CERTIFICATE OF LIABILITY INSURANCEOP ID: DA
CERTIFICATE OF LIABILITY INSURANCE
"'
1 DA1/11/10
11/11/10
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS .;
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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).
PRODUCER 727-784-8554 NAME: CT
Stahl Ross & Associates Inc. 727.789.2823 nHC"x Ext : FAIC No):
3939 Tampa Road L
ADDRESS:
Oldsmar, FL 34677
D
id T
C PRODUCER CLEARI7
CUSTOMER ID S:
av
.
osper INSURER $ AFFORDING COVERAGE NAIC A
INSURED Clearwater Golf Club LLC INSURER A : National Trust Ins. Co.
625 N Betty Ln INSURER B: Zenith Insurance Co!E an
Clearwater, FL 33756 INSURER C : FCCI
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER: 2 REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY NUMBER MMID?IYYri MMNd EXP LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ _ 1,000,00
A X COMMERCIAL GENERAL LIABILITY X CPP00117691 10/01/10 10!01/11
DAMA01! TO RtNT E15
P
REMISES Ea occurrence
$ 100,00
CLAIMS-MADE FKOCCUR MED EXP (Any one person) $ 10,00
PERSONAL & ADV INJURY S 1,000,00
GENERAL AGGREGATE $ 2,000,00
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG 5 Included
POLICY P
irr-T F7 RO- LOC
F% r 0110. n IF
I r%
$
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT S 1,000,000
1
/
1/1 1
1/11
/ (Ea accident)
C ANY AUTO CA00170601 0
0
0 0
0
BODILY INJURY (Per person) $
ALLOWNEDAUTOS
v L
NOV 17 ?o
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS PROPERTY DAMAGE
X HIRED AUTOS (Per accldent) $
RECORD
OFFICIAL A w fry
S AVD $
X NON-OWNED AUTOS
EGISL&M SRV DEPT $
UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 1,000,00
EXCESS LIAB CLAIMS-MADE
1
/
1/1
1
/01/11 AGGREGATE $ 1,000,00
C UMB00114901 0
0
0 0
DEDUCTIBLE $
X RETENTION S $
WORKERS COMPENSATION
' X WC STATU- OTH-
LIABILITY
AND EMPLOYERS
Y
B ANY PROPRIETORIPARTNERIEXECUTIVE Z070896701 10101/10 10/01111 E.L. EACH ACCIDENT $ 500,00
OFFICERIMEMBER EXCLUDED? N I A
500
00
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE ,
S
If yea, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
S 500,00
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space Is required)
City of Clearwater is named as additional insured as respects general
liability only subject to the terms, conditions and exclusions listed on the
policy.
CERTIFICATE HOLDER CANCELLATION
CLEAR-6
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater
100 Myrtle Ave.
Clearwater
FL 33756 AUTHORIZED REPRESENTATIVE
, ,Q?--
Q 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
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