CERTIFICATE OF LIABILITY INSURANCEIDDIYY
CERTIFICATE OF"IABILITY INSURANCE ATE IMM
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2008
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1 z/t s/
PRODUCER
7 THIS CERTIFICATE IS ISSUEfi.... A MATTER OF INFORMATION ONLY AND
Bollinger Inc.
7 CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
101 JFK Parkway; P.Q. Box 390 CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE
NJ 07078-0390
Short Hills AFFORDED !BY THE POLICIES BELOW.
, INSURERS AFFORDING COVERAGE NAIC #
INSURW INSURER A:
Gmnfto State Inaunwme Company
Clearwater Country Club Management Inc DBA Clearwater Country INSURER B.
Club
525 North Batty Lane INSURER C:
FL 33755
Clearwater, INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY
REOUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED 13Y THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POUCIES. AGGREGATE
LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECIWE POLICY EXPIRATION UNIITS
DATE IMM/DD/YY) DATE IMM/DD/YY)
LTR INSRD
GENERAL LIABILITY EACH OCCURRENCE 91 OOD,000
[d COMMERCIAL GENERAL LIABILITY 02-LX-002823877-8 01101109 01/01/10 DAMAGE TO RENTED 0300,000
REMISES Ea occurrence)
?O CLAIMS MADE ]? OCCUR ED EXP(AD one person 915,000
PERSONAL & ADV INJURY 01,000 000
d GENERAL AGGREGATE 93,000,000
GEN'L AGGREGATE LIMIT APPLIES PER 'PRODUCTS COMP/OP AGG 93,000,000
D POLICY ? PROJECT P LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
Q ANY AUTO Ea accident)
0 ALL OWNED AUTOS oe? BODILY INJURY
? SCHEDULED AUTOS (Per rson)
? ){IRED AU705 BODILY INJURY
0 NON-OWNED AUTOS O FICIAI. RECORDS AND {Per accident--
?
DAMAGE
7
LE ISLATIVE SRV S DEPT
? (Per ac
(per ecci dent
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT
? ANY AUTO OTHER THAN EA C
? AUTO ONLY: AGG
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE
? OCCUR 17 CLAIMS MADE AGGREGATE
DEDUCTIBLE
RETENTION a
WORKERS COMPENSATION AND CI WC
EMPLOYERS' LIABILITY STATU-TORY Q OTHER
LIM ITS
LEACH ACCIDENT
ANY PROPRIETORMARTNERAXECUTIVE E.L. DISEASE - EA EMPLOYEE
OFFICER/MEMBER EXCLUDED?
It yea, desvibe under E.L. DISEASE - POLICY LIMIT
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPE4ATIONSILOCATK)N8NEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
The Certificate Holder Is named as Additional Insured as respeM to Leased Land
CERTIFICATE HOLDER CANCELLATION
HOULD ANY OF THE ABOVE DESCRIBEO'POLICIQS 55 8 CANCELLED BEFORE THE
ISSUING
IRATION DATE THIERROF, THE
City of Clearwater CERTTFICATR HOLDER NAMED TO THE LEFT, BUT
DAYS WRITTEN NOTICE TO
PO Box 4748 AIL
LURE TO DO 90 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
Clearwater, FL 33758 NSURER, ITS AGENTS OR REPRESENTATMES.
UTHORIYED REPRESENTATIVE
ACORD CORPORATION
ACORD 25 (2001108)
Cc'.P-A-k 4 N-Q, -
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 andorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse We 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 26 (2001108)