CERTIFICATE OF LIABILITY INSURANCE (103)>~r?
CERTIFICATE OF LIABILITY INSURANCE
I DATE(MM/DDIYYYY)
12/29I2010
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). m
PRODUCER CONTACT
NAME: 'O
Aon Risk services South, Inc. PHONE FAX
Na-Eutr (866) 283-7122 AD No (847) 95375390
NC
`MO
Franklin TN office .
501 Corporate Centre Drive E4M o
suite 300
Franklin TN 37067 USA PRODUCER
CUSTOMER DM 570000005571
INSURER(S) AFFORDING COVERAGE NAIC #
INSURED -INSURER A.' Greenwich Insurance company 22322
ARCADTS U.S., INC. INSURER B: XL Specialty Insurance Co 37885
630 Plaza or Ste 200
Highlands Ranch CO 80129-2379 USA INSURER C:
INSURER D!
INSURER E:
INSURER F:
COVERAGES - - -CERTIFICATE-NUMBER: 570041164648 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. Limits shown are as requests
L SIR TYPE OF INSURANCE DDL UB POLICY NUMBER POLICY EFF POLICY LIMITS
A GENERAL LIABILITY GEC EACH OCCURRENCE $1,000,000
X
COMMERCIAL GENERAL LIABILITY
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ED DAMAGE TO RENTED
PREMISES Ea occunence
$1, 000' 000
CLAIMS-MADE X? OCCUR RECEIV MED EXP (Any one parson) $10,000
X Contractual PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,0100
JAN 0 5 011
GE NT AGGREGATE LIMIT APPLIES PER: J PRODUCTS - COMPIOP AGG $2,000 , 000
POLICY X PRO-
JECT F X]
B AUTOMOBILE LIABILITY AE00010 1 Ol 2012 COMBINED SINGLE LIMIT $1,000,000
g
X
ANY AUTO ADS
gE0001]h®WIr71X1A 1 Y t- ?
f"-c P
01/01/2012
BODILY INJURY (Par parson)
ALL OWNED AUTOS MA BODILY INJURY (Par accident)
SCHEDULED AUTOS PROPERTY DAMAGE
Per accident
X HIRED AUTOS
X NON OWNED AUTOS
A X UMBRELLA LAB X OCCUR UEC 1 01/01/2012 EACH OCCURRENCE $1,000,000
EXCESS LIAR CLAIMS-MADE SIR applies per policy ter ms & Condit ions AGGREGATE $1,000,000
DEDUCTIBLE
X RETENTION $10,000
B WORKERS COMPENSATION AND RWD94351 5 1 01 2011 01 01 2012 U OTH-
X IV
ST T
' ORY
S
EMPLOYERS
LIABILI Y YIN A05 Q
(Man
(Mandatory In NH EJ(CLUDED9
(Mandatory In NH) NIA
WI
E.L. DISEASE-EA EMPLOYEE
$1,000,000
If y
describe under
DISEASE-POLICY LIMIT
E
L
000
000
$1
S6
D ERIPTION OF OPERATIONS below .
. ,
,
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 107, Addibonal Remarks Schedule, if more space is required)
Evidence of insurance.
cancellation Provision shown herein is subject to shorter or longer time periods depending on the jurisdiction of, and reason
for, the cancellation.
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CERTIFICATE HOLDER CANCELLATION
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 cl earwater AUTHORIZED REPRESENTATIVE
Attn: Kathy Bedini (City clerk)
7
Box 4 48
Clearwater S L ? ?
Cleter FL 33758-4748 USA e_]N4??sJ' m
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD