CERTIFICATE OF LIABILITY INSURANCE (95)Client: 148035 COGBROS
ACORD
CERTIFICATE OF LIABILITY INSURANCE DATE (MM/D
D[YYYY)
TM 12
/16/09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Wells Fargo Ins Serv USA- TA,FL ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
800 N Magnolia Avenue
Suite 106 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
, ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Orlando, FL 32803
407.650.9440 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A: SeaBright Insurance Company 15563
Cogburn Bros., Inc.
INSURERS:
3300 Faye Road
INSURER C:
Jacksonville, FL 32226
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.
LTR
NSR TYPE OF INSURANCE POLICY NUMBER DPOLICY EFFECTIVE
T /DD/YY POLICY EXPIRATION
DATE MM/DD/YY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
irrencel $
CLAIMS MADE OCCUR MED EXP (Any one person) $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
POLICY PRO LOC
JECT
AUTOMOBILE LIABILITY
ANY AUTO
COMBINED SINGLE LIMIT
(Ea accident)
$
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS BODILY INJURY
NON-OWNED AUTOS
(Per accident) $
PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR ? CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION AND BB11092009 01/01110 01/01/11 X OR SLIMIT 0ER
r EMPLOYERS' LIABILITY
PROPRI
EGLIT!VE
NE
,
_
'
EACH ACCIDENT
E.L.
$1,000 QQQ
..i..
.
- ....
:,ANPIC
QFt EXCL
M
E
.
.. .. _._ :.._•
.. - .::
. ... - - .
~
•-
_ .. - -
- -- -
E.L. DISEASE - EA EMPLOYEE
'$1,006,000
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT 1
$1.000.000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
IC nVLVCI[
City of Clearwater
c/o Office of County Attorney
City Hall Building, 3rd Floor
112 S. Osceola Ave
Clearwater, FL 33756
LD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30DAYS WRITTEN
E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
'_SENTATIVES,
ORIZED REPRESENTATIVE
ACORD 25 (2001/08) 1 of 2 #M1537781 SMP01 Q 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
~y 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 25-3 (2001/08) 2 of 2 #M1537781