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CERTIFICATE OF LIABILITY INSURANCE (85)ACOR DDATE(MM/DDNYYY) CERTIFICATE OF LIABILITY IN ?? ...."_... _.__... _..... SURANCE 7!17/2009 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION MARSH USA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE TWO LOGAN SQUARE HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR PHILADELPHIA, PA 19103 , ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW Attn: Healthcare.AccountsCSS@marsh.com/FAX: 212 948-1307 . 100607-CIGNA-CAS-09-10 INSURERS AFFORDING COVERAGE NAIC # CIGNA HEALTHCARE (ONSITE HEALTHS) INSURER A:AGE American _ can Insurance Company 22667 (A SUBSIDIARY OF CIGNA CORP.) 11001 N. BLACK CANYON HIGHWAY INSURER B: American Guarantee & _ Liability Ins CO 26247 PHOENIX, AZ 85029 INSURER C: Indemnity Ins Co Of North America 43575 INSURER D " INSURER E: COVERAGE THE POLICIES OF LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING I OR OTHER DOCUMENT WITH SPECT TO WHICH THIS OI PE M E OR MAY RTAIN, HE INSURANCE AFFORDED BY THE POLICIES MAY AND HEREIN S SUBJECT O ALL THE TERMS, EX CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTRNDDSR Y,,. TYPE OF INSURANCE POLICY NUMBER _ _..."._.." POLICY EPPECTIVE POLICY EXPIRATION LIMITS )DD/YYYY) DATE (MMIDDIMlDD/VYYY) DATE (MM A X GENERAL LIABILITY HDOG24932837 0710112009 0710112010 EACH OCCURRENCE 1 000,000 . X I COMMERCIAL GENER L LIABILITY DAMAGE TO RENTED 1 000 000 A CLAIMS MADE ^ OCCUR eperson) - D , , 5,00 PE NAL&AD °-- 1 000 0 ^ , , 00 $ ... GENERAL AGGREGATE $ 3 000 000 GENERAL AGGREGATE LIMIT APPLIES PER .. , , .- _. PRO- - -COMP/O PRODUCTS P qGG , ........ $ ,000,000 1 7 . A AUT OMOBILE LIABILITY ISAH08580017 07/01/2009 07/01/2010 X ANY AUTO COMBINED SINGLE LIMIT (Ea $ 1,10M000 " - ALL OWNED AUTOS ?j BODILY INJURY - SCHEDULED AUTOS (Per person) HIRED AUTOS •. ;? ?ry(? BODILY INJURY $ NON-OWNED AUTOS ?? IItJ (Peraccident) PROPERTY DAMAGE ~ (Per accident) $ GA RAGE LIABILITY („??ij ?"-J I Y/?. IP;U ? DFII - AUTO ONLY -EAACCIDENT ANY AUTO OTHER THAN EA ACC I $"1". . AUTO ONLY: .,. $ _ AGG EXCESS /UMBRELLA LIABILITY _ AUC967096601 07/01/2009 07/01/2010 EACH OCCURRENCE $ 5,000,000 X? OCCUR 11 CLAIMS MADE 11? AGGREGATE $ 5,000,000 DEDUCTIBLE ". -- ..._$ RETENTION S % G WORKERS COMPENSATION AND WLRC45700495 (AOS) 07/01/2009 07/01/2010 X WC STATU- OTH- EMPLOYERS' LIABILITY SCFC45700483 WI T,ORY LIMITS F A ANY PROPRIETOR/PARTNER/EXECUT Y / N ( ) 07/01/2009 07/01/2010 $ 1 000 00!7 IVE OFFICER/MEMBEREXC WLRC45700471 (CA) 07/01/2009 07/01/2010 .L. EACH ACCIDENT , , LUDED? 1 A WLRC45700513 (WV) 07/01/2009 07/01/2010 .L. DISEASE - EA EMPLOYEE -- $ 1,000,000 (Mandatory in NH)If yes, describe under SPECIAL P{?OVISIONS below _ ,.L..DISEASE -POLICY LIMIT - ,_1,000_ 000 OTHER A EXCESS WCUC45700501 (OH) 07/01/2009 0710112010 LIMIT $1,000,000 WORKERS COMPENSATION SIR $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSA/EHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CITY OF CLEARWATER, FL IS INCLUDED AS ADDITIONAL INSURED (EXCEPT FOR WORKERS' COMPENSATION) WHERE REQUIRED BY WRITTEN CONTRACT, CERTIFICATE HOLDER CLE-002372329-02 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF CLEARWATER EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ATTN: CITY CLERK PO BOX 4748 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, CLEARWATER, FL 33758-4748 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND U PO N THE INSURER, ITS AGENTS OR REPRESENTATIVES. 7 H ? p (t AOf MarRIShEUSpI ncSEN'iATNE Mary Radaszewski tavnu ?? tcwyrvl f ©1998-2009 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD ADDITIONAL INFORMATION CLE-002372329-02 DATE(MM/DD/YY) 07/17/2009 PRODUCER MARSH USA Inc. TWO LOGAN SQUARE PHILADELPHIA, PA 19103 Attn: Healthcare.AccountsCSS@marsh.com/FAX: 212 948-1307 100607-CIGNA-CAS-09-10 INSURERS AFFORDING COVERAGE NAIC # INSURED -------- -- ......--- INSURER F: CIGNA HEALTHCARE (ONSITE HEALTHS) - -` (A SUBSIDIARY OF CIGNA CORP.) INSURER G: 11001 N. BLACK CANYON HIGHWAY INSURER H: PHOENIX, AZ 85029 INSURER I: TEXT 1E CERTIFICATE MARKED "NO LONGER REQUIRED", AND WE WILL CITY OF CLEARWATER ATTN: CITY CLERK PO BOX 4748 CLEARWATER, FL 33758-4748 o WRl7Bg rESrzs Mary Raadaszewski Page 2 CERTIFICATE HOLDER 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 holder, nor does it affirmatively or negatively amend,. extend or alter the coverage afforded by the policies listed thereon - Acord 25