CERTIFICATE OF INSURANCE FOR ENTRANCE MONUMENTS IN RIGHT-OF-WAY 2002
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CITY OFCLEARWATER
POST OFFICE Box 4748, CLEARWATER, FLORIDA 33758-4748
CI1Y HALL, 112 Soum OSCEOLA AVENUE, CLEARWATER, FLORIDA 33756
TELEPHONE (727) 562-4090 FAX (727) 562-4086
DEPARTMENT OF THE
C1lY CLERK
April 19, 2001
Morningside Meadows Homeowners Civic Association
C/o Pattililu P.dliQ ~r J II ~ (3//"'1.. Z/MM~/liV'/tTV
P. 0. Box 5182
Clearwater, Florida 34618-5182
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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.
If you have any questions, please contact me at 727/562-4097.
Sincerely,
I) ~
~ . t/
Susan Stephens
Document & Records Supervisor
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Encl.
REC
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CITY CLEr:li(
BRIAN]. AUNGST, MAYOR-COMMISSIONER
J .B. JOHNSON, VICE MAYOR-COMMISSIONER
ED HART, COMMISSIONER
(i)
BOB ClARK, COMMISSIONER
F. DA\lD HEMERlCK, COMMISSIONER
"EQUAl. EMPLOYMENT AND AFFIRMATIVE ACTION EMPLOYER"
.Auto-Owners
. Page
1 55040 (11/87)
Issued 05-11-2001
TAILORED PROTECTION POLICY DECLARATIONS
INSURANCE COMPANY
6101 ANACAPRI BLVD., LANSING, I'll 48917-3999
Renewal Effective 05-15-2001
AG~CY CARLISLE FIELDS & CO INC
12-0025-00 UNIT 68
INSURED MORNI NGSI DE MEADOWS HOMEOWNERS
CIVIC ASSOC
POLICY NUMBER 952312-20517816-01
ADDRESS PO BOX 5182
Agency
Bill
POLICY TERM
12:01 a.m. 12:01 a.m.
05-15-2001 to 05-15-2002
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)
55084 (11-95)
CG0001 01-88)
CL175 (02-86)
55160 (11-95)
55118 (08-91>
CG0220 (07-92)
55069 (01-88)
55163 (11-95)
H0021 01-85)
H0017 01-85)
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: Pine11as
Classi~icatian Sub line
Premium
Basis
Prem/Op Prem
350
Rates
Each 1
1. 024
Premium
CODE 41670
Homeowners &/Or Mobile Homeowners Prem/O~
Associations - No Buildings Or
Premises Owned Or Leased Except For
Office Purposes. Including Products
And/Or Completed Operations.
(Not-For Profit)
$358.00
CODE 49950
Additional Interests
Designated Per/Organization L
City Of Clearwater
Prem/Op
If Any
$0.00
LOCATION 001 PREMIUM
$358.00
Agency Code 12-0025-00
Policy Number 952312-20517816
55181 (11-95)
COMMERCIAL GENERAL LIABILITY
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:
CITY 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
Schedule as an insured 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 limits of liability for the additional insured are those specified in the written contract or agreement be-
tween the Insured and the designated 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
Copyri.ght, Insurance Services OffICe, Inc., 1984
Agency Code 12-0025-00
Policy Number 952312-20517816
55163 (11-95)
COMMERCIAL GENERAL L1ABI L1TY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - CONTROLLING INTEREST
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Name of Person or. Organization:
lITY 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 ot
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