CERTIFICATE OF LIABILITY INSURANCE (8)'4?? °® CERTIFICATE OF LIABILITY INSURANCE TE
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THIS CERTIFICATEIS 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 SUBROGATIONIS 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 NAME:
BROWN & BROWN OF FLORIDA INC/PHS PHONE FA
A/C No Ext): (866)467-8730 (A/C,No): (877) 538-8521
224605 P:(866)467-8730 F:(877)538-8526 F-MAIL
ADDRESS:
PO BOX 29611
CHARLOTTE NC 2 8 2 2 9 CUSTOMER ID a:
INSURER(S) AFFORDING COVERAGE NAIC N
INSURED INSURER A : Hartford Ins Co of the southeast .
INSURER B : Hartford underwriters Ins Co
WILLA CARSON HEALTH RESOURCE CENTER
INSURER C:
1108 N. MARTIN LUTHER KING JR AVE.
CLEARWATER FL 33755 INSURER D
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
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.
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE S 1,000,000
COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) 5 300,000
A CLAIMS-MADE I OCCUR MED EXP (Any one person) $ 10 , 0 0 0
X General. Liab 21 SBM RQ7532 05/02/2011 05/02/2012 1 PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE ($ 2,000,000
N'L AGGREGAIE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S 2,000,000
POLICY L-1 PRO X LOC $
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT
$
(Ea accident) 1,000,000
ANY AUTO
BODILY INJURY (Per person)
5
ALL OWNED AUTOS BODILY INJURY (Per accident) $
A
X SCHEDULED AUTOS
HIRED AUTOS
2?- SBM RQ7532
05/02 /2011
05/02/2012 PROPERTY DAMAGE
(Per accident( $
X NON-OWNED AUTOS $
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION 9 $
WO
AN RKERS COMPENSATION
D EMPLOYERS' LIABILITY
_DRY
X WC SUMITS OER
ANY PROPRIETOR/PARTNER/EXECUTIVEIY / N
E
HE
E N/A E.L. EACH ACCIDENT $ 100, 000
B (Manda
XCLUD
D7 L l
oryInNH 21 WEC.'r GC3515 10/03/2010 10/03/2011 E.L. DISEASE- EA EMPLOYE $ 100,000
If yes, describe under
DESCRIPTION OF OPERATIONS below ,
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Anech ACORD 101, Addtland Remarks Schedule, If more space is required(
Those usual to the Insured's Operations. _D L-Ln kO L?3 U VJ
MAR 17 2011
CERTIFICATE HOLDER CANCELLATION ECONO MIC D
City of Clearwater Florida
Attn: Housing Division SHOULD ANY OF THE BOVE DES CANCELLE
BEFORE THE EXPIRATI
DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.
112 S OSCEOLA AVE
CLEARWATER,FL,33756 AUTHORIZ PRESENTATIVE
A-z- -?
6 9988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD