CERTIFICATE OF LIABILITY INSURANCE (13)
ACORQM CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDNYYY)
12/30/2005
PRODUCER (813)637-8877 FAX (813)637-8484 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Insurance Office of America, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
4915 West Cypress Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Suite 100
Tampa, FL 33607 INSURERS AFFORDING COVERAGE NAIC#
~SURED Bates Electric, Inc. INSURER A: Bridgefield Employers Ins. Co. 10201
William B Goldthorp INSURER B:
7901 Hopi Place INSURER c:
Tampa, FL 33634 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 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.
IN~: ~9;~ TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
-
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
I CLAIMS MADE D OCCUR MED EXP (Anyone person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
Ii n PRO. nLOC
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
I-- (Ea accident) $
ANY AUTO
>--
ALL OWNED AUTOS BODILY INJURY
- (Per person) $
SCHEDULED AUTOS
-
HIRED AUTOS BODILY INJURY
- (Per accident) $
NON-OWNED AUTOS
-
--I PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT $
=1 ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
:=J OCCUR o CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND 0830-22803-0 01/01/2006 01/01/2007 X I ,v;;~~m;,~;, I 10l~'
EMPLOYERS' LIABILITY 500,000
-A ANY PROPRIETOR/PARTNERiEXECUTIVE- - f--.._--- -' _.~ -----~ E.L. EACH ACCIDENT $
,- ---- ------ :--.-. ._.--- - ..
OFFICER/MEMBER EXCLUDED? E.L DISEASE - EA EMPLOYEE $ ")()O.;'C'ffiJO
~ yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
~ddendum to cancellaion: 10 days notice applies for non-payment of premium.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
City of Clearwater BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
POBox 4748 OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Clearwater, FL 34618-4748 AUTHORIZED REPRESENTATIVE ~
Herman Peerv/CURTIF
ACORD 25 (2001/08) FAX: (727) 562-4576
@ACORD CORPORATION 1988
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 alter the coverage afforded by the policies listed thereon.
RECEIVED
, I 'j
,
2005
;1;+~'ICiJ\L RECORDS AND
c,EGISLATlVE SRVCS DEPT
ACORD 25 (2001/08)