CERTIFICATE OF LIABILITY INSURANCE (8)CERTIFICATE OF LIABILITY INSURANCE I DATE
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 CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. 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). _
PRODUCER
MARSH USA Inc-
TWO LOGAN SQUARE
PHILADELPHIA, PA 19103
Attn: Healthcare.AccountsCSS@marsh.com/FAX: 212 948-1307
100607-CIGNA-CAS-11-12
INSURED
CIGNA CORPORATION AND ITS SUBSIDIARIES
TWO LIBERTY PLACE, T1.15B
1601 CHESTNUT STREET
PHILADELPHIA, PA 19192-2438
PHONE
INSURERS AFFORDING COVERAGE NAIC S
INSURER A : ACE American Insurance Company 22667
INSURER B : American Guarantee & Liability Ins Co 26247
INSURER C : Indemnity Ins Co Of North America 43575 -
E:
CnvGRAr.Fe CERTIFICATE NUMRFR: CLE-003505580-09 REVISIUN NUMkshli:1
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.
INSR
LTR
TYPE OF INSURANCE AD R
POLICY NUMBER POLICY EFF
MM/DD/YYYY POLICY EXP
MM/D YYY LIMITS
A GENERAL LIABILITY HDO G2553006-8 0710112011 07/0112012 EACH OCCURRENCE S 1,000,000
_ffA_M7ffff-TO RENTED 1
000
000
MERCIAL GENERAL LIABILITY
C0' PREMISES Ea occurrence ,
,
$
4 CLAIMS-MADE M OCCUR MED EXP (An one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 1,000,000
X POLICY PRO LOG $
A AUTOMOBILE LIABILITY ISA H0863572-9
lixIAXIV 011 0710112012 COMBINED SINGLE LIMIT
Ea accident 1,000,000
?
--
ANY AUTO _ _ _ __
BODILY INJURY (Per pars __
ALL OWNED
AUTOS SCHEDULED BODILY INJURY (Per accident) $
NON OWNED JUL O 5 21 11 PROPERTY DAMAGE $
HIRED AUTOS AUTOS (per accident)
i
B X UMBRELLA LIAB X OCCUR AUC967
' , 07/0112012 EACH OCCURRENCE $ 10,000'000
LE
ISLAM DEPT r 0 10
000
000
EXCESS LIAR CLAIMS MADE AGGREGATE ,
,
$
DED RETENTION $
C WORKERS COMPENSATION WLR C4648115-A (ADS) 0710112011 0710112012 X WC STATU- OTH-
AND EMPLOYERS' ITY
Y
SCF 04648116-1
?I)
07/01/2011 2
07101/201 1
000
000
A ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT ,
,
$
A ?
(Mandatory ain in NH) ER EXCLUDED? N N/A
WLR C4648114-8 (CA & MA)
07/0112011
07/0112012
E.L. DISEASE - EA EMPLOYE
$ 1,000,000
A If D ES r$CR I describePTION OF under OPERATIONS below WLR C4648113-6 (WU) 07/0112011 07/01/2012 E.L. DISEASE -POLICY LIMIT $ 1,000,000
EXCESS LIMIT $1,000,000
A WORKERS COMPENSATION WCU C4648117-3 (OH only) 07/01/2011 07/0112012 SIR $1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS ! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, it more space is required)
CERTIFICATE HOLDER CANCELLATION
CITY OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ATTN: CITY CLERK THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX 4748 ACCORDANCE WITH THE POLICY PROVISIONS.
CLEARWATER, FL 33758
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Donna Clampitt C_?D
ACORD 25 (2010/05)
01988-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
ly
0004170 MB 0273 "AUTO 6 0 0178 33758.474848 •Ci01-P04172.1
CITY OF CLEARWATER
ATTN: CITY CLERK
PO BOX 4748
CLEARWATER, FL 33758-4748 M