CERTIFICATE OF LIABILITY INSURANCE (17)ACOR4 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/Y"
F06/12/2009
PRODUCER 727.797.5193 FAX 727.797.8605
Alley, Rehhaum & Capes Assurance, Inc.
2433 Gulf to Bay Blvd. 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.
P.O. Box 4620
Clearwater, FL 33758
INSURERS AFFORDING COVERAGE
NAIC #
INSURED Thomas & Patricia Wolkowsky INSURER A: SAFECO 39012
DBA: Pirates Pantry INSURERB:
25 Causeway Blvd INSURER C:
Clearwater, FL 33767 INSURER D!
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTVNTHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NTH 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.
INSR
LTR DD'
SR TYPE OF INSURANCE POLICY NUMBER POLICY
DATE M POLICY EXPPJMON
DATE MMID
DIYYYY)
IMITS
GENERAL LIABILITY 25CC27655610 06/07/2009 06/07/2010 EACH OCCURRENCE $ 1,000,00
X COMMERCIAL GENERAL LIABILITY PREMISES En occurrence S 1,000,0001
CLAIMS MADE M OCCUR MED EXP (Any one person) S 10 , 00
A X PERSONAL & ADV INJURY S 1, 000,00
GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S 2,000.00
POLICY PRO. LOC
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO
(Fe ecddent) S
ALL OWNED AUTOS
BODILY INJURY S
SCHEDULED AUTOS (Per person)
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS (Per accident) $
PROPERTY DAMAGE
$
(Per Occident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR F1 CLAIMS MADE AGGREGATE $
S
DEDUCTIBLE S
RETENTION S $
WOR KERS COMPENSATION
AND EMPL OYERS' LIABILITY TORY LIMITS ER
YIN
ANY PROPRIETORIPARTNEWEXECUTIVEM
OFFICERIMEMBER EXCLUDED? E.L. FACH ACCIDENT $
(Mandatory In NH)
d
Ab
d E.L. DISEASE - EA EMPLOYE $
Des.
esc
e un
er
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
$
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
he Certificate Holder is listed as an Additional Insured.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAL 10 DAYS WRITTEN
NOTICE TO THE CERTEICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
City of Clearwater IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
25 Causeway Blvd. REPRESENTATIVES.
Clearwater, FL 33767 AUTHORIZED REPRESENTATIVE
5i nature on File w Company
m.'UmLi'm IAvtlarv11 Vc IVUU-ZUUS AGUKU GUKPOKATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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
This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized
representative or producer, and the certificate hold6t, nor does it affirmatively or negatively amend,
extend or alter the coverage afforded by the policies listed thereon.