CERTIFICATE OF LIABILITY INSURANCE (3)ACORD TM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DO(YY)
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PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.
Cossio Insurance Agency THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
PO Box 188 COVERAGE AFFORDED BY THE POLICIES BELOW
Simpsonville, SC 29681 - 7
(864) 688-0121 INSURERS AFFORDING COVERAGE
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INSURED
A: The Burlington Insurance Company
Ultimate Bounce, LLC
3300 11th Street N
St. Petersburg, FL 33704 INSURED 8.
INSURED C:
INSURED D: ....._i
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INSURED E:
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COVERAGES .
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THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY
REQUIRMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WIHT 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
A!'_!_D Ff•ATF I IAAITC CWnIA/AI RAAV UA\/C OCCAI ?CNI 1h- oV MA- rI n RAC
INSR TYPE OF POLICY- POLICY NUMBER POLICY EFFECTIVE POLICY EXP u
LIMITS
LTR _ __
_ DATE (MM/DD/YY) DATE (MM/DD/YY)
GENERAL
LIABILITY Personal/Advertising Injury $1,000,00
COMMERCIAL GENERAL LIABILITY Products/camp Ops Aggregate $1,000,00
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? ? CLAIMS MADE Ld OCCUR Per Occurrence $1,000,00
General Aggregate $2,000,00
A ? Damages to Premises Rented $100,00
? HGL0025028 7/25/2010 7/25/2011 Medical Payments $1,00
$5
00
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GEN'L AGGREGATE LIMIT APPLIES PER
F&OLICY ?PROJECT ?LOC
AUTOMOBILE LIABILITY R ECEIVED COMBINED SINGLE LIMIT $
? ANY AUTO (Ea accident)
F-1 ALL OWNED AUTOS BODILY INJURY $
? SCHEDULED AUTOS
`J I lp f! O ;J C 2010 (Per Person)
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HIRED AUTOS BODILY INJURY $
? NON-OWNED AUTOS OFFIC IAL RECORDS D (Per accident) _......_-
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? c PROPERTY DAMAGE $
J 5 S D (Per accident)
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GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
? ANY AUTO OTHER THAN EA ACC $
? AUTO ONLY. AGG ... .................................
EXCESS LIABILITY EACH OCCURRENCE $
? OCCUR ? CLAIMS MADE A GGREGATE $
DEDUCTIBLE i ......... ............... ....._.......?._,.?- $
? RETENTION $ $
ORKERS COMPENSATION AND
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WC STATU- OTH-
EMPLOYER'S LIABILITY TORY LIMITS ER
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E.L. DISEASE - EA EMPLOYEE
I E.L. DISEASE - POLICY LIMIT
OTHER
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DESCRIPTION OF OPERATION S/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISION
Party Equipment Rentals Operations located at 3300 11th Street St. Petersburg, FL 33704
Certificate Holder As Additional Insured
I Amusement devices on file with the company for special events dated throughout the policy period located at 10 Pier 60 Drive, Clearwater, FL 33767.
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CERTIFICATE HOLDER CANCELLATION
City of Clearwater ............
P.O. Box 4748 ? BEFORE THE E
INSURER
XPIRATION DA THREOF,
WILL
ISSUING
Clearwater
FL 33758 MAIL 10 DAYS
NOTICE
THE
CERTIFICATE
,
; HOLDER NAMED TO THE LEFT, BUT FAI E TO DO SO SHALL IMPOSE
I NO OBLIGATION OR LIABILITY OF ANY IN ON THE INSURER, IT'S
I AGENTS OR REPRESNETATIVES
AUTHORIZED REPRESENTATIVE
1AUUNU Lb (LUu1/Uts)
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