CERTIFICATE OF LIABILITY INSURANCE (4) CERTIFICATE OF LIABILITY INSURANCE 7/30DATE
/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 Contact Name: Alfonso Rojas
Cossio Insurance Agency Phone 7273652523 Fax 8668391090
PO Box 188 (A/C,No,Ext): (A/C,No):
Simpsonville,SC 29681 E-Mail: Alfonso @TheUltimateBounce.com
(864)688-0121 INSURER(S)AFFORDING COVERAGE NAIC#
INSURED INSURER A: Riverport Insurance Company(MINNEAPOLIS,MN)
SPORTS AND RECREATION PROVIDERS ASSOCIATION INSURER B: US Fire Insurance Company
(PURCHASING GROUP)AND ITS PARTICIPATING MEMBERS:
Ultimate Bounce,LLC INSURER C:
3300 11th Street N
St.Petersburg,FL 33704 INSURER D:
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 POLICY ADDL SUBR POLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR WVD (MM/DD/YY) (MM/DD/YY)
GENERAL LIABILITY Each Occurrence $1,000,000
X❑COMMERCIAL GENERAL LIABILITY General Aggregate $2,000,000
1-11-1 ❑X Personal&Advvertea gpInjury Operations $1,000,000
CLAIMS MADE OCCUR
A ❑ 0 FLDG180312 7/25/2012 7/25/2013 Medical Expenses $5,000
❑ Fire Damage $300,000
Deductible None
GEN'L AGGREGATE LIMIT APPLIES PER
0 POLICY ❑PROJECT ❑LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
❑ ANY AUTO
BODILY INJURY $
❑ ALL OWNED SCHEDULED (Per Person)
AUTOS ❑ AUTOS BODILY INJURY $
❑ HIRED AUTOS NON-OWNED (Per accident)
❑ AUTOS
PROPERTY DAMAGE $
❑ ❑ (Per accident)
❑ UMBRELLA LIAB ❑ OCCUR
❑ EXCESS LIAB ❑ CLAIMS-MADE
❑ DED ❑ RETENTION$
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS'LIABILITY TORY LIMITS ER
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? Y� N/A
(Mandatory in NH)
If yes,describe under
DESCRIPTION OF OPERATIONS below
Maximum Medical Benefit per Claim $10,000
Accidental Death/Dismemberment B $10,000
B Accident Medical US068587 7/25/2012 7/25/2013 Deductible
L _L DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
Party Equipment Rentals Operations located at 3300 11th Street St.Petersburg,FL 33704. Certificate Holder As Additional Insured
Amusement devices on file with the company for special events dated throughout the policy period located at 10 Pier 60,Clearwater Beach,FL 33767.
CERTIFICATE HOLDER: CANCELLATION
City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
100 S Myrtle Avenue EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN
Clearwater,FL 33756 ACCORDANCE WITH THE POLICY PROVISIONS. Ft
—�-v
AUTHORIZED REPRESENTATIVE
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD @ 1988-2010 ACORD CORPORATION.All rights reserved.