CERTIFICATE OF LIABILITY INSURANCE (138)11762
CERTIFICATE OF LIABILITY INSURANCE I DATEQMM/DD/YYYY)
'I /3/2013
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 THI� POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AI,ITHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed. If SUBROGATION IS WAIVEC�, 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 Ch stal Hatcher
NAME: rY
Commercial Lines -(813) 639-3000 PHONN . 813.639.3019 ac No :$13.6::t9.7198
Wells Far o Insurance Services USA, Inc. E-Mai� --
9 noor�ss: chrystal.hatcher@wellsfargo.com
2502 N. Rocky Point Drive, SUlte 4OO __ INSURER(S) AFFORDING COVERAGE NAIC #
Tampa, FL 33607 iNSUReRa: Hartford Fire Insurance Company 19682
INSURED
Image One Corp dba iNSUrteR e: Zenith Insurance Company __ 13269
INSURER C :
6206 Benjamin Rd #301 INSURER D:
� Tampa FL 33634 I INSURER F: 1_�
COVERAGES CERTIFICATE NUMBER: 5440759 REVISION NUMBER: See bel�aw
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POL.ICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO �NHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL 1'HE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR 7ypE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR POLICY NUMBER MM/DD/YYW MM/DDIYI'YY
A GENERALLIABI�ITY 21SBALI1614 1/1/2013 1/1/2014 EACHOCCURRENCE _$ , 1,000,000
X COMMERCIAL GENERAL LIABILIN DAMAGE TO RENTED 300,000
PREMISES Ea occurrence $
CLAIMS-MADE � OCCUR MED EXP (My one person) $ 10,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
X POLICY PRO- LOC $
A AUTOMOBILELIABILITY 21UECLI4905 01l01/2013 01/01/2014 COMBINEDSINGLELIMIT �,000,000
Ea accident
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDUIED BODILY INJURY (Per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per axident
S -
A X' UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 3.000,000
_ 21SBALI1614 1/1l2013 1!1/2014 _ __ _
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 3,000,000
DED X RETENTION $ 10,000 $
WORKERS COMPENSATION x WC STATU- OTH-
B ANDEMPLOYERS'W►BILITY Y�N Z072426001 1/1/2013 1/1/2014
ANY PROPRIETORIPARTNER/EXECUTIVE ❑ E.L. EACH ACCIDENT $ 1,000,000
OPFICERIMEMBER EXCLUDED? N � A — ---
(Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1.000,000
If yes, describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $
� i � �;T';1
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Altach ACORD 701, Additional Remarks Schedule, if more space is requirea�° ` �--
CERT�FICATE HOLDER IS ADDITIONAL INSURED AS RESPECTS GENERAL LIABILITY
•.. .. .:. t, .� ..:, . ,
� _r..._....., ..,'< ._ _ ,
CITY OF CLEARWATER
ATTN: CITY CLERK
P O BOX 4748
CLEARWATER FL 33758
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELI�.ED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
9`�'�/�-
oona�a
The ACORD name and logo are registered ma►ks of ACORD OO 1988-2070 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) I II'I'll III IIIIII) IIII IIIII (IIIII IIII IIIII IIII) IIIII IIIII IIIII IIIII IIIII IIIII I'III IIII IIII -cveoino3ioozzsoiovoz�aoroio�
Commercial Lines - (813) 639-3000
Wells Fargo insurance Services USA, Inc.
2502 N. Rocky Point Drive, Suite 400
Tampa, FL 33607
CITY OF CLEARWATER
ATTN: CITY CLERK
P O BOX 4748
CLEARWATER FL 33758
******x********************************.*******�.*«.*«********.,************************************************,***
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