CERTIFICATE OF LIABILITY INSURANCE (4)
ACORQM CERTIFICATE OF LIABILITY INSURANCE I DATE (MMlDD/YYYY)
12/30/2005
PRODUCER (813)933-6691 FAX (813)932-6287 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Adcock & Adcock Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
315 W. Fletcher Ave. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tampa, FL 33612-3414
Jeffrey Kemp INSURERS AFFORDING COVERAGE NAIC#
INSURED Jeffrey Hardeman and INSURER A: Southern-Owners Insurance Co. 10190
Hardeman Landscape Nursery Inc INSURER B: Auto-Owners Insurance Co. 18988
POBox 1980 INSURER c: Zenith Insurance Co.
Seffner, FL 33583-1980 INSURER 0:
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.
INSR DO' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY 20599539 04/01/2005 04/01/2006 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000
. c'. - I CLAIMS MADE m OCCUR MED EXP (Anyone person) $ 10,000
A PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
II POLICY m ~~8i n LOC
AUTOMOBILE LIABILITY 4273681700 04/01/2005 04/01/2006 COMBINED SINGLE LIMIT
~ $
X ANY AUTO (Ea accident) 1,000,000
~
ALL OWNED AUTOS BODILY INJURY
~ $
SCHEDULED AUTOS (Per person)
B ~
HIRED AUTOS BODILY INJURY
'X $
NON-OWNED AUTOS (Per accident)
~
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY 4273681701 04/01/2005 04/01/2006 EACH OCCURRENCE $ 2,000,000
~ OCCUR D CLAIMS MADE AGGREGATE $ 2,000,000
B $
~ DEDUCTIBLE $
X RETENTION $ 10,000 $
- . I WnRKI'RS COMPENSATIOI'.,ulli!L.~._ 1------- __. We: TO BE ISSUED 01l0JI~06 011011200] T _\,:,{S.~T~1."~'_ T JD~'
EMPLOYERS' LIABILITY 1,000,,000
. C- ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE $ 1,000,000
If yes. describe under
SPECIAL PROVISIONS below E.L. DISEASE. POLICY LIMIT $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
City of Clearwater
OCL Dept
POBox 4748
Clearwater, FL 33758
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
~ DAYS WRmEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
CERTIFICATE HOLDER
Jeffre
ACORD 25 (2001108)
@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
'j ,', >:l 200"
. "', 0
( 'i+ICIAL RECORDS AND
Ll:G/SI.AT/VE SRVCS DEPT
ACORD 25 (2001/08)