CERTIFICATE OF INSURANCE (2)
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ACORD
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CERTIFICATE OF LIABILITY INSURANCE
~RODUCER (727)461-3704
Lancaster Insurance Agency
1210 S. Myrtle Ave.
POBox 2856
Clearwater, FL 33757
INSURED Mt Carmel Comnunity Development Corp
1751 Kings Highway
Clearwater, FL 33755
FAX (727)441-3298
DATE (MMIDDIYYYY)
11/01/2004
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.
INSURERS AFFORDING COVERAGE
NAIC#
Crump Insurance Services
INSURER A
INSURER B:
INSURER c:
INSURER D:
INSURER E
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO ll-IE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOlWlTHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR Oll-lER 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.
INSR ~!JD;~ TYPE OF INSURANCE POLICY NUMBER P8H'i::Y,ij~~gJJt.E Pg~g I~Xrv\;~~N LIMITS
LTR INSR
GENERAL LIABILITY CPS0611513 09/26/2004 09/26/2005 EACH OCCURRENCE $ 1,000,000
- ~~~~~J9 ,,~ENTED
X COMMERCIAL GENERAL LIABILITY ^' $ 50,000
- =:J CLAIMS MADE [8] OCCUR
MED EXP (Anyone person) $ 5,000
-
A PERSONAL & ADV INJURY $
-
GENERAL AGGREGATE $ 2,000,000
-
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS - COMP/OP AGG $
I nPRO- n
POLICY JECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- (Ea accident) $
ANY AUTO
-
ALL OWNED AUTOS BODILY INJURY
- (Per person) $
SCHEDULED AUTOS
-
HIRED AUTOS BODILY INJURY
- (Per accident) $
NON-OWNED AUTOS
~
f--- PROPERTY DAMAGE $
(Per aCCident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONL Y AGG $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $
tJ OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND I WC STATU-: I IOJ~-
TORY 1M TS
EMPLOYERS' LIABILITY E.L. EACH ACCIDENT $
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? EL. DISEASE - EA EMPLOYEE $
If yes. describe under E.L. DISEASE - POLICY LIMIT $
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER
City of Clearwater
Attn: Debbie
POBox 4748
Clearwater, FL 33758
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Eric Butler
ACORD 25 (2001/08) FAX: 562-4825
@ACORDCORPORATION 1988
LYJ l'-la Ulall
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.
r'i:lye L1L
ACORD 25 (2001/08)