CERTIFICATE OF INSURANCE (010)
THIS CERI;fICATE IS IssID:~1~~~!~j~:~~::A~~ (~,~ S,~ ,I~~.~;ii:
ThiS CEfl'!FICATE DOES"'.C:,l r\ II/E I\; 0, EXTEND OR II.L 'ER "~'c ::':. "'o";,!: ,,!":'C'I"DETl
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SHAFER-BROWN INS INC
POBOX 1328
CLEARWATER FL
33517
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~=~::~__~.._.r;_1~~ I N~f.lJ:L_l~S _~9 ,_ ,...____...__...____._.._ __
t.:~~rt':__~_________.___...,_ ._,._ ...._._..."_,__.,,_,..__,'__._.__,.__._
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r>.i,~ME AND ADDRESS OF trv~URF0
PINEL LAS YOUTH FOOTBALL CON IN
BOX 1626
PINEL LAS PK FL 34290
COMPANY
LETTER
This is to certify that policie:!:l of Insurance listed oelow have been iss.ued to the Insured r:ai""leC JC(I.... ,;. "Ie ,;J! : Ir~ '~y::p at ',:::I~, .\,)l"'l: i:r' if',;; .'. :'11. te1:' -1 1)" I r: "'idl~l{/
of any contract or other document wIth respect to which this certificate may be 'issued or rray p~-:~~tain, F e In~(Jran(;e ,:1fi'....1!"':1ed by the r<'-'lCiPS df::sc;t.{'d !)e~'CJ; ;.S Sl.IJjec1: tc all th
terms, exclusions and condition, ot '''ch polic",,-,
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3/01/85
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RECEIVED
K- ::~~~:;~~:::.::~::;,\~;CE
r-X snOAD FORM n:~C)PU;;TY
DAMAGE I
t-X. 1~;DFPE~[)U,l C)'J -.ucms I CITY ,r--,! r-' '..
PEflS0NAL INJUH, -.-~----_.~-----.~-"=~=,~...~~t--
AUTOMOBILE LIABILITY !
F~ <:u.i"Rt"i'N~'VE r. '1-'M "
t- OWNED I
f HIf:U::e:: (
CJ ~<)"<JWNEil
I--T-EXCESS LIABILITv-i-
"JMBRELLA r:(1H"./ I
OTHEF THAI\: UM8FF.LL,\
FORM
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EMPLOYER'S 1.IAI~~!-t _.._____ _____.____. ___ .., __ _ __.___
OTHER I
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MAR
1
1984
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td.' .
,[ 300
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DESCRI~TION OF OPERATION:,,'lOC:A T10N':::''-VEHICLES
F"OOIBALL..__E~()GRAMAT "VARIous LOCATIONS
WITH CITY OF CLEARWATERFLORIOA-NAMED
AS ADDITIONAL INSURED
Cancellation: Should any of the above described pollcie, be cal"ce'lecl Iy,.)",' :he~^r;'r;.t :)!I UJ'I' ':',t' ,,,), , th;:, Iss'Jlnq :,OlrJ
pany will endeavor to Iliad 10 _ day" WI':t'~I.,r1 '1::: ::e ':' l!'e beloN 1"He:r.! C,,:I: ",c;, :'- hi)'I!I'1 ':'1[' lall,;"
I',j mail such notice shall impose 1"0 obliqation or' IlilLI 11'1 IY"",' k iit.! '-1:1')1', tni~ i..Clrpar:,
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NA!I/!E AN!) ^~(~~RE:S-S OF-c;~~'Tii---::~:TE rl'~_~=~_._---'"-------'.'-_._-'---'
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CITY OF CLEARWATER FLORIDA
POBOX 4748
CLEARWATER FLA33518
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