CERTIFICATE OF LIABILITY INSURANCE (11)
ACORQM CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYYYY)
12/13/2005
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
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
315 W. Fletcher Ave. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tampa, FL 33612-3414
Jeffrey Kemp INSURERS AFFORDING COVERAGE NAIC#
INSURED Gul f El ectrl c Co Inc Martl n Slmpson INSURER A: FCCI Commercial Insurance Co.
12522 US Hwy 301 N Ste 12 INSURER B: Progressive Express Ins. Co. 10193
Thonotosassa, FL 33592 INSURER C: Burns & Wilcox Ltd.
INSURER D: Bridgefield Casualty Ins CO
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 MAYBE 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.
I,N~: t19.'?,'~ TYPE OF INSURANCE POLICY NUMBER PRH~Y EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY CPPOOO31723 12/16/2005 12/16/2006 EACH OCCURRENCE $ 1,000,000
"X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000
T CLAIMS MADE 0 OCCUR MED EXP (Anyone person) $ 5,000
A X $500 PO Oed PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000
-, n PRO- nLOC
POLICY JECT
AUTOMOBILE LIABILITY 4177843-2 12/16/2005 12/16/2006 COMBINED SINGLE LIMIT
- (Ea accident) $
ANY AUTO 1,000,000
-
ALL OWNED AUTOS BODILY INJURY
~ $
X SCHEDULED AUTOS (Per person)
B "X
HIRED AUTOS BODILY INJURY
~ $
NON-OWNED AUTOS (Per accident)
f--
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY UMB TO BE ISSUED 12/16/2005 12/16/2006 EACH OCCURRENCE $ 2,000,000
m OCCUR D CLAIMS MADE AGGREGATE $ 2,000,000
C .' $
~ DEDUCTIBLE $
X RETENTION $ 10,000 $
WORKERS COMPENSATION AND 83033829 04/01/2005 04/01/2006 I TV;;~~T f;1g:." I 10J~-
-- -E'MPLOy!:T{S'UAilflifY------ ___d_ --~------~._~- - - i-- ___ u__
D ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 500,000
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 500,000
If yes, describe under E.L. DISEASE - POLICY LIMIT $ 500,000
SPECIAL PROVISIONS below
OTHER CMOOO1953 04/01/2005 04/01/2006 $150,000 limit
A Rented Equipment $1,000 ded
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
City of Clearwater
100 S Myrtle
Clearwater, Fl
C CELLATION
SHDULD 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,
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
ACORD 25 (2001/08)
@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).
__ ---------~--_f}fSCLAIMER H_ d_d~ _____ ____________d_ __d__d -
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.
RECE\VED
DEe 2~: 2005
OFFICIAL RECORDS AND
LEGISLAllVE SRVCS DEP"
ACORD 25 (2001/08)