CERTIFICATE OF LIABILITY INSURANCE (128)Client#: 5955
ADVASYS3
ACORD? CERTIFICATE OF LIABILITY INSURANCE
DATE (MMIDD/Y
3/09/2010 YYY)
0
PRODUCER
ISU Suncoast Insurance Assoc
P.O. Box 22668 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.
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 & Surety Co 19038
Suite 330 INSURER D: XL Specialty Insurance Company 37885
Clearwater, FL 33762
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.
INSR
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATEYEFFECTIVE POLICY EXPIRATION
LIMITS
A GENERAL LIABILITY 6606851126A 10/02/09 10/02/10 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY
A
MAGE TO RENTED-
D
P M,
RE SE
1 OOO 000
CLAIMS MADE D OCCUR MED EXP (Any one person) $10,000
PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000
POLICY X jE OT LOC
B AUT OMOBILE LIABILITY BA48831-69109 08/17109 08/17110 COMBINED SINGLE LIMIT
(Ea accident) $1,000,000
ANY AUTO
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS R CE NE D (Per person) $
X HIRED AUTOS BODILY INJURY
X
NON-OWNED AUTOS
M I?
1
0
0 (Par accident) $
1.1 1
1 2 PROPERTY DAMAGE
ft. A
(Per accident) $
GARAGE LIABILITY ' ??C AUTO ONLY - EA ACCIDENT $
LEW SM N ."
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY CUP6849Y191 08/17/09 08/17/10 EACH OCCURRENCE $55,000,000
X OCCUR El CLAIMS MADE AGGREGATE $5,000,000
DEDUCTIBLE $
X RETENTION $ 10000 $
[; WORKERS COMPENSATION AND UB6848Y20109 08/17/09 08117110 X I CST OTH-
. ,---. -EMPLOYERS' LIABILITY :. - -- : - ------
E.4• Z&Lij-ACCIDENI
_
- -
$500,0100-
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $500 00,000
IT yes, describe under
SPECIAL PROVISIONS below
E.L- DISEASE - POLICY LIMIT 1
"500.000
D OTHER Professional DPR9684682 03/10110 03/10111 $2,000,000 per claim
Liability $2,000,000 annl aggr.
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I 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)
CERTIFICATE HOLDER
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 &I DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AU ORIZED REPRES TATIVE
'Oft W.b rti --- -
ACORD 25 (2001/08) 1 of 3 #S239345/M239340 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-S (2001/08) 2 of 3 #S239345/M239340
IESCRIPT'M ?d, #lrorn> P a
additional insured applies to the General Liability, Auto Liability,
Excess
Liability and Workers Compensation policies.
AMS 25.3 (2001108) 3 of 3 #S239345/M239340