CERTIFICATE OF INSURANCE (20)
AC.ORQM
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDNYYY)
10/02/2004
THIS CERTIFICATE IS ISSUED AS AMATTER 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 (305)822-7800 FAX 3058270585
Collinsworth, Alter, Fowler, Dowling
& French Group Inc.
P. O. Box 9315
Miami Lakes, FL 33014-9315
INSURED ost, uc ey, c u ,
d/b/a PBS&]
2001 NW 107 Avenue
Miami, FL 33172-2507
nc.
INSURERS AFFORDING COVERAGE
INSURER A: Sentry Insurance a Mutual Compan
INSURER B: Steadfast Insurance Company A XV
INSURER C: L oyds 0 Lon on A XV
INSURER 0:
INSURER E:
NAIC#
A+ XV
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 'lfk.Ji~t"MIDD1YY1 II'KI~I-W(MM/DD1Yii' LIMITS
GENERAL LIABILITY 90-15807-03 09/30/2004 09/30/2005 EACH OCCURRENCE $ 1,000,00U
~ COMMERCIAL GENERAL LIABILITY ~~:;;~'Es rEa occurencel $ 1,000,00C
I CLAIMS MADE ~ OCCUR MED EXP (Anyone person) $ 25,00(]
A X I Contractual lab PERSONAL & ADV INJURY $ 1,000, ocR
i-- GENERAL AGGREGATE $ 2,000,000
'-- PROOUCTS - COMP/OP AGG 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: $
II . M PRO- M LOC
POLICY JECT
AUTOMOBILE LIABILITY ~0-15307-04 U:l1 '1 U:l1 JVI <-VVJ COMBINED SINGLE LIMIT
nr- ANY AUTO 90-15807-05 (Ea accident) $
1,000,000
Ix- ALL OWNED AUTOS BODILY INJURY
f-- (Per person) $
SCHEDULED AUTOS
A Ix-
HIRED AUTOS BODILY INJURY
Ix- (Per accident) $
NON-OWNED AUTOS
Ix- Contractual Liab PROPERTY DAMAGE
(Per accident) $
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY V;JI/ ", V;JI/ JVI <-VVJ EACH OCCURRENCE $ l ~ , UUU ,UO(J
~ OCCUR D CLAIMS MADE AGGREGATE $ Z 5 ,000, OOU
B $
~ DEDUCTIBLE $
RETENTION $ 10,00< $
WORKERS COMPENSATION AND ::IU-.l~lSU{..:u.I U;JI/ JVI "VV U::IIJv/..vVJ ^ I TORY LIMITS I rER'
EMPLOYERS' LIABILITY 90-15807-02 E.L. EACH ACCIDENT $ .l,UUU,OOll
A ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICERlMEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ l,uuu,uuu
If yes, describe under NO E.L. DISEASE - POLlCYLlMIT $m u .l ,uuu , uuu
SPECIAL PROVISIONS below
~ssional/ ..1 U:l1 J~I ..~~ U::II JU/,,"UUJ ;jl~,UUU, U01 L1 mTl;S
C ~ollution Liability Ea Claim and Annual Aggregate
CLAIMS-MADE FORM 11/11/1961 Retrodate
lief: City of Clearwater.
ertificate Holder i s na~ o ~srr1~ ~~Ulf w~tiin the General & Auto liability, excl udi ng
professional services.
'.. j i
.n OCT I 9 2004 l J\
CERTIFICATE HOLDER I j T CANCELLATION
! -'~'-f !.~_.~ ('.;";' ~: .. ."--. ~ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
Clearwater, City o~_._:J'f)i.:LY'il \J . EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Engineer of Record ~ DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
100 S. Myrtle Avnue BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Engineering - Suite 220 OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES.
Clearwater, FL 33756 ~"'-;.:~?ii?:--:-~/
Meade Collinsworth/EEC ..i:P ..; .~;t:f._ ,.r; .,~.J.~~, _
I 25 ,"'UU IIUOI c 198f
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.