CERTIFICATE OF INSURANCE (043)
Brandow Howard Kohler & Rosenbloom, Inc.
3601 Park Center Blvd.
Minneapolis, MN 55416
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
INSURED
COMPANY A
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY D
LETTER
E
Insurance Co. of North America
E
Wardell M. Montgomery
3618 Rainbow Dr.
Minnetonka, MN 55343
THIS IS to_CERTIEY.THAIJ'OLICIES OF INSURANCE L1$TEOBELOWHAVE BEEN ISSUED TO THE INSURED NAMED ABOV(J~ME p6Ubl~iClIOD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTAER DOCUMENTWITH RESPE 1-9iHIClr1'RS'~TiFICATE MAY
BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS, AND CONDI.
TIONS OF SUCH POLICIES.
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION LIABILITY LIMITS IN THOUSANDS
DATE (MMIDD/YY) DATE (MM/DD/YY) EACH AGGREGATE
OCCURRENCE
BODILY $ $
INJURY
PROPERTY $ $
DAMAGE
9/3/84 9/3/85 BI & PD
COMBINED $ 500, $ 500,
PERSONAL INJURY $ 500,
BODILY $
INJURY
(PER PERSON)
BODILY
INJURY $
(Pl:R ACCIDENT)
PROPERTY $
DAMAGE
BI & PD $
COMBINED
BI & PD $
COMBINED
10-4-84 10-4-85 (EACH ACCIDENT)
(DISEASE-POLICY LIMIT)
(DISEASE-EACH EMPLOYEE)
GENERAL LIABILITY
X COMPREHENSIVE FORM
PREMISES/OPERATIONS
UNDERGROUND
EXPLOSION & COLLAPSE HAZARD
PRODUCTS/COMPLETED OPERATIONS
CONTRACTUAL
INDEPENDENT CONTRACTORS
BROAD FORM PROPERTY DAMAGE
X PERSONAL INJURY
OBP-DO-94-98-59-A
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS (PRIV PASS.)
ALL OWNED AUTOS (OTHER THAN)
PRIV. PASS.
HIRED AUTOS
NON-OWNED AUTOS
GARAGE L1ABI L1TY
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS' COMPENSATION
AND
EMPLOYERS' LIABILITY
04-1856-1
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/SPECIAL ITEMS
It is hereby understood and agreed that the Certificate Holder shall be an Additional Insured,
but only as respects their interest in work done for them by the Named Insured. This does
not apply to Workers' Compensation.
City of Clearwater
P.O. Box 4748
Clearwater, FL 33518