CERTIFICATE OF LIABILITY INSURANCE (5)�� � CERTIFICATE OF LIABILITY IN DATE(MM/DDlYWY)
,,,� S U RANC E ,o,o5,ZO,2
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(sl.
PRODUCER Mutual Insurance Inc
1900 1st Ave North
PO Box 12350
St Petersburg
INSURED
Harvard Jolly, Inc.
2714 Dr Mlk Jr St N
St Petersbu�g
FL 33713
FL 33704-2722
Mitchell Marsh ext 2214
(7271896-0006
Auto Owners Insurance Co
821-7483
8988
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 SUBR P F POLICY EXP LIMITS
OENERAL UABILITY EACH OCCURRENCE
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED
CWMSMADE � OCCUR O�T O �0�� MED EXP An one rson $
PERSONAL & ADV INJURY $
�y g�+C,��, �� �� ��� `� GENERALAGGREGATE $
GEN'l AGGREGATE UMIT APPUES PER: ���.���� �@�� �� � PRODUCTS - COMP/OP AGG 3
POLI Y PRO- � $
A AUTOMOBILE LIABILITY X 967%� i�OOO � i/O8/ZO�Z i i/OH/ZO1$ COMBINED SINGLE LIMIT
X ANY AUTO BODILY INJURY (Per
person) E 1,000,000
ALLOWNED SCHEDULED BODILYINJURY(PeraccideM) $ 'I,OOO,OOO
AUTOS AUTOS PROPERTY DAMAGE g �,OOO,OOO
X HIRED AUTOS X AUTOS�ED
$
UMBRELLA UAB p�CUR EACH OCCURRENCE S
EXCESS LIAB CWMS-MADE AGGREGATE S
WORKERS COMPENSATION WC STATU- OTH-
AND EMPLOYERS' UABILITY Y 1 N
AMY °R^PR:�70WF;.RT�:G-i3;EX€CiliidE �j N� A E.L. EACH ACCIDENT
OFFICER/MEMBER EXCLUDED? ��
(AAandatory in NH) E.L. DISEASE - EA EMPLOYEE
If es, describe under
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES 1Akach ACORD 107 Additlonal Remarks Schedule, If moro space is roquirotl1
Cancellation Terms: 30 days notice of cancellation except for 10 days notice for non payment of premium. The City of Clearvvater is an additional insured as per
the Commercial auto policy with a waiver of subrogation in favor of the additionai insured.
30 days notice of cancellation.
n� .�' reNr.�i i eTinu A1009139
City of Clearwater
Attention: City Clerk
PO Boz 4748
Clearwater
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
FL $$�S$-4�4a AUTHORIZED REPRESENTATIVE ��
Fax: ()- O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) The ACORD name and logo are registered marks of ACORD