CERTIFICATE OF LIABILITY INSURANCE (2)•
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From: Alvina Davis At: Rae Insurance FaxID: To: Marie Orsello
Date: 10/12010 03:27 PM Page: 2 of 3
OP ID
CERTIFICATE OF LIABILITY INSURANCE
ACORD DATE (MM/DD/YYYY)
_
rouNVIL 10/01/10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Greg Roe Insurance, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
9851 State Road 54 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
New Port Richey FL 34655
Phone:727-376-0030 Fax:727-376-2262 INSURERS AFFORDING COVERAGE NAIC9
INSURED INSURERA Riverpozt Ing=ance Cvmpa y 04377
INSURER B. Undelwriters at Lloyd's
Foundation Village
Neighborhood Fam:Lly Ctr, Inc. INSURERc
918 Woodlawn St.
t
33756-2157 INSURER0
er FL
Clearwa
INSURER E.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECTTO 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
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE (MM/DD DATE (MMIDOlYY LIMrrS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A ]{ COMMERCIAL GENERAL LIABILITY NIA1816799 10/01/10 10/01/11 PREMISES (Eaoccurence) $ 100,000
CLAIMS MADE Fx7 OCCUR VIED EXP (Any one person) $ 5,000
PERSONAL &ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 3,000,000
GFN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS - COMP/OP AGG $ 3,000,000
POLICY PERO LOC
JC7
AUT OMOBILE LIABILITY
COMBINED SINGLE LIMIT
$ 1,000,000
A ANY AUTO NIA1816799 10/01/10 10/01/11 (Ea accident)
ALL OWNED AUTOS BODILY INJURY
$
X SCHEDULED AUTOS (Per person)
X HIRED AUTOS BODILY INJURY $
}{ NON-OWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO REC E E D OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE p
?I IV 10
RRR ??, V 2010 AGGREGATE
$
DEDUCTIBLE OFFICIAL RECO RDS AND $
RETENTION $ 1 r_ $
WORKERS COMPCNSATION AND TORY LIAIU- ER
EMPLOYERS' LIABILITY
ANY' PROPRIETOR/PARTNER/EXECUTIVE
E L. EACH ACCIDENT _
$ ?_mm^
OFFICER/MEMSFR EXCLUDED? E.L. DISEASE - EA EMPLOYEE $
If yes, de5cnbe under
SPECIAL PROVISIONS below E.L. DISEASE- POLICY LIMIT $
OTHER
A Crime NTA1816199 10/01/10 10/01/11 Bldg 303,000
B Property L13506 02/22/10 02/22/11
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
*30 DAYS NOTICE OF CANCELLATION, EXCEPT 10 DAYS NOTICE OF CANCELLATION FOR
NON-PAYMENT OF PREMIUM. WORKERS COKPENSATION APPLIES TO FLORIDA OPERATIONS
ONLY.
CERTIFICATE HOLDER CANCELLATION
CITYCLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
CITY OF CLEARWATER
FAX #727-562-40217 w DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
ATTN: MARIE ORSELLO ?lr
112 S. OSCEOLA AVENUE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
CLEARWATER FL 33756 REPRESENTATIVES.
A IZEDREPRESENTATIV
ACORD 25 (2001108) -Th Y)I ® ACORD CORPORATION 1988
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From: Alvina Davis At: Roe Insurance FaxID: To: Marie Orsello
Date: 10/1/2010 03:27 PM Page: 3 of 3
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.
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C7
ACORD 25 (2001108)