CERTIFICATE OF LIABILITY INSURANCE (11)r 1 ® DATE (MMIDDNYYY)
,4? ° CERTIFICATE OF LIABILITY INSURANCE 2/4/2011
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).
PRODUCER NAMEACT Certificate Department
Commercial Lines - (813) 639-3000
PHONE g13-639-3000 FAX 81
3-639-71$0
Wells Fargo Insurance Services USA, Inc. N Ext : alc No
E-MAIL
ADDRESS; clw.certrequest@wellsfargo.com
2502 N. Rocky Point Drive, Suite 400 PRODUCER u? 8493
CUSTOMER ID M
Tampa, FL 33607 INSURERS AFFORDING COVERAGE NAIC #
INSURED uT INSURER A: Arch Insurance Company 11150
Chi Chi Rodriguez Youth Foundation, Inc. INSURER B: Zenith Insurance Company 13269
3030 McMullen Booth Road INSURER C :
INSURER D :
Clearwater FL 33761 INSURER E :
INSURER F :
rror?orerc r.n r??ocn. 734n17R oI:X1ICInM MI IMRFZP- S'PP hPlnw
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.
m_
INSR
LTR TYPE OF INSURANCE INSR S V UER POLICY NUMBER MMIDDY/YYYY
fDD/YYYY
MM
LIMITS
A GENERAL LIABILITY
NCPKG0126000
02101/11
02/01/12 EACH OCCURRENCE $ 1,000,000
X
COMMERCIAL GENERAL LIABILITY DAMAUFT RENTED
PREMISES Ea occurrence
$ 1,000,000
CLAIMS-MADE Fx_1 OCCUR MED EXP (Any one person) $ 20,000
PERSONAL & ADV INJURY $ 1,000,000
mm
GENERAL AGGREGATE 2,000,000
$
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $ --- 2,000,000
POLICY PRO LOC $
A AUT OMOBILE LIABILITY NCAUT0126000 02/01/11 02/01/12 COMBINED SINGLE LIMIT
(Ea
accident)
$ 1,000,000
X ANY AUTO ?+r, p
```yyy???E/?E.`/
? ?
F BODILY INJURY (Per person) $
ALL OWNED AUTOS ?I `? N
.
BODILY INJURY (Per accident)
$
SCHEDULED AUTOS PROPERTY DAMAGE
HIRED AUTOS '' s"1
20 3 (Per accident) $
NON-OWNED AUTOS Y
$
- $
A X UMBRELLA LIAR X OCCUR NCUM , ?., 11 02/01/12 EACH OCCURRENCE $ 1,000,000
EXCESS LIAR CLAIMS-MADE
. ?•'. `,?
J
AGGREGATE
$ 1,000.000
DEnUCTIBL.F $
FX_
RETENTION $ 10,000
$
WORKERS COMPENSATION
'
2836521211
02/01/11
02/01/12 X WC STATU- OTH-
TQRY IM.
"-"-
B AND EMPLOYERS
LIABILITY Y1 N
ANY PROPRIETORIPARTNER/EXECUTIVE E.L. EACH ACCIDENT $ 1,000,000
?
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH) N I A -
E.L. DISEASE - EA EMPLOYE
$ 1,000,000
If yes, describe under
DESCRIPTION OF OPERATIONS below
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
Certificate Holder is an Additional Insured with respects to General Liability.
P`CGTIGIr%ATC uni mcm f`_eMl'.FI 1 eTInN
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 4748
Clearwater, FL 33758 AUTHORIZED REPRESENTATIVE 9
(U 1985-2009 AGUKU C;URPOKA I IUN. All rights reservea.
ACORD 25 (2009109) The ACORD name and logo are registered marks of ACORD