CERTIFICATE OF LIABILITY INSURANCE (3)ACORD CERTIFICATE OF LIABILITY INSURANCE OP ID KR
BELLO-1 DATE(MM/DOrr"Y)
E 11/11/09
PRODUCER
Lykes Insurance, Inc. - WP
P. O. Box 2703 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Winter Park FL 32790
Phone: 407-644-5722 Fax:407-628-1363
INSURERS AFFORDING COVERAGE
NAIC #
INSURED INSURER A: Old Dominion Insurance Co. 40231
INSURER B: St Faul Fire & Marine Ins. Co.
Bellomo Herbert & Camp an
Inc. INSURER C:
T
801 N. Orange Ave Suite /30
FL
2801
l
d INSURER D:
an
Or
o
3 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:jm
LTR
NSR
TYPE OF INSURANCE
POLICY NUMBER
DATE MM/D
DATE MMID
LIMITS
- - - GENERAL-LIABILITY .-.._:.._ EACH OCCURRENCE $1,000,000
A X COMMERCIAL GENERAL LIABILITY BPG0373A 10/23/09 10/23/10 PREMISE9(Eaoccu7ence) $ 1001000
- 7 CLAIMS MADE F_X] OCCUR MED EXP (Any one person) $ 5,000
X Contractual Liab PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000
X[ POLICY PRQT LOC
JEC
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT
000
000
1
A X ANY AUTO BPG0373A 10/23/09 10/23/10 (Eaacddent) ,
,
$
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS U IY/ (Per person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS C(li '
l ` (Peracddent) $
PROPERTY DAMAGE
(Per acddent) $
GARAGE LIABILITY L GI
Q NI) AUTO ONLY - EA ACCIDENT $
ANY AUTO Ht?c?s
EP
OTHER THAN EA ACC
$
AUTO ONLY: AGG $
EXCESSfUMBRELLALUU3ILITY EACH OCCURRENCE s2,000,000
A X OCCUR CLAIMSMADE CUG0373A 10/23/09 10/23/10 AGGREGATE s2,000,000
$
DEDUCTIBLE $
X
0 RETENTION $10,000 $._-.-_ -?-
WORKERS COMPENSATION AND X TORY LIMITS ER
A EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE WC0373A 10/23/09 10/23/10 E.L. EACH ACCIDENT $500,000
OFFICERIMEMBEREXCLUDED? E.L. DISEASE - EA EMPLOYEE $500,000
If yyes, describe under
SPECIALPROVISIONS below
E.L. DISEASE - POLICY LIMIT
$500,000
B OTHER
Professional
Liability
QP03814885
05/13/09
05/13/10
Per Claim 11000,000
Aggregate 1,000,000
DESCRIPTION OF OPERATIONS/ LOCATIONS/ VEHICLES/ EXCLUSIONS ADDED BY ENDORSEMENT/ SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
CITY! OO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
City of Clearwater
112 South Osceola Ave IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Clearwater FL 33756 REPRESENTATIVES.
AUT R
NTATN
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ACORD 25 (2001/08) 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).
T - -- -? 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.
A
,
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ACORD 25 (2001/08)