CERTIFICATE OF LIABILITY INSURANCE (5)H ULK 11HUA I L Ur LIABILI I Y MbUKANGL
PROD?cRAllied Specialty Insurance, Tnc
10451 Gulf Blvd.
Treasure Island, FL 33706
800/237-3355
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,
INSURERS AFFORDING COVERAGE N'AIC #
INSURED Emerald Coast Bungee, Inc. INSURERA:T. H. E. Tn.sur e C0m_pan
10 Causeway Blvd. INSURER B:
Clearwater Beach FL 33767 INSURER C:
INSURER D:
INSURER E:
GOVERAGES
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.
INSR'ADD'L POLICY EFFECTIVE POLICY EXPIRATION i
POLICY NUMBER LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1, _000 00Q_
!
Al X• COMMERCIAL GENERAL LIABILITY C P P 010 0 5 7 5- 01 03/11/11' , 0 3/ 11 / 1 AM 0 RENTED
21 PREMISES Ea occurrence) S 5 0, 0 0 0
CLAIMS MADE ! OCCUR ! _M_ED EXP (Any one person) $ ?W
• PERSONAL & ADV INJURY 0 0 a.0 0
GENERAL AGGREGATE $ 2, 9S 0 0Q O
I
GEN'L AGGREGATE LIMIT APPLIES PER: 1
PRODUCTS - COMPIOP AGG $
POLICY j PRO- I LOG
AUTOMOBILE LIABILITY I
COMBINED SINGLE LIMIT
i Ea accident
( ) $
ANYAU70 RECEIVED H
ALL AWNED AUTOS SOO!LY INJURY
5
SCHEDULED AUTOS
'
` (Per person)
_
?A
R 3 0 2011 i
,•.,
! HIRED AUTOS
I
BODILY INJURY
$
NON-OWNED AUTOS j
L (Per accident)
OfflCIA
REWRDS A
?+? ?/?
LECASLAT ? ? ,S CS DCry GF g PROPERTY DAMAGE $
I (Per accident) !
I GARAGE LIABILITY ( AUTO ONLY - EA ACCIDENT $
1 ANY AUTO EA ACC ! $
OTHER THAN
AUTO ONLY: AGG $
EXCESS I UMBRELLA LIABILITY I EACH OCCURRENCE 5
OCCUR ! CLAIMS MADE `AGGREGATE $
j iirGL'CT18LE ! $
u RETENTION S $
-
-
WORKERS COMPENSATION I WC S rATUJ
709
1
TORY LIMIT
AND EMPLOYERS' LIABILITY y l N I - -T-
ANY PRO PRIE?TOFt'PARTP!ER/EXEC!1TIVE ? I I E.L. EACH ACCIDENT I $
1 OFFICER/MEMBER EXCLUDED?
(Mandatary In NH) E.L. DISEASE - EA EMPLOYEE 5
f s, describe under
SPECIAL PROVISIONS below
E.L. DISEASE - POLICY LIMIT : 5
OTHER I
I
I
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
ADDITIONAL INSURED: CITY OF C:LrEARWATER FOUNDATION INC AS RESPECT TO THE
PRIMARY & NON-CONTRIBUTORY OPERATIONS OF THE NAMED INSURED ONLY.
WAIVER OF SUBROGATION APPLIES TO GENERAL LIABILITY.
CERTIFICATE HOLDER CANCELLATION
F"HFFYPIPATION
CITY OF CLEARWATER
_ •, _, __ _? HOU?pNVnrrw eanv nKCralaPnaniirisr+E AN,G
100 MYRTLE AVENUE
CLEARWATER FL 3 3 7 6 7 DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRE TATIVES. N _-2
AU7 R R RES ATIV "
ACORD 25 (2009/01) O 1988-2009 A RD CORPORATION. All rights reserved
Q't 1. f6<z,'k_'4 QQ_Qt4A' The ACORD name and logo are registered marks of ACORD