CERTIFICATE OF LIABILITY INSURANCE (145)Client#: 5955
ADVASYS3
ArOR& CERTIFICATE OF LIABILITY INSURANCE
DATE
07
129/2010 '
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 S 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 REQUREMENT, 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.
1
LTR
NSR TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
A GENERAL LIABILITY 6606851 L26A 10/02109 10/02/10 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY
E TO RENTED
MS .r
DA
MA
RE ES ?E 'currencel
1,000,000
CLAIMS MADE F
_x1OCCUR MED P (Any one person) $10,000
_ PERSONAL & ADV INJURY $110001000
GENERAL AGGREGATE s2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $2,000,000
R2r POLICY X PRO LOC
JECT
B
AUTOMOBILE LIABILITY
BA4883L691 'I
08/17?Q1
08/17/11
COMBINED SINGLE LIMIT
000
000
$1
ANY AUTO (Ea accident) ,
,
ALL OWNED AUTOS E BODILY INJURY
SCHEDULED AUTOS 10 (Per person) $
X HIREDAUTOS A
V 20
O BODILY INJURY
y
" (Per accident) $
X NON-OWNED AUTOS p
ECC T
GI R
D ? PROPERTY DAMAGE
Oft,
1
S?
(Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
1 F AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY CUP6849Y191 08/17110 08/17/11 EACH OCCURRENCE s5,000,000
X OCCUR ? CLAIMS MADE AGGREGATE $5,000,000
DEDUCTIBLE $
X RETENTION $ 10000 $
C -
WORKERS COINPENSATION AND
UBf 848Y20
08/17/10
08117/11 WC STATU-0
X TORY.LIMITS -
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $500 OOO
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
E.L. DISEASE - EA EMPLOYEE
$500,000
If yes, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT
$500,000
D OTHER Professional DPR9684682 03110/10 03/10111 $2,000,000 per claim
Liability T
$2,000,000 annl aggr.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / 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)
City of Clearwater
Attn: City Clerk
PO Box 4748
Clearwater, FL 33758-4748
Tor Non-r
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL AA DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO $O SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
AUT "Oft RESEjITAT QIV11,
;P
ACORD 25 (2001/08) 1 of 3 #S262247/M262243 KEB 6) 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 #S262247/M262243
I , . ,... DESCRIPTIONS (Continued. from Page 1)
additional insured applies to the General Liability, Auto Liability,
Excess
Liability and Workers Compensation policies.
AMS 25.3 (2001/08) 3 of 3 #S262247/M262243