CERTIFICATE OF LIABILITY INSURANCE (20)94/06/2011 14:52 7274469147 SANDBERGEN PAGE 01102
a?°R°? CERTIFICATE OF LIABILITY INSURANCE pATE(MMIDD/YYYY)
4/6/2011
THIS CERTIFICATIE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOWER. 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), AUTHORM
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE? HOLDER.
IMPORTANT: If the Oertftste holder Is an ADDITIONAL INSURED, the pollsy(les) mm be endorsed. If SUBROGATION IS WAIVED, Subject to
the terms and conditions of the pollCy, **gain Policies may require an endorsement. A statement on this certi£ICate does not confer rights to the
certificate holder In lieu of such endor-*Amh (s).
PRODUCER CONTACT
PONE- -- _._-- FAIL
Sandbergen Insurance 1. No. -__-.•... ,4A/C, NO
2121 1N,Z. Coachman Rd. Eg
PROW i:lii"" pooo2642
Clearwater - FL 33765-2616 -_-INSURER(9)AFFORDING GOVERAGL'?__.-.._._._... NAICN
INSURED •_. M- IN5URE•RA•ITrav01cxs 5658
INSURERS;
Marina Restaurant INSURER c
25 Causeway Boulevard, INSURFRO:
INSURER E
Clearwater Reach FL 33767-2064 INSURERF
COVERAGES CERTIFICATE NUIYPER:CL114601079 REVISION NUMBER:
TMI5 1.5 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 W1TH RESPECT TO WMICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED EIY THE POLICIES DESCRIBED HEREIN 1$ SUBJECT TO ALL THE TERMS
,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
TYPE Of EXP
LIMITS
GENERAL L IAIALm I I
][ GGtiIMERGIAL GENERAL L1A6aITY EACN OGG RRENCE
RENWM- . _--y $ 2,000,006
-----•---
?-
A ICLAIMS-WOE `OCCUR ]C
6608947P40=F11 /1/2011 /1/2012 (Eeaearrenee) ffi _--...._.100,000
5
000
MEpFXP(Any gngperson) $
,
PERSONAL a AIN INJURY S 2,000,000
?••----_--.._...__. GENERAL AGGREGATE S 4,
00
0,000
GEN'L AGGREGATE LIMIT APPLIES PER; PRODUCTS • COMP/OP AGO _
_
6 4,000,000
POLICY • PRO- i LOO I - _•_ S _ -_
AUTOMOO&F.IJAe1LITY
ANY AUTO
j
ALL OWNED AUTOS
I COMBINED SINGLE LIMIT
(Ed)-
60DILY INJURY (PA` Adrian) S
-
S
'
9CHEDULED ALTOS I
' BODILY INJURY (Parecoldont)
...-. S
. . ....._....
' I
. . I HIRED AUTO$ PROPERTYpAMAOE
(Per eooldeM) $
NON-OWNED ALTOS $
UMBRELLA LIAe OCCUR EAGN OCCURRENCE
EXCUSS LIAC
--.. .._.....?_?.?.
AGORE13ATE
S
DEDUCTIBLE j 8
RETENTION $ $
WORKCRB COMP11ROAmoN I
AND EMPLOYERS" LWaILF Y YIN
1 I
I I qTU ti H-
P-1voaY L.rMITS I ER
,
1
1 ANY PRCPRIETOR/PARTNERIEXECVnVE
OFFICERIMEMeER E%CLUDEb?
MIA
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..
E.L EACH ACCIDENT l #
(MaAd0lary In NH)
DESCRIPTION OP OPERATION
h E.L DISEASE . EA EMPLOYEE S
alow
S E, L, DISEASE -POLICY LIMT $
I
DESCRIPTION OF OPERATIONS f LOCATIONS (VEHICLES 4AMth AOORD 101, AdtlNbnal ReMAft Selwduk. N MOSS Space M regWrOM
CertifieeL" holdor is named ne ndittJ%*n" i,naared
CERTIFICATE HOLDER CANCELLATION
(727) 4 62- 6957 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES IRE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Clearwater ACCORDANCE WITH THE POLICY PROVISIONS.
The Marine & Aviation Division
25 Causeway nlvd
Clearwater, 1~L 33767
ACORD 26 (2009109) 011968-2008 ACORD CORPORATION. All rights reserved.
INS13251zoogws The ACORD name and logo are registered marks of ACORD