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CERTIFICATE OF LIABILITY INSURANCE (5) ''O RP- CERTIFICATE OF LIABILITY INSURANCE MIDDfYYYY) DATE 06/29/ 06/29/2010 PRODUCER THIS CERTIFICATION IS ISSUED AS A MATTER OF INFORMATION MARSH USA Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE TWO LOGAN SQUARE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR PHILADELPHIA, PA 19103 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Attn: Healthcare.AccountsCSS@marsh.com/FAX: 212 948-130 7 100607-CIGNA-CAS-10-11 • INSURERS AFFORDING COVERAGE NAIC # L...... INSURED ---- -- -- --- INSURER A ACE American Insurance Company 22667 CNA HEALTHCARE (ONSITE HEALTHS) (A SUBSIDIARY OF CIGNA CORP.) INSURER B: American Guarantee & Liability Ins Co 26247 11001 N BLACK CANYON HIGHWAY . PHOENIX, AZ 85029 INSURER C: Indemnity Ins Co Of North America 43575 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 TH E POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND AGGREGATE TS SHOWN MAY HAVE BEEN REDUCED BY PAID S. CONDITIONS OF SUCH POLICIES. NS ADD' TYPE OF INSURANCE pl --------- POLICY NUMBER ? DD' - A POLICY EFFECTIVE POLICY EXPIRATION LIMITS ECTIVE ----RTION - ------- --J--•---.---- LTR INSR DA7EIMNU4 DALE1 MM/DD/YYYY) A X GENERAL LIABILITY HDOG25519036 07/01/2010 07/01/2011 EACH OCCURRENCE 1,000,000 COMMERCIAL. GENERAL LIABILITY DAMAGE TO RENTED PREMISES(Ea occurrence $ 1,000,000 `. CLAIMS MADE .X.. OCCUR _.... __ _ .. . _ ..._.. _ .. ...... _.. -. _ MED EXP (Any-one:person) - _ _ $ " -5,000 PERSONAL & ADV INJURY $ 1 1 000 000 GENERAL AGGREGATE , , $ 3,000,000 GENERAL AGGREGATE LIMIT APPLIES PER PRO- PRODUCTS - COMP/OP AGE $ 1 ,000 000 XI POLICY JECT LOC A AUT OMOBILE LIABILITY ISAH08590412 07/01/2010 07101/2011 SINGLE LIMIT COMBINED $ 1 000 000 X ANY AUTO F R ? s caccident) , , ALL OWNED AUTOS I Y„ ?! P BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS JUL u C 2010 BODILY INJURY $ NON-OWNED AUTOS I - (Per accident) T!QA1 O PROPERTY DAMAGE $ K, i't ta, i't.'L,.? t? 1. s (Per accident) GARAGE LIABILITY 5 a-'S ., AUTO ONLY - EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ _ AUTO ONLY: $ AGG B EXCESS / UMBRELLA LIABILITY - AUC967096602 07/01/2010 07/01/2011 EACH OCCURRENCE $ 5,000,000 x 1 OCCUR 7 CLAIMS MADE AGGREGATE $ 5,000,000 $ DEDUCTIBLE RETENTION $ C WORKER EMPLOYE S COMPENSATION AND RS' LIABILITY WLRC46137073 (AOS) 07/01/2010 07/01/2011 X WC STATU- OTH- .. TS A SCFC46137115 (WI) 07/01/2010 07/01/2011 000 000 $ 1 Y/N ANY PROPRIETOR/PARTNEWEXECUTIVE WLRC46137036 CA MA 07/01/2010 07101/2011 -L. EACH ACCIDENT , , A _ OFFICERIMEMBEREXCLUDED? ( , ) A ?? I' WLRC46136998(WV) 07/0112010 07/01/2011 -L. DISEASE - EA EMPLOYE $ 1,000,000 (Mandatory in NH) IF yes, describe under L DISEASE -POLICY LIMIT 000 000 $ 1 SPECIAL PROVISIONS below . . , , A EXCESS WCUC46137152 (OH) 07/01/2010 07/01/2011 LIMIT $1,000,000 WORKERS COMPENSATION SIR $1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CITY OF CLEARWATER, FL IS INCLUDED AS ADDITIONAL INSURED (EXCEPT FOR WORKERS' COMPENSATION) WHERE REQUIRED BY WRITTEN CONTRACT. CERTIFICATE HOLDER CLE-002372329-03 CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE CITY OF CLEARWATER EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ATTN: CITY CLERK 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, PO BOX 4748 CLEARWATER, FL 337584748 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND THE INSURER, ITS AGENTS OR REPRESENTATIVES. UPON p qE Aof Mef8hED REFR CSENTA7NE (J S ?t l ??+_' C? Katey E- JJ onne s ACORD 25 (2009/01) ©1998-2009 ACORD CORPORATION. All Rights Reserved The ACORD name and logo are registered marks of ACORD 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 This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized the cert representative -....-_,._... ..-and thetpol c es; noristed thereonffirmatively or ne gativelyamend, _ does it ext nd or alter he odverage affo ded byifica Acord 25 (2009101) ADDITIONAL INFORMATION PRODUCER - --- MARSH USA Inc- TWO LOGAN SQUARE PHILADELPHIA, PA 19103 Attn: Heal thcare.AccountsCSS@marsh-com/FAX: 212 948-1307 100607-C IGNA-CAS-10-11 INSURED n CIGNA HEALTHCARE ONSITE HEALTHS) (A SUBSIDIARY OF CIGNA CORP.) 11001 N. BLACK CANYON HIGHWAY PHOENIX, AZ 85029 CLE-002372329-03 INSURERS AFFORDING COVERAGE INSURER F INSURER G: INSURER K INSURER I: DATE (MM/DDIM 08/29/2010 NAIC # TEXT F "IF EVIDENCE OF COVERAGE IS NO LONGER REQUIRED, KINDLY RETURN THE CERTIFICATE MARKED "NO LONGER REQUIRED", AND WE WILL ADJUST OUR FILES ACCORDINGLY." CERTIFICATE HOLDER CITY OF CLEARWATER ATTN: CITY CLERK PO BOX 4748 CLEARWATER, FL 33758-4748 Of MafShEl1lrFE. ENTATIVE y R? Katey E. Jones MARSH USA INC. TWO LOGAN SQUARE PHILADELPHIA, PA 19103 ATTN: HEALTHCARE.A000UNTSCSS@MARSH.COM/ 023288 CITY OF CLEARWATER M-023288 ATTN: CITY CLERK PO BOX 4748 CLEARWATER FL 33758-4748 050723