CERTIFICATE OF LIABILITY INSURANCE (9)A� °� CERTIFICATE OF LIABILITY INSURANCE °ATE`MM'°°"'n'r'
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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), AUTHORI2ED
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
NAME:
Brown & Brown Insurance - Clearwater PHONE Fnx
P.O. Box 2456 A/C No Ext: - - A/C,No: - -
E-MAIL
Sll1t.2 6 6 0 ADDRESS:
Clearwater FL 33757-2456 PRODUCER
CUSTOMER ID #:
INSURER/Sl AFFORDING COVERAGE NAIC #
INSURED
King Engineering Assoc., Inc.
4921 Memorial Hwy Ste 300
Tampa FL 33634
INSURERA:NatlOridl Fire I71S Ot Hartto
iNSUReRe:Transportation Insurance Co
INSURER C: Vallev Forae Insurance ComD
INSURER E :
INSURER F :
20494
COVERAGES CERTIFICATE NUMBER:39295616 REVI510N 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.
INSR TypE OF INSURANCE ADDL UBR POLICY EFF POLICY EXP LIMITS
LTR IN R WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
A GENERALLIABILITY C2066728229 1/1/2012 1/1/2013 EACH OCCURRENCE $1,000,000
DAMAGE TO RENTED
X COMMERCIALGENERALLIABILITY PREMISES Eaoccurrence $500,000
CLAIMS-MADE � OCCUR MED EXP (Any one person) $5 , 000
X XCU Included PERSONAL&ADVINJURY $1,000,000
X Contractual Liab GENERALAGGREGATE $z,000,000
GEN'LAGGREGATEIIMITAPPLIESPER: PRODUCTS-COMP/OPAGG $2.000,000
POLICY X PRO- LOC � ' � � $
A AUTOMOBILELIABILITY C2066728232 �� `0'� �°"' t/ �%2012 1/1/2013 COMBINEDSINGLELIMIT
(Ea accident) Sl, 000, 000
X ANY AUTO
D�� � e. �� �� BODILY INJURY (Per person) $
ALL OWNED AUTOS
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE
X HIRED AUTOS y^� ""�Fg , ��z� -` (Per accident) $
6.J�6�� n�as�. ,. � E �., t . ..^.4,.;. �
X NON-OWNED AUTOS E �/^�S'� �`i` --' -i $
6.9GE,� .a.4 +.tl � �7 ' � „� � �
$
g UMBRELLA LIAB X OCCUR C2066728246 1/1/2012 1/1/2013 EACH OCCURRENCE $5, 000, 000
EXCESS LIAB CLAIMS-MADE AGGREGATE $5, 000, 000
DEDUCTIBLE $
X RETENTION $0 $
C WORKERSCOMPENSATION WC163672015 1/1/2012 1/1/2013 X WCSTATU- OTH-
AND EMPLOYERS' LIABILITY Y � N T RY LIMIT ER _
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E.L. EACH ACCIDENT $1, 000, 000
OFFICER/MEMBER EXCLUDED? N � A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYE $1, 000, 000
If yes, describe under
-DESCRIPTIONOFOPERATIONSbelow E.L.DISEASE-POLICYLIMIT $1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attacb ACORD 101, Additional Remarks Schedule, if more space is required)
Certificate Holder is additional insured per the terms of the liability policy with respect to Bodily
Injury or Property Damage arising from the work performed by the named insured per form G140331B O1/09
(attached). Waiver of Subrogation for General Liability is included in blanket form. * 10 Day Notice
See Attached...
CERTI
TION
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
Attn: City Clerk
PO BOX 4 74 8 AUTHORIZED REPRESENTATIVE
Clearwater FL 33758-4748
/�'.�, —F- �.�
O 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID:
LOC #:
�� � ADDITIONAL REMARKS SCHEDULE Page 1 of 1
AGENCY NAMEDINSURED
Brown & Brown Insurance - Clearwater King Engineering Assoc., Inc.
4921 Memorial Hwy Ste 300
POLICY NUMBER Tampa FL 3 3 6 3 4
CARRIER
ADDITIONAL REMARKS
NAIC CODE
EFFECTIVE DATE:
ACORD 101 (2008/01) O 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
�i4usji� u�uy
�
Policy #C20b6728229 rage i ozL
THIS ENDORSEMENT CHANGES THE P�LICY. PLEASE READ IT CAREFULLY.
BLANKET ADDiTiONAL tNSURED - Q1�/NERS, LESSEES OR
CONfRACTQRS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABELITY COVERAGE PART
SCHEDULE (OPTIONQLj
Name of Additianal Insured Person(s)
(As required by written contract/agreement per Paragraph A. belvw.)
of Coverecf
(As per the wrii#en contrac#Iagreement, provided the location is within ihe "coverage territory" of ti�is Coverage
Part. }
(Coverage under this enciorsement is not affected by an entry or lack of entry in the Schedule above.)
A. Section fi - Who Is An Insured is amended to inciude as an additionaf insured any person(s} or organizaiion
(s), including any person or organization shawn in the Schedule above, whom you are requirett to add as an
additionaf insured on ihis Coverage Part under a written contract ar written agreement, provided:
a. The written c�ntract ar wri#ten agreernent was executed prior to:
1. 'The "bodily injury" or "properiy damage"; or
2. The offense that caused ihe "personaf and advertising injury"
for which the additiona! insured seeks coverage under this Coverage Part; and
b. The writien contract or written agreement pertains to your ongoing opera6ons or "your work" for the
additionaf insured{s}.
B. The insu.rance provided to the additional insured is iimited as fo(lows:
9. The persan or organization is an additional insured only with respect ko liability for "bodify injury," "property
damage," or "personal and advefising injury" caUSed in whole or in pa�t by:
a. Your acts or omissions; or
b. The acts or omissions of those acting on your behalf
in the performance of your ongoing operations for the addi#iana! insured(s) or
c. "Your work" ihat is included in the "products-completed aperations hazard" and performed for the
additional insured, but only if this Coverage Part provides such coverage, and t�nly if the writfen
contract or written agreement requires you to provide the additional insured such c�verage.
2. Fiowever, we wiil not provide ihe additionai insured any broader coverage or any higher limit of insurance
ihan ths least of those:
a. Required by the written contract or written agreement;
b. Described in B.1. above; or
c. Afforded to you under this poficy.
http://formnet-ci.cna.com/glhtm/cna7788.htm 1/8/20i0
Ci�4U331B 0109 Yage'l of "l
��v�i� ho�. �,�,du�c�`��j �d.
3, Th�s insurance is excess of �!I other insurance available to the additionai insured, whether �rimary,
excess, contingent or on any othsr basis, unless the writien contract or agreement requires this insurance
to be primary. fn that event, this insurance will be primary relative to insurance which covers tkte
additional insured as a named insured. We will not require con#ribution from such insurance if the written
contract or written agreement aisa requires that this insurance be non-contributory. But wi#h respect to ail
other insurance under which the additional insured qualifies as an insured or additiar�al insured, this
insurance wifl be excess.
4. The insurance providec� to the additional insured terminates when your operations for the additionai
insured are comple#e. But if the written cantract or written agreement specifies a date untiE which this
insurance must apply, then thls insurance terminates:
a. Or� the date specified in fhe wr9tten contract or wriften agreement; or
b. When this poficy expires or is cancelfed,
whichever occurs first
C. With respect to ihe insurance afforded to the additionak insured, the foilowing addiiionaf exclusions apply.
This insurance daes not ap�sly to:
1. "Bodily injury," "property damage," or "personaf and advertising injury" arising out of the rendering of, or
ihe failure tQ render, any professional architectural, engineering, or surveyir�g services, including:
a. The preparing, approving, or failing to prepare or approve maps, shop drawings, opinions, repotts,
surveys, feld arders, change orders or drawings and specificatior�s; and
b. Supervisory, inspection, architectural or engineering activities.
2. "Bodily injury," "property damage," or "persor�al and advertising injury" arising out of any premises ot work
for which the additional insured is specificafly lisfed as an additional insured on another endorsement
aitached to this Coverage Part.
D. SECTION IV — COMMERCIAL GENERAL LlABILITY CON�ITIONS is amended as fof�ows:
1. The puties In The Event of Occurrence, Offense, Claim or 3uit cond'+tion is amended to add tt�e
fo!lowing additionai conditions applicable to #he additiona! insured:
An addifsonai insured under this endorsement wili as soon as practicable:
(7 ) Give us written notice of an "occurrence" or an offense which may result in a claim or "suit" under this
insurance, and o# any cfaim or "suit" that does resuli;
(2) Tender the defense and indemn{ky of any claim or "suit" to any other insurer or self insurer whose
policy or progtam applies to a loss we cover under this Coverage Pa�t;
(3} Except as provided in Paragraph 6.3 of this endorsement, egree #o make avai{able any ofher
irssurance the addiEionaE insured has for a loss we cover under this Coverage Part; and
(4) Send us copies of all legal papers received, and otherwise cooperate with us in the investigation,
d.efense, or setflement of the claim or "sui#."
We have no duty to defend or indem�ify an additional insured under this endorsemenE untiE we receive
from the acfditional insured written nofice of a claim or "sust."
Z. With respect only to the insurance provided by this endorsement, the first sentence of Paragraph 4.a. of
the Other Insurance Conditian is deleted and repEaced with the foflowing:
4. Other Insurance
a, Primary (nsurance
This insurar►ce is primary and non-contributory excepE when rendered excess by this
endorsement, ar when Paragraph b. befow applies.
E. The provisions of the writien contract or written agreemen# do not in any way broaden ar amend this
Coverage Part.
http://fornnnet-ci.cna.com/glhtm/cna7788.htrn 1/8/2010
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POLICYNUMBER: C20667 28 229 CG24041093
THIS ENDORSEMENT CHANGES THE POLiCY. PLEASE READ IT CAREFULLY.
WAIVER �F TRANSFER �F RIGHTS
OF RECQVEi�Y AG/�iNST OTHERS TO US
This endorsement modifies insurance provided under ihe foitowing:
COMMERCIAL GENEFtAL LiAB1L1TY COVERAGE PART
SCNEDULE
Name of Persan or Org�anizatian:
ANY PERSOIV OR ORCANIZATION WITH WHONI Y�U
AGREE IN GVRITIP7G 'TO WAiVE YOUR RIGH'T TO
RECOVER AGAINST THEM. YOU NII75T P,GREE TO
THiS WAIVER PRIOR TO THE DATE OF LOSS.
(if no entry appears above, infiormaiion required to compfete this endorsement will be shown ir� #he Qeclaraiions as
applic�ble to fhis endorsement.)
The TRANS�ER OF RIGHTS OF REGOVERY AGAtNST
�THERS TO US Conditian (Sec6on tV -- COMMERCIRL
GENERAI LIABIi.1TY CONDITIONS) is amended by the
additi�n of the following:
We waiva any r+ght of recovery we may have against fhe
person or arganizatian shown in the Scheduie above
CG 24 04 10 93
because of payrnenEs we maEce for injury or damage arising
oui ot your ongoing operatians or "your vdork" dQne under a
contract with that person or organization and inctuded in the
"products-compleied operations hazard." This waiver
app{ies only to the person or organization shown in the
Schedule above.
Copyright, fnsurance Services Of€ice, Inc., 1992
�'�' °� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
�....---` iz/za/zoii
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 dces not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
NAME:
Brown & Brown Insurance - Clearwater PHONE F,vc
P.O. Box 2456 �vc No exc: - - ac,No: - -
E-MAIL
Slllt2 660 ADDRESS:
Clearwater FL 33757-2456 PRODUCER ^y
INSURER(S) APFORDING COVERAGE NAIC #
INSURED INSURERA:NatlOridl Fire Ins of Hartford 20478
King Engineering Assoc., Inc. iNSUReRe:Trans ortation Insurance Co. 20494
4921 Memorial Hwy Ste 300
Tampa FL 33634 iNSUReRC:Valle For e Insurance Com an 20508
INSURER D :
INSURER E :
INSURER F :
COVERAGES CERTIFICATE NUMBER:1226144127 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.
INSR TypE OF INSURANCE A DL UBR POLICY EFF POLICY EXP
LTR IN R WVD POLICY NUMBER MM/DD/YVYY MM/DD LIMITS
A GENERALLIABILITY C2066728229 1/1/2012 1/1/2013 EACHOCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED 500, 000
PREMISES Ea occurrence $
CLAIMS-MADE � OCCUR MED EXP (Any one person) $5 , 000
X XCU Included PERSONAL& ADVINJURY $1,000,000
X Blk WOS GENERALAGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: � PRODUCTS - COMP/OP AGG $Z . 000 , 000
POLICY X PRO- LOC �v`,� � � � $
A AUTOMOBILELIABILITY C2066728232 1/1/2012 1/1/2013 COMBINEDSINGLELIMIT $1,000,000
(Ea accident)
X ANY AUTO f� n �'� �
!_ n �` ' BODILY INJURY (Per person) $
AL� OWNED AUTOS DE�+ BODILY INJURY (Per accident) $
SCHEDULED AUTOS
p�^ PROPERTY DAMAGE
X HIRED AUTOS �O �y��d�� � � � � � ��� .� � (Per accident) $
X NON-OWNED AUTOS �������' . • • - $
$
g UMBRELLA LIAB X OCCUR C2066728246 1/1/2012 1/1/2013 EqCH OCCURRENCE $5, 000, 000
EXCESSLIAB CLAIMS-MADE AGGREGATE $5,000,000
DFDUCTIBLE $
X RETENTION $ 0 g
� WORKERSCOMPENSATION WC163672015 1/1/2012 1/1/2013 X WCSTATU- OTH-
AND EMPLOYERS' LIABILITY Y� N T RY IMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $1, 000, 000
OFFICER/MEMBER EXCLUDED? � N � A
(Mandatory in NH) E.L. DISEASE -EA EMPLOYE $1, 000, �00
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $1, 000 , 000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
* 10 Day Notice for Non Payment of Premium
Coverage is primary & Non Contributory to any policies held by the certificate holder as required by
written contract.
HOLDER
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.
City of Clearwater
Attn: City Clerk
PO BOX 4748 AUTHORIZEDREPRESENTATIVE
Clearwater FL 33758-4748 /
'��..c.�s...T. ��l�
O 1988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25 (2009/09) The ACORD name and logo are registered marks of ACORD
��� OP ID: KR
'`�`�,.°�ROr CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY)
12/28/11
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 ho�der in lieu of such endorsement s.
PRODUCER 407-644-5722 NAME: CT Kristin Rodri uez
Lykes Insurance, Inc. - WP 407-628-1363 PHONE 407-478-4979 ac No : 407-626-1363
A/C No Ext :
P. O. Box 2703 E-MAIL
Winter Park, FL 32790 PRODUCER rodri uez I kesinsurance.com
Mark E. Jackson A129051 cusTOnneRion:KINGE-1
INSURED King Engineering Associates,
Inc.
4921 Memorial Highway #300
Tampa, FL 33654
COVERAGES CERTIFICATE NUMBER:
INSURER S AFFORDING COVERAGE NAIC #
iNSUReRn:Continental Insurance Co. 35289
INSURER B :
INSURER C :
INSURER D :
INSURER E :
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 7YFE OF INSURANCE ADDL UBR pOLICY NUMBER MMIDDYIYYYY MM DDY/YYYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMA R NT D
PREMISES Ea occurrence $
CLAIMS-MADE � OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY $
GENERALAGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
POLICY PR� LOC $
AUTOMOBILE LIABILITY �� .,`.�� 'e� _�t COMBINED SINGLE LIMIT
(Ea accident) $
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED AUTOS DEC �.� � A�
BODILY INJURY (Per accident) $
SCHEDULED AUTOS
PROPERTY DAMAGE $
HIREDAUTOS �e��ry°-. � f,`-�� , ��g.; ���,;+* (PeraccidenQ
�.a�G o-B�.�x � � ��. : ,...� ,-i� ��
NON-OWNED AUTOS i� �.e �.a n� �, � �,, � -� �, � ;y $
E�l:De:i�-:�t�`�.. �r.�.J �J W ..I��
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETEN�i101J 5 � $
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' LIABILITY Y� N RY LIMI R
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? � N/ A E.L. EACH ACCIDENT $
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
q Professional AEH173805181 01/01/12 01/01/13 Per Claim 2,000,00
Aggregate 4,000,00
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Blanket Waiver of Subrogation is included when required by contract.
C�i3:i11�[y_\1�
City of Clearwater
Attn: City Clerk
P.O. Box 4748
Clearwater, FL 33758-4748
ACORD 25 (2009I09)
CITY474
CANCELLA'
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
i�G��� �/7��
O 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD