CERTIFICATE OF LIABILITY INSURANCE (123)� � 11762 DATE (MM/DD/YYYY)
A� � CERTIFICATE OF LIABILITY INSURANCE
1/11/2012
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 AFFORDEO 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 certifcate 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 CONTACT Chr stal Hatcher
NAME: y
Commercial Lines - 813 639-3000 PHONE F�
i ) 813.639.3019 _ � 813 639_7198
_ (NC. N Ext _ (A/C, No):
Wells Fargo Insurance Services USA, ItIC. E-MAIL chr stal.hatcher welisfar o.com
ADDRESS: y @ 9
2502 N. Rocky Point Drive, Suite 400 INSURER(S) AFFORDING COVERAGE NAIC # _
---- ---- __ _ —
- ----- --- ----- — - ----
Tampa, FL 33607 iNSURERA: Hartford Fire Insurance Co. 19682
_ ------- ----- -
INSURED INSURER B :
Image One Corp dba
INSURER C :
----------- - -------
6206 Benjamin Rd #301 INSURER D:
INSURER E :
Tampa FL 33634
COVERAGES CERTIFICATE NUMBER: 3�1UU/ti REVISION NUMBER: See below
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 ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YY MM/DD/YYYY
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A _ 21SBALI1614 01/01l2012 01/01/2013 -- -- -- - —
D,4MAGE TO RENTED
X COMMERCIALGENERALLIABILITY ��r/"'�f'"��'�'� ., PREMISES Eaoccurrenc� __$ .__ 300,000
- F t° • rf rt+� " -
. _ _� CLAIMS-MADE [%�� OCCUR �'^x-- - p �-�µ t 6. ; �� MED EXP (Any one person) $ _ 10,000_
PERSONAL 8 ADV INJURY $ 1,000,000
g q k�d (c� GENER.4LAGGREGATE $ 2,000,000
--. -- -- -- .:is . '. : �4� �
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
X POLICY PRO- LOC ,�"'�,^;�; '� � �_ ,� , �.. $
A XUTOMOBILE LIABILITY Z'IU -�� ,_ � O���QS�2O'IZ 01/01/2013 COMBINED SINGLE LIMIT 1,000,000
__ 1 u, ' LEa acade� $---
�=�. r - ---___-- -
ANY AUTO BUDILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $ �
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE
x HIRED AUTOS x AUTOS Per accident __ _ $. _____
- $ -
X�� UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3,000,000
A 21SBALI1614 01/01/2012 01/01/2013 - - — - — _ __
� EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000
-� - ----- �--� --- ------__.- --. _-_ ._- ---__-----------
�� DED X RETENTION $ 10,000 $
WORKERS COMPENSATION x WC STATU- OTH
A ANDEMPLOYERS'LIABILITY y�N 21WECDU9811 01/01/2012 ��/��/2��3 - i�48Y_�LMII�__._ .E.R_ __
--- __..___
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E L EACH ACCIDEN7 g 1 000,000
OFFICER/MEMBER EXCLUDED? N � A - - -- -- -- - -" --"- - - -"-
(Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1.000,000
If yes. descnbe under -�- --- �-- - - - ---- -- ---� - --. .- . .- - - - -- � �--- -
DESCRIPTION OF OPERATIONS below E.L DISEASE - POLICY �IMIT $ 1,000.000
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
CERTIFICATE HOLDER IS ADDITIONAL INSURED AS RESPECTS GENERAL LIABILITY
ERTIFICATE HOLDER
CITY OF CLEARWATER
ATTN: CITY CLERK
P O BOX 4748
CLEARWATER FL 33758
CANCELLA'
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOP, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
g��,�„/,�
ooZSO9 The ACORD name and logo are registered marks of ACORD OO 1988-2010 ACORD CORPORATION. All rights reserved.
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COmmercial LineS _
Wells Fargo �ns (813) 639_
2502 N. urance Se 3000
Ta Rocky po�nt Dri� Nices USq, Inc.
mpa' F� 33607 e� Suite 400
CITY pF C�EARWATER
ATTN; CITY C�ERK
P � B�X 4�48
C�EARwATER F� 33758
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