CERTIFICATE OF LIABILITY INSURANCE (22)ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DDIriYY)
TM 06/06/2012
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 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
NAME:
Alley, Rehbaum & Capes Assurance, Inc. PHONE 72�.�g�,5193 727.725.5773
A/C No Ext : A/C, No :
2433 Gulf to Bay Blvd. E-MAIL
ADDRESS:
P.O. BOX 4620 INSURER�S) AFFORDING COVERAGE NAIC #
Clearwater, FL 33758 INSURERA: Flf 5't National Insurance Co
INSURED Thomas & Patri ci a Wol kowsky INSURER 6:
DBA: Pirates Pantry INSURERC:
25 Causeway Blvd., #4 INSURERD:
Clearwater Beach, FL 33767 INSURERE:
INSURER F :
COVERAGES CERTIFICATE NUMBER: 13/13 Li abi 1 i ty 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 AFFOROED 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 TYPE OF INSURANCE INSR NND POUCY NUMBER MM/DD MM/DD/YYYY LIMITS
GENERAL LIABIUTY 25CC276556 06/OT/2012 06/07/2013 EACH OCCURRENCE $ 1� ��� � Q�
X COMMERCIAL GENERAL LIABILfTY PREMISES Ea occurtence $ 1� OOO � OO
CLAIMS-MADE � OCCUR MED EXP (Any one person) $ IO � OO
A X PERSONAL 8 ADV INJURY $ 1� OOO � OO
GENERAL AGGREGATE S Z� OOO � OO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG S Z� OOO � OO
POUCY PR� LOC $
JECT
AUTOMOBILE LIABILITY Ea accident $
ANY AUTO R�� f� BODILY INJURY (Per person) S
ALL OWNED SCHEDULED BODILY INJURY (Per accident) S
AUTOS AUTOS
HIRED AUTOS NON-OVIMED $
AUTOS Per accident
S
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS UAB CLAIMS�AADE O�F�Cl/"�. IYG�J DS r'U'r� AGGREGATE S
DED RETENTION S S
WORKERS COMPENSATION -
AND EMPLOYERS' LIABILITY Y� N TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTN� E.L. EACH ACCIDENT S
OFFICER/MEMBER EXCLUDED? N � A
(Mandatory in NH) E.L. DISEASE - EA EMPLOYE S
If yes, desaibe under
DESCRIPTION OF OPERATIONS balow E.L. DISEASE - POLICY LIMfT $
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addkionai RemaAca Schedule, If more space ia requtrad)
he Certificate Holder is listed as an Additional Insured.
CERTIFICATE HOLDER
FAX: 727.462.6957
City of Clearwater
25 Causeway Blvd.
Clqarwater, FL 33767
TION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLE� BEFORE
THE EXPIRATION DATE TMEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
���_
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