CERTIFICATE OF LIABILITY INSURANCE (178)ADVASYS3
ACORDT. CERTIFICATE OF LIABILITY INSURANCE
DATE (MM201D 1m
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
ISU Suncoast Insurance Assoc
P.O. Box 22668
Tampa, FL 33622 -2668
813 289 -5200
CONTACT
NAME:
A/C Ext): 813 2$9.5200 FAX
PHONE No , (NC, No): 813 289-4561
E -MAIL
ADDRESS:
PRODUCER
CUSTOMER ID #:
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURED
Advanced Systems Engineering, Inc.
PO Box 1915
Oldsmar, FL 34677
INSURER A: Phoenix Insurance Company
25623
INSURER B : Travelers Indemnity Company
25658
INSURER C : Travelers Casualty & Surety Co
19038
INSURER D :
$1,000,000
INSURER E :
DAMAGE TO RENTED
PREMISES (Ea occurrence)
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.
MISR
LTR
TYPE OF INSURANCE
ADDL
INSR
SUER
WVD
POLICY NUMBER
POLICY EFF
$MM /DDIYYYY)
POLICY EXP
JMM /DD/YYYY)
LIMITS
A
GENERAL
LIABILITY
COMMERCIAL GENERAL LIABILITY
OCCUR
6606851 L26A
10/02/2010
10/02/2011
EACH OCCURRENCE
$1,000,000
X
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$1,000,000
CLAIMS -MADE
X
MED EXP (Any one person)
$10,000
PERSONAL & ADV INJURY
$1,000,000
$2,000,000
GENERAL AGGREGATE
GEN'L AGGREGATE LIMIT APPLIES PER:
PRODUCTS - COMP /OP AGG
$2,000,000
—I POLICY X PF O LOC
$
A
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
6606851 L2IRECEI E
JUL 1 5 20
�•, 3CIAL RECORDS
LEGISLATIVE .�.ZfCS
/02/2010
I`�IM
DEPT
10/02/2011
COMBINED SINGLE LIMIT
(Ea accident)
$1 000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
X
X
$
$
B
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
CUP6849Y191
08/17/2011
08/17/2012
EACH OCCURRENCE
$5,000,000
AGGREGATE
$5,000,000
$
DEDUCTIBLE
X
RETENTION $ 10000
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR /PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If DE CRIPTION OF OPERATIONS
-' '
I I
N/A
UB6848Y201
08/17/2011
08/17/2012
-`
X TORY IAMITS PP
E.L. EACH ACCIDENT
$500,000
E.L. DISEASE - EA EMPLOYEE
$500,000
below
E.L. DISEASE - POLICY LIMIT
$500,000
DESCRIPTION OF OPERATIONS / LOCATIONS! VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space a required)
Certificate holder is listed as an additional insured with respects to
General Liability, Auto Liability and Excess Liability policies on a
(See Attached Descriptions)
CERTIFICATE HOLDER
City of Clearwater
Attn: City Clerk
PO Box 4748
Clearwater, FL 337584748
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2009/09) 1 of 2
#S328084/M328081
01988 -2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
KEB
DE CRI P O,
S (Co ntinue, from Page 1)
primary and non - contributory basis. Waiver of Subrogation in favor of the
additional insured applies to the General Liability, Auto Liability,
Excess
Liability and Workers Compensation policies.
AMS 25.3 (2009/09) 2 of 2
#5328084/M328081