate Holder is Additional Insured with
respect to General Liability if required by written contract per form
#G17957G. 10 day notice a£ cancellation for non payment of premium,
CITY--CL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE GANCELLED BEFORE THE EXPIRATM
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRIT1 eN
NOTICE TO THE CEItTIFTCATE "OLDER NAMED TO THE LFFT, BUT FAILURL TO DO SO SMALL
City of Clearwater UPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AeFATS OR
PO Box 4748
Clearwater FL 33758 REPRESENTATIVES 00
ACORD 15 120011091 v (D ACORD CORPORATION 1992
N1 AF.2C. 2 09 3:32AM CUMBEY & FAIR, INC
NO, 659 P. 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 not confer rights 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 (2001108)