CERTIFICATE OF LIABILITY INSURANCE (10)v
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.
D'
SR
TYPE OF INSURANCE
POLICY,NUMBER POLICY EFFECTIVE POLICY E%PIRATION
DATE (NIMIDOWn
LIMITS
A GENERAL LIABILITY NCPKGO126000 02/01110 02101/11 EACH OCCURRENCE $ 1,000,000
X DAMAGE T RENTED 000
000
1
r COMMERCIAL GENERAL LIAeILrTY 1 REMISE _b n.., ,
,
CLAIMS MADE 7 OCCUR MED EXP (Arry one Berson) $ 20,000
• PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS -COMP10PAGG $ 2,00D,D00
1 7 POLICY j,C LOC
A AUT OMOBILE LIABILITY NCAUT0126000 02/01/10 02/01/11 COMBINED SINGLE LIMIT
000
000
$ 1
X ANY AUTO (EaaccldenU ,
,
ALL OWNED AUTOS R E I E
V
BODILY INJURY
$
SCHEDULED AUTOS (Per person)
HIRED AUTOS r
G 2010
130DILY INJURY
(Peraccident) $
NON-OWNED AUTOS
WD PROPERTY DAMAGE
$
OFFICIA L RECORDS (Per ealdent)
AGE LIABILITY L7
iVF SRVC AUTO ONLY - EA ACCIDENT $
ANY AUTO bTHERTHAN EAACC S
AUTO ONLY: AGG S
A EXCESSAIMBRELLA LIABILITY NCUMB0126000 02/01/10 02101/11 EACH OCCURRENCE $ 1,000,000
X OCCUR E? CLAIMS-MADE AGGREGATE • $ 1.000,000
S
DEDUCTIBLE S
X RETENTION $ 10,000 S
X WCSTATU- H3-
' WORKERS COMPENSATION AND 2836521210 02101110 02/01/11
B EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT 1,0D0,00D
$
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERIMEMBEREXCLUDED?
E.L. DISEASE-EA EMPLOYEE
S 1,000,000
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Certificate Holder Is an Additional Insured with respects to General Liability,
A
O' `D. CERTIFICATE OF LIABILITY INSURANCE OAT 2110/2D/YYYY)
2/10/2010
T
PRODUCER Wells Fargo Insurance Services USA
Inc THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
,
. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Southeast, Inc, HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. O. Box 31666
Tampa FL 33631-3666 INSURERS AFFORDING COVERAGE NAIC #
INSURED Chi Chi Rodriguez Youth Foundation
Inc, - INSURER A: Arch Insurance Company 11150
,
M
M
ll
B
h
d INSURERS: Zenith Insurance Company 13269
3030
c
u
en
oot
Roa
INSURER C: -
INSURER D:
Clearwater FL 33761 INSURER E;
Twee n n_ee
City of Clearwater
PO Box 4748
Clearwater, FL 33758
8403
LID ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 90 DAYS WRITTEN
;E TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SD SHALL
3E NO OBLIGATION OR LIABILITY OP ANY KIND UPON THE INSURER, ITS AGENTS OR
AUTHORIZED REPRESENTATIVE
ACORD 25 (2001108) 1 of 2
ra AC/lRn rnRIP17RATION 19RF
i-IMPORTANT
16
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, certaln -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•S (2001/08) 2 of 2 #S915260/M915043