Loading...
CERTIFICATE OF LIABILITY INSURANCE / DATE (MMIODIVYY'I) 07/30/2004 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIACA TE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ACORQM CERTIFICATE OF LIABILITY INSURANCE FAX (727)536-9985 PRODUCER (727)530-0684 Jack Rice Insurance, 13080 S. Belcher Rd. Largo, FL 33773 Inc. INSURED Gulf Coast Legal Services, Inc. 641 First St. S. St. Petersburg, FL 33701 INSURERS AFFORDING COVERAGE NAlC # INSliRERA Bridgefield Employers Ins. CO. INSURER B INSURER C INSL'RER D INSURER E COVI=RAGES THE POLICIES OF INSURANCE L15rED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWITH5rANDlNG 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. I~ ADD;I lYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS fNSR GENERAL LIABILITY EACH OCCURREI\CE $ f-- ; DAMAGE TO RENTED COMMERCIAL GENERAL LIABILITY $ J CLAIMS MADE o OCCUR IIo'ED EXP (Any one person) $ PERSONAL & ADV INJURY $ f-- GENERAL AGGREGATE $ ~ GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS. CONPIOP AGG $ h POlICY n ~8T nLOC AUTOMOBILE LIABILITY COMB:NED SINGLE LIMIT f-- IEi' accident) $ /IN( AUTO ~ ALL OWNED AUTOS BODL Y INJURY I-- $ SCrEDUlED AUTOS Iper person) f....- HIRED AUTOS BODl.. Y INJURY f....- (Per accident) $ NON.OWNED AUTOS t-- f....- PROPERTY DAMAGE $ (Per aCCIdent) GARAGE LIABILITY AUTO ONlY- EA ACCIDENT $ =j/lN( AUTO OTHER THAN EA ACC $ AUTO ONLY AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ ~ OCCUR o CLAlMSMADE AGGREGATE $ $ =1 DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND 083003589 04/01/2004 04/01/2005 XI~l~1 10TH- ER EMPLOYERS' LIABILITY El EACH ACCIDENT $ 100,000 A /IN( PROPRlETORJPARTNERlEXECUTlVE OFFICERlMEMBER EXCLUDED? EL DlSEASE.EAEMPLOYEE $ 100,000 W€t?:~~w6~r~I~NS below E L DISEASE. POlICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS Glasser Schoenbaum Human Services Center 1750 17th St Unit J Sarasota, Fl 34234 CANCELLATION SHOULD ANY OF THE ABOVE DesCRIBED POUCIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ...1!l.- DAYS WRITTEN NOTICE TO THE CERT1FICATE HOLDER NAMED TO THE LEFT, BUT FAlLURETO MAIL SUCH NOTICE SHAlL IMPOSE NO OBUGATION OR LIABILITY CERTIFICATE HOLDER OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE d?7tiJ~ Sandi Vernacchio FlN ACORD 25 (2001/08) @ACORDCORPORATION 1988 09:06 JUl 30, 2004 TEL tJO: 532-9602 10616 PAGE: 4/4 Additional Coverages and Factors 03/05/2004 Line of Business Coverages for Workers Compensation Coverage we & Employer's liability Limits 100000/500000/ 100000 Ded/Ded Type Rate Premium Factor Adjst. to reconcile-exp mod. premium Expense constant 4,560.00 1.00000 140.00 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 SUBROGA nON 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) Date. 8/17/2004 Time. 10:39 AM To: @ 17278213340 Cllent/l: 5208 lJage: uV":;-UI..i.J GULFLEG ACORD... CERTIFICATE OF LIABILITY INSURANCE DATE (MM/ODIYYYY) 07/20/04 THIS CERTlACATE IS ISSUED ASA MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIACATE HOLDER. THIS CERTlACATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POUCIES BELOW. I'ROO\JCER The CIMA Companies, Inc. (CIM) 216 S. Peyton Street Alexandria, VA 22314 703 739-9300 Gulfcoast Legal Services Inc 641 First Street South St Petersburg, FL 33701-5003 INSURERS AFFORDING COVERAGE INSURERA: Lloyd's of London INSURER B: INSURER C: INSURER D: INSURER E: NAlC# INSURED COVERAGES THE POLICIES OF INSURANCE LISTED BaOw HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWlTHSTANDING ANY REQUIREMENT, TERM OR CONDmON 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 HERBN IS SUB,JECTTO ALL lliETERMS. EXCLUSIONS AND CONDmONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID ClAIMS. LTR N<:Ar 'TYPE OF INSURANCE POUCY NUMBER PJ'A~~'~~ Pg~i.~~RC~ UMfTS ~NERALUABIUTY EA01 CCCURRENCE $ COMMEROAL GENERAL L1ABIUTY ~~b~t TO RENTED $ 1 a..AIMS MADE 0 OCDJR MED EX? 1A"i ate person) $ PERSONAl & ADV INJURY $ GENERAL AGGREGATE $ ~~AGGREnE;;:T APr~t PE~ PROOUCTS . COMP/OP AGG $ POUCY :IECT LOC ~OMOBILE UABIUTY COMBINED SINGLE UMIT $ my AUTO GOa accident) - - ALL ONNED AUTOS BOOILY IN.lJRY per perSO"l) $ ~ sa-tEDULED AlJTOS I-- HIRED AUTOS BOOIL Y IN.lJRY per aa:idenl) $ I-- NOIl.OWNED AUTOS PROPERTY DAMAGE $ per aa:idenl) ~GE UABIUTV AUTO ONLY. EA ACODENT $ my AUTO OTHER THm EAACC $ AUTO ONLY: AOO $ ~CESSNMBREu.A UABlUlY EA01 CCCURRENCf: $ OCCUR D OJ\lMSMADE AGGREGATE $ $ ~ DEDUCTIBLE $ RETENTION Ii $ WORKERS COMPENSATION AND I T~JT~r~.; I IOJ~' EMPLOYERS' UABIUTY E1.. EA01 ACClDE NT $ my PRa>RlETa:l/PARTNERl8<ECUTIVE OFFICf:R/MEMBER EXa.UDED? E.L. 01 SEASE . EA EMPLOYEE $ ~~~~~~'I:3NS baow E1.. DISEASE. POUCY UMIT $ A OTHER Professional LP5024 08/01ft)4 OB/01ftJ5 $1,000,000/$1,000,000 Liability DESCRIPTION OF OPERATIONS / LOCATIONS J VEHClES I EXQ.USlONS ADDED BY ENDORSEIIENT J SPEaAL. PROVISIONS Project: 01-0122 Ryan White Care Act I Certificate is subject to all policy terms,limlts, conditions and exclusions. CERTlACATE HOLDER CANCELLAnON HiIIsborough County BOCC P.O. Box 1110 Tampa, FL 33601 Attn: Insurance & Claims Mgmt. D SHOULD ANY OFnlE ABOVE DESCRIBED POUClES BE CANCELLED BEFORE THE EXPIRATION DATE nlEREOF, THE ISSUING INSURER WIll.JODDIlIOI!IlDMAlL -30.... DAYS WRITTEN NOTICE TO nlE Cf:RTIFlCATE HOLDER NAMED TO THE LEFT,~ REPRESENTATIVE ~ ACORD 25 (2001/08) 1 of 2 #221929 TWD €) ACORD CORPORATION 1988 Date: 8/17/2004 Time: 10:39 AM To: @ 17278213340 Page: 00J-003 -' 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 atter the coverage afforded by the policies listed thereon. ACORD 25~S (2001/08) 2 012 #221929 ~-Z:'.--j%--__!MW+E4@j_W%%W4__~j:::;:~~j:~::1::::J .~...T.~~~:~.i~.~~ .c~~~~ity. ~~.d..S~~~tyC~~.p~~)~.~fA~~~i.~~".... .... ......0 ..T~~~:~I~~~.C~~~.~lty..~~d.S~~~tyC~~p~~y ~f.Ii.iinois .. o Tra,'elers Casualty and Surety Company Naperville, Illinois 60563 (Stock Insurance Companies, herein called the Company) Hartford, Connecticut 06183-9062 IN RETURN FOR THE PA YMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. 1. NAMED INSURED: GULFCOAST LEGAL SERVICES, INC. The Named Insured listed above or as may be amended by endorsement includes any Employee Benefit Welfare or Pension Plan, as defined in Title I of the Employee Retirement Income Security Act of 1974 (ERISA) and any amendments thereto, sponsored exclusively by anyone or more of those entities named as Insureds under this Policy. 2. MAILING ADDRESS: 641 FIRST STREET SOUTH, SAINT PETERSBURG FLORIDA 33701 3. POLICY PERIOD: From AUl!:Ust 01. 2003 to AUl!:Ust 01. 2004 (12:01 A.M. Standard Time at your mailing address shown above) 4. LIMIT OF INSURANCE AND DEDUCTIBLE: Subject to Section 6 of this Policy. D The Limits of Insurance for Insuring Agreements I through VI are S and the Deductibles for Insuring Agreements I through VI are S ; or ~ The Limit ofInsurance and Deductibles for each Insuring Agreement(s) shall apply as follows: Insurine: Al!reements Limit of Insurance Insuring Agreement I - Employee Dishonesty $125,000.00 Insuring Agreement II - Forgery or Alterations Not covered Insuring Agreement III - On Premises Not covered Insuring Agreement IV - In Transit Not covered Insuring Agreement V -Money Orders & Counterfeit Currency Not covered Insuring Agreement VI - Computer Fraud & FTF Not covered Deductible $500.00 D The Limit of Insurance and Deductible for Optional Insuring Agreement(s) shan apply as follows: Optional Insurine: Ae:reements Limit of Insurance Deductible If "Not Covered" is inserted above opposite any specified Insuring Agreement, such Insuring Agreement and any other reference thereto in this policy is deemed to he deleted therefrom. 5. ENDORSEMENTS FORMING PART OF THIS POLICY WHEN ISSUED: F-3116 01-97, F-3075 06-99 6. CANCELLATION OF PRIOR INSURANCE: By acceptance of this Policy, you give us notice canceling prior Policy or Bond Numbers The cancellation to be effective at the time this Policy becomes effective. NOTICE: A state surcharge may apply. Please refer to )'our billing statement. '/1JA~~dL Countersigned By (if required) Authorized Company Representative F-3000 (6/97)