CERTIFICATE OF LIABILITY INSURANCE (224)�''"~�"�4 OP ID: .i
"`�'�'� �°� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDD/YYYY)
— 08123/12
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 POL.ICIES
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 condkions of the policy, certain policies may requi�e an endorsement. A statement on this certiflcate does not confer rights to the
certiflcate holder in Ueu of such endorsement(sl.
PRODUCER
Lykes Insurance, Inc. - WP
P. O. Box 2703
Ninter Park, FL 32790
Hark E. Jackson A129051
INSURED
Inc.
4921 Memorial Highway #300
Tampa, FL 33654
407-644-5722 NAME•`'� Kristin Mcintosh
407-628-1363 ac"N E�:407-478-4979
n oD R�ess: kmcintosh lykesinsurance.com
cu m�MeR io e� KING E-1
INSURER A; C+OIlt117Q11�I II1SU�8�1C@ CO.
INSURER B :
INSURER C :
INSURER D :
407-626-1363
NAIC #
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. NOTIMTHSTANDING 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 POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE POLICY NUMBER MM/DD/YYW MMIDD/YYYY LIMITS
GENERAL LIABWTY EACH OCCURRENCE S
COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence Z
CLAIMS-MADE � OCCUR MED EXP (Any one person) $
PERSONAL & ADV INJURY S
GENERALAGGREGATE 3
GEN'l AGGREGATE LIMIT APPIIES PER: PRODUCTS - COMP/OP AGG 3
POLICY PRO- LOC y
AUTOMOBILE W161LITY COMBINED SINGLE LIMIT a
ANY AUTO (Ea accident)
BODILY INJURY (Per person) b
ALLOWNEDAUTOS Al�G 2 4 20i2 BODILYINJURY(Persccident) $
SCHEDULEDAUTOS PROPERTY DAMAGE
HIREDAUTOS r-,��l�i,�g �Fy� � (Peraccidern) S
NON-OWNEDAUTOS `i�p�.�� �r�$gJ��e p,p t�d�c �y $
L��Y�:.i'i�l 1 V� iiY V.7 1.� � a
UMBRE�LA L1AB pCCUR EACH OCCURRENCE S
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DEDUCTIBLE y
RETENTION S y
WORKERS COMPENSATION VuC STATU- TH-
AND EMPLOYERS' LIABILITY Y� N 1f RY IMIT ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT 3
OFFICER/MEMBER EXCLUDED? � N � A
(Mandatory In NH) E.L. DISEASE - EA EMPLOYE L
If yes, describe under
DESCRIPTION OF OPERATIONS belav E.L. DISEASE - POLICY LIMIT E
A Professional AEH113805181 01/01/12 01/01/13 Per Claim 2,000,00
Aggregate 4,000,00
DESCRIPTION OF OPERA710NS / LOCATIONS / VEHICLES (Attach ACORD 701, Addkional Remarks Sehedule, t( more spaee Is requlred)
Blanket Waiver of Subrogation is included when required by contract.
, _,
City of Clearwater
City Clerk
P.O. Box 4748
Clearwater, FL 33758-4748
ACORD 25 (2009/09)
CITOCLE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELNERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR¢ED REPRESENTAi11/E
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