CERTIFICATE OF LIABILITY INSURANCE (18)POR-22-2010 09:57 From:5ANDBERGEN 7274469147 To:7274626957 P.1/1
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A ° ° CERTIFICATE OF LIABILITY' INSURANCE 4DATE /2`2/20" a'
PRCNCER (727)442-0012 FAX: (727)446-9147 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
Sandbergen Xnsuranee Inc. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
2121 N.E. Coachman Road
Clearwater FL_ 33765-2616 _ INSURERS AFFORDING COVERAGE NAIC a
INSURED INSURER A: Travelers Insurance Co. ? 25659
Marina Restaurant 6 Coffee Shop INSURER B• _
Thomas or Patty Wolkowsky INSURER C: _
25 Causeway Boulevard INSURER D:
Clearwa er Beach FL 33767-2064 INSURER E.
COVERAdES
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 IPY PAID CLAIMS,
INSR ADFL POLICY NUMBER POLICY EFFECTIVE
an == LIMITS DATE MMIDUO=
GENERAL LIABILITY EACH OCCURRENCE $ 2, as 000
IC
COMMERCIAL 4ENERAL LIABILITY DAMA CNTtD
P . ISES
(Ea cecurrence)
$
X00 000
A CLAIMS MADE uOCCUR 6608947P40ACOP1D 4/1/2010 4/1/2011 ,
MEOEMP(
one arson S 5,000
_ -_
_PERSONAL S ADV INJURY s 2 000, 000
••- GENERAL AOCREOATE 4,000,9
GEN'L AGGREGATE LIMIT APPLIES PER:
. nO0VCTS - COMPIOP AGG S 4,00 0 000
1 PRO LOC
POLICY 1
AUT OMOBILE LIABILITY
ANY AUTO
E
EIVE COMBINED SINGLE LIMIT
(En ==dent) S
AI I OWNED AUTOS ._.
BOOK V INJURY
SCHEDULED AUTOS
(Par paw) ;
HIRED AUTOS
AP
2 6 2010
HODILY INJURY _ _
NON-OWNED AUTOS (Per acaldenq
QrFICU1L ?; l±,
u)() PROPERTY DAMAGE
.
(Per acaldenq I s
vARAQE LIABILtTV _ AUTO ONLY - EA ACCIOEN'I' $
ANY AUTO OTHER THAN E.A ACC $
AUTO ONLY: AGO S
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
0"..UR H CLAIMS MADE AGGREGATE $
?- s
DEDUCTIBLE
--- s
RETENTION P - s
WORKERS COMPENSATION CSTATU- OTH-
AND EMPLOYI V LIABILITY TORY LIMRB
EB-
YIN A
ANY PR
1E
TOR)PARTNEA/EXEDU71VE
M
FH r., L. EACH ACCIDENT $
O
OEMER EXCWOED7
RI
E
B
(MondaUn In NIQ
E.L DISEASE,- EA EMPLOYE F
S
Iryee, cnaa unuer
pea
.SPECIAL
PROVIS NS IOW L.L DISEASE . POLICY LIMIT S
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
OFIRTIFICATR NAI nFF1 reullw I Arlnu
(727)462-6957 SHOULD ANY CF TNEABOVE DESCRIBED POLICIES BE CANC£I I ED BEFORE TH C EXPIRATION
City of Clearwater DATE THEREOF, THE ISSUINO INSURER WILL ENDEAVOR TO MAI4 10 DAYS WRITTEN
The Marine a Aviation Division
25 Causeway Boulevard NOTICE TO THE CERTIFICATE NOLDCR ED TO THE LEFT, BUT PAILURE DO SO SHALL
Clearwater Beach, FL 33767 IMPOSE NO OBLIGATION OR U ANY KIN THE I UR , TS AGENTS OR
REPRESENTATIVES.
AUTNDRLMO REPRE9ENTA E
_.ST
.Steven R. Sandb zg
ACORD 25 (20a9/OT) 0 INS-2009 ACORD CORPOF1AITMDN. All rlghtor'FAServed.
INS025 (pwwl) The ACORD name and logo are registered marks of ACORD ?1