CERTIFICATE OF LIABILITY INSURANCE (129)ACRD CERTIFICATE OF LIABILITY INSURANCE CuIrsD &F-1 DATE(MMIODlYY 0 OP A_71K1 a3 1s 10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
`rallace Welch & Willingham Inc HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
In 1 a* alre Q^ R+-h 77 nnr ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Phone : 727-522-7777 Fax: 727-521-2902 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURER A, Nat'l Fire Ina Co of Hartford 015055
INSURER R; Architects 6 Engineara Ins Co 44148
Inc.
Cumbey & Fair INSURER C: Transportation Ina. Co. 20494
,
2463 Enterprise Rd.
FL 33763
Cl
t INSURER D: Florida Ratail Federation SIF
earwa
er
- INSURER £:
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 DESCRI8ED 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 HUMBER POLIY
DATE hSM?t)lYY E DATE A XXM1VDD! Y LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X COMMERCIALGENERALLIABILITY 2086949437 03/16/10 03/16/11 PREMISES(Eaoccurence) $ 300,000
CLAIMS MADE ? OCCUR MED EXP (Anyone person) $10,000
PERSONAL HADVINJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $2,000,000
POLICY X PR OT LOC Em Ban. 1 000 000
AUT OMOBILE LIABILITY
COMBINED SINGLELIMIT
1
000
000
(Ea accident)
S
,
,
A X ANY AUTO 2088208783 03/16/10 03/16/11
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HI RED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Peraccldent)
PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY - EAACCIOENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY. AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $2,000,000
C ICLaIMSMADE
X OCCUR I 2086949471 03/16/10 03/16/11 AGGREGATE $2,000,000
- $
H DEDUCTIBLE S
X RETENTION $10,000 S
WORKERS COMPENSATION AND X TORY LIMITS ER
A PR4 EMPLOYERS'LIABILITY
ANY PROPRIETORlPARTNERIEXECUTIVE
ANY RI£T
052024651
03/16/10
03/16/11
f.L.EACH ACCIDENT
$ 1,000,000
OFFICERIMEMBEREXCLUDED? E.L. DISEASE - EAEMPLOYEE $1,000,000
I(yes, describe under
SPECIAL PROVISIONS belayy
E.L. DISEASE -POLICY LIMIT
$ 1 000 000
OTHER
B Professional Liab AEICPG08 03/16/08 03/16/11 Ea Claim 1,000,000
CLAIMS MADE Aggregate 1,000,000
DESCRIPTION OF OPERATIONS 1 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Certificate holder is additional insured on a primary and noncontributory
basis with respect to General Liability if required by written contract per
form G17957G and certificate holder is additional insured with respect to
auto liability and Excess policy per coverage forma, waiver of subrogation
applies to to General Liability & Auto Liability if required by ->->->
r?
CERTIFICATE HOLDER CANCELLATION
City of Clearwater
City Clert
P.O. 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 30 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.
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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 26 (2009108)
NOTEPAD:
written contract.
r. premium.
t
HOLDER CODE CUM&F-1 PAGE 3
IN5URED'5 NAME Cumbey & Fair, Inc. OP 1D AJK1 DATE 03/16/10
10 day notice of cancellation applies for non payment of