CERTIFICATE OF LIABILITY INSURANCE (6)s«:VGIVCU
JAN 18 2011
ACORO""
L CERTIFICATE OF LIABILITY, INSURANCE
L Date (mm/dd/yy)
1/13/2011
Producer
WELLS FARGO INS SERVICES USA
PO BOX 30001 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.
TAMPA, FL 33630 S RA NAIC #
INSURER American States Insurance Company
A 19704
INSURER
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Insured B cwqlt
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CL OX 175ER HISTORICAL SOCIETY INC
CLEARWATER, FL 34617 INSURER JA 20I1
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INSURER
D 9773ftft
COVERAGES
1.
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 0-1 HER DOC:UMEN I WI I H RESPEG I 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
LTR
DD
INSp
TYPE OF INSURANCE
POLICY NUMBER POLICY
EFFECTIVE
MM ATE DDCLY POLICY
EXPIRATION
M DAT YY
LIMITS
GE NERAL LIABILITY EACH OCCURRENCE $
A COMMERCIAL GENERAL LIAB 01 CG 11649300 1/20/2011 1/20/2012 DAMAGE TO RENTED PREMISES $ 500 0T_
CLAIMS MADEFAOCCUR MED EXP (Any one person) U
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
GEN'L AGG LIMIT APPLIE PRODUCTS - COMP / OP AGG $
71POLICY PROJECT LOC $
A AUTOMOBILE LIABILITY
ANY AUTO
01 CG 11649300
1/20/2011
1/20/2012 COMBINED SINGLE LIMIT
(Ea accident)
$ 500,000
ALL OWNED AUTOS
SCHEDULED AUTOS
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'?'j BODILY INJURY
(Per person)
$
HIRED AUTOS
NON-OWNED AUTOS ua •' BODILY INJURY
(Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
ANY AUTO
i .
OTHER THAN EA ACC
$
S AlVi;, AUTO ONLY: AGG $
EXCESS LIABILITY L?
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?? ®E EACH OCCURRENCE $
OCCUR CLAIMS MADE E
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'"?' AGGREGATE $
$
DEDUCTIBLE $
RFTFNTIr1N $ g
WORKERS' COMPENSATION &
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LIVI NNyy ppRRpppp?? ppLfApBpIRLlTNEY ""'
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ECUTIV
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R/
EL EACH ACCIDENT
$
AFFICERlME
MBE
EXCLUOED9
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u
d EL DISEASE - EACH EMPLOYEE $
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SPECIAL PROVISIONS below EL DISEASE -POLICY LIMIT $
OTHER
-
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DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT ! SPECIAL PROVISIONS
-
CERTIFICATE HOLDER CANCELLATION
(,)
Clearwater City Manager
112 S Osceola Ave
Clearwater, FL 33756 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 • 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 COMPANY, ITS AGENTS OR REPRE-
SENTATIVES.
AUTHORIZED
REPRESENTATIVE
I, VNI
ACORD 25
' (z00'`I/0„8) °,
I Insurance Visions, I,
Inc. ® AGOR'a' CORPORA' 1 TION 9 988
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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ACORO 25 (2001/08)