CERTIFICATE OF LIABILITY INSURANCE (154)f4ienHt• r2QRr%
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ACORDT, CERTIFICATE OF LIABILITY INSURANCE 09/17/ 010 '
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ISU Suncoast Insurance Assoc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 2266$ 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 a Travelers Casualty& Surety Co 19038
Suite 330 INSURER D: XL Specialty Insurance Company 37885
Clearwater, FL 33762
INSURER E'
rnVPDAnEs
' THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
ANY REQUIREMENT
,
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.
INS
LTR D
NSR
TYPE OF INSURANCE
POLICY NUMBER POLICY EFFECTIVE
p POLICY EXPIRATION
E LIMITS
A GENERAL LIABILITY 66068511
26A 10/02/10 10/02/11 EACH OCCURRENCE $1.000,000
X COMMERCIAL GENERAL LIABILITY _ DAMAGE TO
RENTED
(E. V
_MISr
$1,000,000
CLAIMS MADE F_x1OCCUR MED EXP (Any one person) $10,000
PERSONAL & ADV INJURY $1.000.000
GENERAL AGGREGATE $2 OOO OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG s2,000,000
I M POLICY X JERC0j F7 LPG
8 AUTOMOBILE LIABILITY BA48831_691 08/17110 08/17/11 COMBINED SINGLE LIMIT $1 OOO
OOO
ANY AUTO (Ea accident) ,
ALL OWNED AUTOS /+?
1 ED BODILY INJURY
?/ $
SCHEDULED AUTOS
(Per person)
X HIRED AUTOS ?] 1 BODILY INJURY
$
X NON-OWNED AUTOS SEP 2 0 6010 (Per accident)
PROPERTY DAMAGE
nrnclAL ,a 1 AN
A
.? V `
(Per accident)
$
GARAGE LIABILITY EG'i5?A11 sky`) AUTO ONLY-EA ACCIDENT $
4
4
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B EXCESS/UMBRELLA LIABILITY CUP6849Y191 08/17/10 08/17/11 EACH OCCURRENCE $5,000,000
X OCCUR 0 CLAIMS MADE AGGREGATE $5,000.000
DEDUCTIBLE $
X RETENTION $ 10000 $
G WoRtcERSGoMPENSATIdN Arm - X OTH-
- .-.
__ .:.._...._ _.-_ .: _
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $5OO 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 03/10/11 $2,000,000 per claim
Liability $2,000,000 annl aggr.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Professional Liability is claims made and reported.
Certificate holder is listed as an additional Insured with respects to
General Liability, Auto Liability and Excess Liability policies on a
primary and non-contributory basis. Waiver of Subrogation in favor of the
(See Attached Descriptions)
CERTIFICATE HOLDER L;ANt;1:LLA 1 ILIN 'I u ua S Tor rvon-ra meni
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Clearwater DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
Attn: City Clerk NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
PO BOX 474$ IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Clearwater, FL 33758-4748 REPRESENTATIVES.
AU ORIPED REPRESS TATIVE
OU?p 1*31111. 06-WA. A92 -^--~r
ACORD 25 (2001/08) 1 of 3 #S272508/M272504 KEB Q ACORD CORPORATION 1988
x
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.
ACORN 25-5 (2001/08) 2 of 3 #S272508/M272504
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 . #5272508/M272504