CERTIFICATE OF INSURANCE FOR ENTRANCE MONUMENTS IN RIGHT-OF-WAY 2003
CITY OF CLEARWATER
POST OFFICE Box 4748, CLEARWATER, FLORIDA 33758-4748
CIlY HALL, 112 Sourn OSCEOLA AVENUE, CLEARWATER, FLORIDA 33756
TELEPHONE (727) 562-4090 FAX (727) 562-4086
DEPARTMENT OF mE
CIlY CLERK
April 15, 2002
Momingside Meadows Homeowners Civic Association
C/o Bill Zimmerman
P. O. Box 5182
Clearwater, Florida 34618-5182
Re: Agreement with City of Clearwater for Monument in Right -of- Way
To Whom It May Concern:
I am hereby requesting an insurance certificate from the Homeowners Association naming the City of
Clearwater as an additional insured with regard to the monument structures your association has placed
in the City right-of-way at the entrance to the subdivision. The agreement dated April 4, 1995 requires
that you carry liability insurance naming the City as an additional insured. Your current policy expires
May 15, 2002. .
If you have any questions, please contact me at 727/562-4097.
Sincerely,
1 ~'''' _~ ';'
/ - . /:. ,,/;/,A,-1.4'~ ~/
~ /, . "<./1'''9'''/./'''-
Susan Stephenson "
Document & Records Supervisor
/ss
End.
RECEIVED
MAY 032002
CITY CLtfiK OEP,i\RTMENT
*
"EQUAL EMPLOYMENT AND AFFIRMATIVE ACTION EMPLOYER"
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Carlisle Fields & Company, Ine
P.O. Box 7910
Clearwater, FL 33758-7910
Phone: 727-797-0441 Fax: 727-725-3663
2051781602
I N V 0 ICE # 66185
Morningside Meadows Homeowners
Civic Assn. % WiIliam Murray
P.O. Box 5182
Clearwater, FL 33758-5182
Auto Insurance Company
.......~1\it ............~l>lMTIq.(>..... ..........<............i..>.......>...~ij.#i9#~lffi91li...<i.......... ........
05/15/02 05/15/03 05/15/02
315603 05/15/02 REN GL-S
02' - 03' GL Renewal
$
358.00
Invoice Balance:
$
358.00
:dt,90\
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PLEASE PRINT YOUR CUSTOMER ID & INVOICE # ON YOUR CHECK FOR
FASTER PROCESSING! This is your only invoice. Thank You!
Auto-Owners
Page
1 55040 (11187>
Issued 04-01-2002
TAILORED PROTECTION POLICY DECLARATIONS
INSURANCE COMPANY
6101 ANACAPRI BLVD., lANSING, MI 48917-3999
AGENCY CARLISLE FIElDS 8 CO INC
12-0025-00 UNIT 068 (727) 797-0441
INSURED MORNI NGSI DE MEADOWS HOMEOWNERS
CIVIC ASSOC
Renewal Effective 05-15-2002
POLICY NUMBER 952312-20517816-02
ADDRESS PO BOX 5182
Agency
Bill
POLICY TERM
12:01 a.m. 12:01 a.m.
05-15-2002to 05-15-2003
CLEARWATER, Fl 33758-5182
In consideration of payment of the premium shown below, this policy is renewed. Please attach this
Declarations and attachments to your policy. If you have any questions, please consult with your agent.
COMMERCIAL GENERAL LIABILITY COVERAGE
LIMITS OF INSURANCE
General Aggregate limit
(Other Than Products-Completed Operations)
Products-Completed Operations Aggregate limit
Personal And Advertising Injury limit
Each Occurrence limit
Fire Damage limit
Medical Expense limit
$500,000
500,000
500,000
500,000
50,000 Any One Fire
5,000 Any One Person
"General Aggregate limit" shown above, is reinstated once per policy period at no
additional charge, in accordance with form 55050.
AUDIT TYPE: Non-Audited
FORMS
55081
55050
55137
59246
THAT APPLY TO LIABILITY:
(08-88) 55029 (07-87)
(07-87) 55064 (07-87)
(06-92) 55146 (07-96)
(05-00) 55145 (12-01)
55084 (11-95)
CG0001 (11-88)
C1l75 (02-86)
55160 (11-95)
55118 (08-91>
CG0220 (07-92)
55069 (01-88)
55163 (11-95)
Il0021 (11-85)
Il0017 (11-85)
CG2147 (09-89)
55181 (11-95)
LOCATION OF PREMISES YOU OWN, RENT OR OCCUpy
LOC 001 BLDG 001 2296 Habersham Drive
Clearwater, Fl 33764
TERRITORY: 004
COUNTY: Pinel1as
Classification Subline
Premium
Basis
Rates
Each 1
1.024
Premium
CODE 41670
Homeowners 8/0r Mobile Homeowners Prem/Op
Associations - No Buildings Or
Premises Owned Or leased Except For
Office Purposes. Including Products
And/Or Completed Operations.
(Not-For Profit)
Prem/Op Prem
350
$358.00
Additional Interests
Designated Per/Organization l
City Of Clearwater
CODE 49950
Prem/Op
If Any
$0.00
lOCATION 001 PREMIUM
$358.00
Agency Code 12-0025-00
Policy Number 952312-a"
55181 (,
COMMERCIAL GENERAL L1ABILI\
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR
ORGANIZA TION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization:
CITV OF CLEARWATER
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
1. WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Scheduleas.aninsured but only with respect to liability arising out of your operations or premises owned by or
rented to you.
2, The following is added to LIMITS OF INSURANCE (Section III):
8, The JimitsofHabUity for the additional insured are those specified in the written contract or agreement be-
tween the.lnsuredandthedesignated person or organization, not to exceed the limits provided in this policy.
These limits are inclusive of and not in addition to the limits of insurance shown in the Declarations.
Includes copyrighted material of Insurance Services Office, Inc., with its permission
Copyright, Insurance Services Office, Inc., 1984
, .
iCY Code 12-0025-00
Policy Number 952312-20517816
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
55163 (11-95)
COMMERCIAL GENERAL LIABILITY
ADDITIONAL INSURED - CONTROLLING INTEREST
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or Organization:
lIlY OF CLEARWATER
(if no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
1.
WHO IS AN INSURED (Section II) is amended to in- 3.
clude as an insured the person(s) or organization(s)
shown in the Schedule, but only with respect to their
liability arising out of
a. Their financial control of you; or
b. Premises they own, maintain or control while
you lease or occupy these premises.
This insurance does not apply to structural alter-
ations, new construction and demolition operations
performed by or for that person or organization.
2.
The following is added to LIMITS OF INSURANCE
(Section III):
8. The limits of liability for the additional insured
are those specified in the written contract or
agreement between the Insured and the con-
trolling interest, not to exceed the limits pro-
vided in this policy. These limits are inclusive
of and not in addition to the limits of insurance
shown in the Declarations.
Includes copyrighted material of Insurance Services Office, Inc., with its permission
Copyright, Insurance Services Office, Inc., 1984
~yCode 12-0025-00
Policy Number 952312-20517816
~
~
55145 (12-01)
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
AMENDMENT OF POLLUTION EXCLUSION _
EXCEPTION FOR BUILDING HEATING EQUIPMENT
This endorsement modifies insurance provided under the COMMERCIAL GENERAL LIABILITY COVERAGE FORM,
It is agreed:
Under SECTION I - COVERAGES, COVERAGE A. BODILY INJURY AND PROPERTY DAMAGE LIABILITY, 2. Exclu-
sions, exclusion f., subparagraph (1) (a) is deleted and replaced by the following:
This insurance does not apply to:
f. (1) "Bodily injury" or "property damage" arising out of the actual, alleged or threatened discharge, dis-
persal, seepage, migration, release or escape of pollutants:
(a) At or from any premises, site or location which is or was at a-ny time owned or occupied by, or
rented or loaned to any insured. However, this subparagraph, (a), does not apply to "bodily injury"
if sustained within a building at such premises, site or location and caused by smoke, fumes, va-
por or soot from equipment used to heat a building at such premises, site or location.
All other policy terms and conditions apply.
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
Copyright, Insurance Services Office, Inc., 1996, 1997
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