CERTIFICATE OF LIABILITY INSURANCE (111)All\/ACVC4
A ORDTM CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD[YYYY)
09
/24/2009
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ISU Suncoast Insurance Assoc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 22668 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Tampa, FL 33622-2668
813 289-5200 INSURERS AFFORDING COVERAGE . NAIC #
INSURED INSURER A: Phoenix Insurance Company 25623
Advanced Systems Engineering, Inc. INSURER B: Travelers Indemnity Company 25658
13555 Automobile Blvd. INSURER c: Travelers Casualty 81 Surety Co 19038
Suite 330 INSURER D: XL Specialty Insurance Company 37885
Clearwater, FL 33762 INSURER E:
.. THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN 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.
INS
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER POLICY EFFECTIVE
MM DD POLICY EXPIRATION
DATE MM/ D
LIMITS
A GENERAL LIABILITY 6606851 L26A 10/02/09. 10/02/10 EACH OCCURRENCE $1,000,000
- ... X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $1 000 000
CLAIMS MADE 51 OCCUR MED EXP (Any one person) $10,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2,0002000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000
M POLICY X PLCO LOG
B AUT OMOBILE LIABILITY BA48831_69109 ... 8117/10 COMBINED SINGLE LIMIT
000
000
$1
ANY AUTO D R ??? 1(r?a (Ea accident) ,
,
ALL OWNED AUTOS ?? I) BODILY INJURY $
(Per person)
SCHEDULED AUTOS
I 09
X HIRED AUTOS . >>> ! BODILY INJURY $
X NON-OWNED AUTOS •-? ! (Per accident)
•
? ,` l PROPERTY DAMAGE
i
?ATIVE SR', C8 UEpT (Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY CUP6849Y191 08/17/09 08/17/10 EACH OCCURRENCE $5 000 000
X OCCUR FICLAIMS MADE AGGREGATE $5.000.000
$
R DEDUCTIBLE $
X RETENTION $ 10000 $
C_ WORKERS-COMPEN$ATIONAND- -.?-=_-: -- UR6$4SY-20-109= .08/1.7/-09 - - .0.$I-1-7/10•--=. WC STATU_
-X O7H-
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $5OD OOD
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYEE
$500,000
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
1$500,000
D OTHER Professional DPR9618465 03/10/09 03/10/10 $1,000,000 per claim
Liability $1,000,000 annl aggr.
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Professional Liability is claims made and reported.
Certificate holder is listed as an additional insured with respects to
General Liability, Auto Liability and Excess Liability policies on a
primary and non-contributory basis. Waiver of Subrogation in favor of the
(See Attached Descriptions)
CERTIFICAIt HULUtK t ANL CLLAIIUN Iv Nays Iyr ?y(/IL-rpyIllGn?
City of Clearwater
Attn: City Clerk
PO Box 4748
Clearwater, FL 33758.4748
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30_ DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $0 SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
04 AUTIJORIZ "E V RESEjdTAT?IV,Eb
ACORD 25 (2001/08)1 of 3 #S214102/M214097 KEB 0 ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statement on this certificate does not confer rights to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25$ (2001108) 2 of 3 #S214102/M214097
,'
1'"?'??'r'????'??'??r?l"',?I ?, ? ? :"T'I
DESGINPQIS° Cont inued from Pry e 1
additional insured applies to the General Liability, Auto Liability,
Excess
Liability and Workers Compensation policies.
AMS 25.3 (2001/08) 3 of 3 #S214102/M214097