CERTIFICATE OF LIABILITY INSURANCE (81)ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID AS DATEIMM/DD/YYYY)
JI+?CDE-1 05 05 09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Wallace Welch & Willingham Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
300 First Avenue South, 5th Fl HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 33020 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 INSURER A: svereet Indemnity Ineuranoa Co
INSURER 8:
Marquesas LLC &
t Inc.
velo
J
g INSURER C:
OQ
4th
2201
3traet
St
Petersbur
FL' 3 704 INSURER D:
.
g
INSURER E:
COVERAGES
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-
LTR
N
TYPE OF INSURANCE
POLICY NUMBER
DATE Y P"N
DATE MMID
LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY
- PREMISES (Ee occurence $
CLAIMS MADE F
IOCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
POLICY PROJECT LOC
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS
(Per person) $
HIRED AUTOS
BODILY INJURY
NON-OWNED AUTOS
(Per accident) $
PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $5,000,000
A X OCCUR F-1 CLAIMSMADE 7101000115-091 05/01/09 05/01/10 AGGREGATE $5,000,000
over: $GL
H DEDUCTIBLE $ Auto
.
RETENTION $ $ EL
WORKERS COMPENSATION AND
U_ IVIH-
TORY LIMITS
ER
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
E-L. EACH ACCIDENT
$
ETi/M
QFFI
C -0.SF?SE
64
EMPkOYEE .._._?.__. ?..,?..?_
.
..
_
.
. -:
-
- _
$.
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE -POLICY LIMIT
$
OTHER
DESCRIPTION OF OPERATIONS 1 LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Certificate holder is listed as additonal insured with respects to General
Liability ATIMA.
CERTIFICATE HOLDER CANCELLATION
CITCL--1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
City of Clearwater NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
City Manager
PO Box 4748 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Clearwater FL 33758-4748 REPRESENTATIVES'
A D RESE E
ACORD 25 (2001108) v . . ®ACORD CORPORATION 1988
111, I I91;J11 Elk, I
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).
f 171--1d >r1TTJZF::1
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)