CERTIFICATE OF INSURANCE (158)
THE FORDUAM AGENCY INC
5141 SEMINOLE BOULEVARD
F' 0 BC);': 030:7
ST PETERSBURG) FLORIDA
NAME AND ADDRESS OF INSURED
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COMPANIES AFFORDING COVERAGES
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COMPANY A
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY D
LETTER
COMPANY E
LETTER
~~I U T C).... Oi,,} ,'.,Ie F: ~:; I i\/ ~:;" CO"
GOLDEN TRIANGLE ASPHALT
PAVING co. ETAL
P. (J. E{O>( ?O()B~.'.)
c'"''
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F'ElEF;~~::;f':URc-;.. FL.
33742
This is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time. 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.
TYPE OF INSURANCE
(:]
GENERAL lIAB..ILITY
I3J COMPREHENSIVE FORM
I3J PREMISES-OPERATIONS
IKJ EXPLOSION AND COLLAPSE
HAZARD
IZJ UNDERGROUND HAZARD
IKJ PRODUCTS/COMPLETED
OPERATIONS HAZARD
I3J CONTRACTUAL INSURANCE
IZJ BROAD FORM PROPERTY
DAMAGE
IKlINDEPENDENT CONTRACTORS
IZJ PERSONAL INJURY
POLICY NUMBER
POLICY
EXPIRATION DATE
Limits of Liability in Thousands (
oCCG~~~NCE AGGREGATE
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AUTOMOBILE LIABILITY
D COMPREHENSIVE FORM
IZJ OWNED
I3J HIRED
IKJ NON,OWNED
BoDil.YINjURY
, $
$
EXCESS LIABILITY
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IZJ UMBRELLA FORM
D OTHER THAN UMBRELLA
FORM
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WORKERS' COMPENSATION
and
EMPLOYERS'L1ABILlTY
OTHER
PROPERTY DAMAGE
BODILY INJURY AND
PROPERTY DAMAGE $
COMBINED
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:I
PERSONAL INJURY,
$
:::: (> 1 -4 0 !.::.i ~~.i 0
BODILY INJURY
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT)
1
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PROPERTY DAMAGE
BODIL Y INJURY AND
PROPERTY DAMAGE
COMBINED
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BODILY INJURY AND
PROPERTY DAMAGE
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COMBINED
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES
ADDITIONAL INTEREST: CITY OF CLEARWATER) FLORIDA
JUL 1 3. 8"1
Cancellation: Should any of the above described pOlicies be cancelled before the expiration date thereof, the issuing com,
pany will endeavor to mail :I. 0 days written notice to the below named certificate holder, but failure to
mail such notice shall impose no obligation or liability of any kind upon the company,
NAME AND ADDRESS OF CERTIFICATE HOLDER
DATE ISSUED:
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P.. CJII r:o:::<: 4:}.4B
CITY OF CLEARWATER
CI...[f~h:~.J~] TEF: l FI...
ATTN: WILLIAM C. BAKER
CiEUF:GE: F'OF:I:iH(',i"I
AUTHORIZED REPRESENTATIVE
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