CERTIFICATE OF LIABILITY INSURANCE (199)���� CUM&F-1 OP ID: BLW1
'`�`�„°R�� CERTIFICATE OF LIABILITY INSURANCE DATE�MM/DDIYYYY)
03/16/12
THIS CERTIFICATE IS ISSUED AS A MAi"fER 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 hoider 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 halder in lieu of such endorsement(s).
PRODUCER - %2%-522-%%%% NAME: CT
Wallace Welch & Wiliingham Inc 727_521-2902 PHONE ac No :
300 1 st Ave. So., 5th Floor ac No eM :
St. Petersburg, FL 33701 a DRESS:
Weyman Willingham
NA�c e
INSURED Cumbey & Fair Inc
2463 Enterprise Rd
Clearwater, FL 33763
INSURER�S) AFFORDING COVERAGE
INSURERA: N8t'I Fire Ins Co of Hartford 07505
�NSUReR a: Transportation Ins. Co. 20494
iNSUReRC:RetailFirst Insurance Co.
�r,suReRO:Architects & En ineers Loss Co
INSURER E :
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.
INSR TypE OF INSURANCE ADDL UB pOLICY NUMBER MM/DDY/YYYY MM DD/YYYY LIMITS
LTR
CaENERAL LIABILITY EACH OCCURRENCE $ 'I�OOO�OO
i�1 X COMMERCIAL GENERAL LIABILITY C2086949437 03/16/12 03/16/13 pREM SES Ea occur ence $ ���,�
CLAIMS-MADE � OCCUR MED EXP (Any one person) $ 5,00
PERSONAL & ADV INJURY $ 'I �OOO�OO
X Per Project Limit GENERAL AGGREGATE $ Z�OOO�OO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ Z�OOO,OO
POLICY PR� LOC Emp Ben. $ 1,000,00
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT �,OOO�OO
Ea accident 3
A X ANY AUTO C20$$Z�8783 03/16l12 03/16/13 BODILY INJURY (Per persan) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE $
HIREDAUTOS AUTOS Peraccident
$
UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 'I �OOO�OO
B EXCESS LIAB CLAtMS-MADE C2086949471 03/16/12 03/16/13 qGGREGATE $ �,���,��
DED X RETENTION $ O $
WORKERS COMPENSATION X WC STATU- OTH- . �
AND EMPLOYERS' LIABILITY TORY LIMITS ER
C ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N 52024651 03/16/12 03/16/13 E.L. EACH ACCIDENT $ � r��Or��
OFFICER/MEMBER EXCLUDED? � N � A`
(Mandatory in NH) E.L. DISEASE - EA EMPLOYEE $ �,��0,�0
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 'I,OO ,
p Professional Liab AEICPG11 03/16/11 03/16/14 Ea Claim 1,000,00
CLAIMS MADE �r� 1,000,00
C
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Certifcate holder is additional insured on a primary and noncontributory MAR 2 0 2012
basis with respect to General Liability if required by written contract per
form G77957G. Certificate holder is additional insured with resQect to Auto
Liability per Auto Coverage Form and on the Excess Policy sub�ect to the
underlying policy termsn and conditions. A Waiver of Subrogation m favor > �F��(, ��S A�
l�fl�'i.ATIVE SRVCS D�f''T'
City of Clearwater
City Clert
P.O. Box 4748
Clearwater, FL 33758-4748
ACORD 25 (2010/05)
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
� r�
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