CERTIFICATE OF INSURANCE (13)
Client#: 14106
OWENA YRES
A~RDTM CERTIFICATE OF LIABILITY INSURANCE
- .
DATE (MM/DDIYYYY)
01/26/04
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.
PRODUCER
WAUSAU INSURANCE COMPANIES
3430 OAKWOOD MALL DRIVE
SUITE 300
EAU CLAIRE, WI 54701
OWEN AYRES AND ASSOCIATES INC
ATTN TOM STUMM
PO BOX 1590
EAU CLAIRE, WI 54702-1590
INSURERS AFFORDING COVERAGE NAIC #
INSURER A: WAUSAU UNDERWRITERS INSURANCE O.
INSURER B: EMPLOYERS INSURANCE OF WAUSAU
INSURED
INSURER C:
INSURER D:
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 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.
LTR NSR[ TYPE OF INSURANCE POLICY NUMBER P~+~~J~~68~~\E Pg~fl,~x~~~~N LIMITS
A GENERAL LIABILITY YY JY91503188064 01/01/04 01/01/05 EACH OCCURRENCE $1.000 000
I-- ~~~t,;~~l9E~En~b~~~nce'
rX- COMMERCIAL GENERAL LIABILITY $300 000
t-- ~ CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $5,000
PERSONAL & ADV INJURY $1.000.000
t--
GENERAL AGGREGATE $1,000,000
I--
n'~ AGGREAE LIMIT APnS PER: PRODUCTS - COM PlOP AGG $1.000.000
PRO-
POLICY JECT LOC
A AUTOMOBILE LIABILITY ASJY91503188024 01/01/04 01/01/05 COMBINED SINGLE LIMIT
I-- $1,000,000
~ ANY AUTO (Ea accident)
ALL OWNED AUTOS BODILY INJURY
t-- $
SCHEDULED AUTOS (Per person)
I--
~ HIRED AUTOS BODILY INJURY
$
X NON-OWNED AUTOS (Per accident)
I--
t-- PROPERTY DAMAGE $
(Per accident)
RRAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
B @ESS/UMBRELLA LIABILITY THCY91503188034 01/01/04 01/01/05 EACH OCCURRENCE $5.000.000
X OCCUR D CLAIMS MADE AGGREGATE $5 000 000
$
~ DEDUCTIBLE $
X RETENTION $10000 $
A WORKERS COMPENSATION AND WCJY91503188044 01/01/04 01/01105 X I T'f!,~,N~!~~ I IOl~-
EMPLOYERS' LIABILITY $100,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT
I..,'" .OFfICER/ME.MBER EXCl UDED? _ " ..' ..' ~, .--,,---- -.-", ...-...,. , .- ---- -.-.- - .- . E.C O1SEASE~"EAEMPLOYEE $100,OOO~ ..' .-
If yes. describe under ~: I $500,000
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS IVEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
PROJECT: CITY OF CLEARWATER, 2003 ENGINEER OF RECORD CONTACT
CITY OF CLEARWATER IS INCLUDED AS ADDITIONAL INSURED UNDER THE
GENERAL LIABILITY POLICY PER GL0492 AND AS LIMITED INSURED-VICARIOUS
LIABILITY UNDER THE AUTO POLICY PER WA8421.
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ---3.0..... DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES,
UTHORI~ED REPRESENTATIVE
'I~
VLS
@ ACORD CORPORATION 1988
CITY OF CLEARWATER
PO BOX 4748
CLEARWATER, FL 33758-4748
ACORD 25 (2001/08) 1 of 2
#M311236
1:.
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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u
ACORD 25-5 (2001/08)
2 of 2
#M311236