CERTIFICATE OF LIABILITY INSURANCE (16)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE JOXMRRNA I DATE (MM/DDIYYYY)
12/29/2005
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY
Risk Transfer Holdings AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
Suite 350 CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE
301 E. Pine Street COVERAGE AFFORDED BY THE POLICIES BELOW.
Orlando, FL 32801
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: First Commercial Insurance Company
Afford-A-Staff, Inc. INSURER B:
1554 South Fort Harrison
ClealWater, FL 33756 INSURER C:
INSURER D:
INSURER E:
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OR ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY
PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY APID CLAIMS.
INSR DD'L TYPE OF INSURANCE POLICY NUMBER Pgi:i~::~g~E Pgi~:(~::ft'~N LIMITS
LTR NSRD
~ERAL LIABILITY . EACH OCCURANCE $
COMMERCIAL GENERAL LIABILITY ~~~~~~~OE~~~~';~nce) $
- :=J CLAIMS MADE D OCCUR
MED EX? (Anyone person) $
-
PERSONAL & AOV INJURY $
GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
II nPRO- n
POLICY JECT LOC
~TOMOBILE LIABILITY COMBINED SINGLE UNIT $
ANY AUTO (Ea accident)
-
LL OWNED AUTOS
- BODILY INJURY $
SCHEDULED AUTOS (Per person)
-
HIRED AUTOS
I-- BODILY INJURY $
NON-OWNED AUTOS (Per accident)
~
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
=i ANY AUTO EA ACC $
OTHER THAN
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
:=J OCCUR o CLAIMS MADE AGGREGATE $
$
=i ~EDUCTIBLE $
RETENTION $
A WORKERS COMPENSATION AND 15396-4 01/01/2006 01/01/2007 X I f'frR,?'GI"YTS I IOTH-
EMPLOYERS' LIABILITY ER
.__e -- f--.- __ _n ___ --~---- -.- ~i!ACI'IACC1OENT .-- "$'----- - 1,OOO;OU(,
P ^ lUNaR 'IiXEGUnVE--"-' ._- . - - -- --- ..
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $ 1,000,000
If yes. describe under E.L. DISEASE - POLICY LIMIT $ 1,000,000
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS I ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Coverage is extended to the leased employees of altemate employer (Florida Operations Onr6 688 Skate Park, Inc. - # 01-01-122-
Effective - 01/18/04 DISCLAIMER: This Certificate of Insurance does not constitute a contrac etween the issuin~ insurerfs,
authorized representative or producer, and the certificate holder, nor does itaffirmativel~ or negatively amend, ex end or a ter the
coverage afforded by the policies listed thereon. This certificate only applies to Skating ink.
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN NOTICE
09504**********3-DIGIT 337 TO THE CERIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO
City of Clearwater OBLIGATION OF LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
CI!1 Clerk
P Box 4748 REPRESENTATIVES.
Clearwater, FL 33758-4748 AUTHORIZED REPRESENTIVE
1..11...11.1...1.1.1.1111..1..11...1.1..11111..1..11..1.1.1..1 ~
COVERAGES
CERTIFICATE HOLDER
CANCELLATION
ACORD 25 (2001/08)
@ACORD CORPORATION 1988