CERTIFICATE OF LIABILITY INSURANCE (169)PLISARC3
aCoRkD_ CERTIFICATE OF LIABI
PKUDUGER
ISU Suncoast Insurance Assoc
P.O. Box 22668
Tampa, FL 33622-2668
813 289.5200
INSURED
Plisko Architecture, P.A., AIA
800 Drew St
Clearwater, FL 33755
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIC
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TI-
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR PDD'g
POLICY EFFECTIVE POLICY EXPIRATOOI
TR NSR TYPE OF INSURANCE POLICY NUMBER
DATE M DATE (MMjPDffYj
A GENERAL LIABILITY 660243211749 06/18/10 06/18/11
X COMMERCIAL GENERAL LIABILITY
CLAIMS MADE ® OCCUR.. _. - ..:.:.:.:. _ _..
GEN'L AGGREGATE LIMIT APPLIES PER:
POLICY PRO-
CT LOC
A AUTOMOBILE LIABILITY 660243211749 06/18/10
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
X HIRED AUTOS
X ?r
NON-OWNED AUTOS
GARAGE LIABILITY
ANY AUTO CI
??
.
EXCESS/UMBRELLA LIABILITY
OCCUR D CLAIMS MADE
DEDUCTIBLE
B WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
_ - PROPRIETOR/PARTNER/EXECUTIVE
OFFICI:R/MEMBER EXCLUDED?
If xm describe under
SPECIAL PROVISIONS below
C OTHER Professional
Liability
L I TY INSURANCE DATE (MM/DD/YYYY)
5/25/2011
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 NAIC #
INSURER A: Phoenix Insurance Company 25623
INSURER B: Travelers Casualty and Surety C 19038
INSURER C: XL Specialty Insurance Company 37885
INSURER D:
INSURER E:
09/11/10 109/11111
r PERIOD INDICATED. NOTWITHSTANDING
IS CERTIFICATE MAY BE ISSUED OR
:XCLUSIONS AND CONDITIONS OF SUCH
LIMITS
EACH OCCURRENCE $1,000,000
DA
MAGE TO RENTED
RE S (E
$1 000 000
MED.EXP (Any one person -$1 .000
PERSONAL & ADV INJURY $11000.000
GENERAL AGGREGATE $2.0 0000
PRODUCTS - COMP/OP AGG $2 000 000
COMBINED SINGLE LIMIT
(Ea accident)
$1,000,000
BODILY INJURY $
(Per person)
BODILY INJURY $
(Per accident)
PROPERTY DAMAGE $
(Per accident)
AUTO ONLY - EA ACCIDENT $
OTHER THAN EA ACC $
AUTO ONLY: AGG $
EACH OCCURRENCE $
AGGREGATE $
$
$
WC STATU- OTH-
>tti. EACH:AtCIDEN7 $10Ob0O
E.L. DISEASE - EA EMPLOYEE $1 OO OOO
E.L. DISEASE- POLICY LIMIT $500,000
$1,000,000 per claim
$1,000,000 annl aggr.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Professional Liability Is written on a claims made and reported basis.
City of Clearwater
Attn: City Clerk
PO Box 4748
Clearwater, FL 33758-4748
ACORD 25 (2001/08) 1 of 2 #S320611/M270513
06/18/11
U B7080Y545 -` 44 109/01 110 -109/01 /11
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL _20 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
A ORIZED REPREwS? TATIVE
% 'h t0-0
LWA 0 ACORD CORPORATION 1988
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25.S (2001/081 n s 7 •al+7nn?ww it-------
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