CERTIFICATE OF LIABILITY INSURANCE (21)From ARC Thu 16 Jun 2011 02:28:22 PM EDT Page 2 of 2
A( UHU,, CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
06/16/2011
THIS CERTIFICATE IS 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 CER'T'IFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terns and conditions of the policy, certain policies may require an endorsement. A statement ?n this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAME: GUNTAUT
Alley, Rehbaum & Capes Assurance, Inc. HON Exf:727.797.5193 aCN,;727.725.5773
2433 Gulf to Bay Blvd. E DRESS:
P.O. Box 4620 PRODUCER D 00020854
Clearwater, FL 33758 INSURER(S) AFFORDING COVERAGE NAIC#
INSURED INSURER A: First National Insurance Co
Thomas & Patricia wolkowsky INSURER B:
DBA: Pirates Pantry INSURER C:
25 Causeway Blvd INSURER D:
Clearwater Beach, FL 33767 INSURER E:
INSURER F :
rnvcoer_ee CFRTIFICCTF NLIMRIl 11-12 Liab REVISION NUMBER:
THIS •ISTO 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 CONTRACTOR 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.
I R
L TR TYPE OF INSURANCE INSR WVD 12000Y NUMBER FPULICY
MM/OOlYYY PM/DDIYYYY LIMITS
GENERAL LIABILITY Z SCC2 765 56 06/0712011 06/07/2012 EACH OCCURRENCE $ 1,000,00(
X COMMERCIAL GENFRAL LIABILITY DAMAGE TO RENTED $ 1,000,00(
CLAIMS-MADE FX] OCCUR MED FXP (Any one person) $ 10,00
A X PERSONAL & ADV INJURY $ _ 1,000,00(
GENERAL AGGREGATE $ 2,000,00(
GEN'L AGGREGAI"L•• LIMIT APPLIES PER: PRODUCTS COMP/OP AGG $ 2,000,000
POLICY PE LOC $
AUT OMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea acrid ant)
ANY AUTO ?Iqi
?
] BODILY INJURY (Per person) S
ALL OWNED AUTOS ???? ?.1
r BODILY INJURY (Par accident) $
SCHEDULED AUTOS PROPERTY DAMAGE $
HIREDAUTOS (Per accident)
NON-OWNED AUTOS 1i'A?
JUN j
2011 $
$
UMBRELLA LIAB OCCUR '. `:? ???Aa RE< ®?? ?? EACH OCCURRENCE $
,
EXCESS LIAB CLAIMS-MADE ? AGGREGATE $
????W? i?y
? D ?
DEDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION WCSIATU- OTH-
TORY LIM11 S ER
AND EMPLOYERS' LIABILITY Y f N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACI I ACCIDENT $
?
OFFICER/MPIMBER EXCLUDED?
(Mandatory In NH) NIA
E.L. DISEASE - EA EMPLOYE
$
IF yes, describe uldor L. DISEASE -POLICY LIMIT
E $
DESCRIP PION OF OPERATIONS below .
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
he Certificate Holder is listed as an Additional Insured.
CERTIFICATE HOLDER CANCELLATION
FAX: 727.462.6957
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater
4:..........
AUTHORIZED REPRESENTATIVE
25 Causeway Blvd.
Cl arwater, FL 33767 C nthia Fletcher KM
tvivae-LUUyACORDCORFORAllwrv. All riwhi* Imx+rslveu.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD