CERTIFICATE OF INSURANCE (2)
A~ORrt CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/DDIYY)
1 2/1 5/04
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Acardia Southeast. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. Box 31666 HOLDER, THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
Tampa. FL 33631-3666
727-796-6666 INSURERS AFFORDING COVERAGE
INSURED INSURER A: AUTO OWNERS-09703
Partners in Self Sufficiency INSURER B: HARBOR SPECIALTY INS. CO.
901 Chestnut Street. Ste E
Clearwater FL 33756 INSURER c:
INSURER D:
I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR mE POLICY PERIOD INDICATED, NOTWITHSTANDING
ANY REQUIREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED 0
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN is SUBJECT TO All THE TERMS. EXCLUSiONS AND CONDITIONS OF SUCI
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I~~,f TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE ~k'f.v EXPIRATION LIMITS
A ~NERAL LIABILITY 2062094404 8/30/04 8/30/05 EACH OCCURRENCE $ 1nnnnoo
~ OMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anv one fire) $ 100nnn
f-- CLAIMS MADE [X] OCCUR MED EXP (Anv ooe person) $ 1 nnnn
- PERSONAL & ADV INJURY $
- GENERAL AGGREGATE $
~'L AGGREn LIMIT APn PER: PRODUCTS - COMP/OP AGG $
POLICY ~~9T LOC
A ~TOMOBILE LIABILITY 2062094404 8/30/04 8/30/05 COMBINED SINGLE LIMIT
(Ea accident) $ 1000000
- ANY AUTO
- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
f--
ti HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per accident)
- PROPERTY DAMAGE $
(Per accident)
==rAGE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
~-OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
8 WORKERS COMPENSATION AND 4959204 12/07/04 12/07/05 )( I TVX~JT ~r.~c I lOW
EMPLOYERS' LIABILITY 1 nnonn
E.L. EACH ACCIDENT $
E,L. DISEASE - EA EMPLOYEE $ 10nnnn
E,L. DISEASE - POLICY LIMIT $ <;nnnnn
OTHER
DESCRIPTION OF OPERA TlONS/LOCA TIONSMHICLESIEXCLUSIONS ADDED BY ENDORSEMENT /sPECIAL PROVISIONS
. - "-k" ?: ~;;;:-.-". ~::. ;
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION 'I,,;q: L'f~i,-, J:_--' :.........,
CITY OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL -1Q.. DAYS WRITTEN
CITY HALL NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL
112 SOUTH OSCEOLA A VENUE IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
CLEARWATER. FL 33756 REPRESENT liIfIltEs, /J
-~~~
I
ACORD 25-$ (7/97) 45- 66 .r f/ -, S ACORD CORPORATION 1988
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