CERTIFICATE OF LIABILITY INSURANCE (144)�""�
ACOR�� CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDM/YY)
�./ 05/14/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HC)LDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THIE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AIITHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certiflcate 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 PhOf1B: (813) 988-1234 F9X: (813) 968-0989 CONTACT Toni Valentine
ASSOCIATES AGENCY� INC. NAME:
PO BOX 16190 ac° No e�n :(813) 988-1234 ^,� No :(813) 9H8-0989
E-MAIL toni@associatesins.com
11470 N. 53RD ST. no�Ress:
TEMPLE TERRACE FL 33687 INSURER�S) AFFORDING COVERAGE NAIC #
TAMPA SCREENS AND ALUMINUM, INC. 8�
TAMPA OUTDOOR KITCHENS LLC
PO BOX 272363
TAMPA FL 33688
Agency Lic#: L062850 � INSURER A
INSURER 8
INSURER C :
INSURER D:
INSURER E :
INSURER F :
FCCI Commercial Ins. Co.
FCCI INSURANCE CO. 10178
COVERAGES CERTIFICATE NUMBER: 278081 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLIC'Y 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 ADD'L SUBR pOLICY NUMBER POLICY EFF POLICY EXP LIMITS
LTR INSR WVD MMIDD MMIDD
A GENERAL LIABILITY CPP0011780 12/01/12 12/01/13 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 'I OO,OOO
PREMISES (Ea occurence)
CLAIMS-MADE I� OCCUR MED. EXP (Any one person) $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERALAGGREGATE $ Z,OOO,OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $ 2,000,000
PRO-
POLICY JECT LOC $
A AUTOMOBILE LIABILITV CA0009742 12/01/12 12/01/13 COMBINEDSINGLELIMIT ,�'o00'000
(Ea accident) $
x ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY Per accident $
AUTOS AUTOS � �
X HIREDAUTOS x NON-OWNED PROPER7vDAMAGE $
AUTOS (per acciaent)
$
q X UMBRELLA LIAB X occuR UM60011532 12/01/12 12/01/13 EACH OCCURRENCE $ 2,000,000
excess LIAB CLAIMS-MADE AGGREGATE $ Y,OOO,OOO
DED X RETENTION $ 'I O,OOO $
B WORKERS COMPENSATION 001-WC13A-64290 05/15/13 05/15/14 X TORYLIMTS ER $
AND EMPLOYERS' LIABILITY _
ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACFiACCIDENT $ ��OOO�OOO
OFFICER/MEMBER EXCLUDED9 N�q E.L. DISEASE-EA EMPLOYEE $ 1 OOO OOO
(Mandatory in NH) i �
ii yes, dascribe under E.L. DISEASE-POLICY LIMIT $ � QQQ�QQQ
DESCRIPTION OF OPERATIONS below �
� �
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) �a r,.;r�
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CERTIFICATE HOLDER CANCELLATION
CITY OF CLEARWATER
P.O. BOX 4748
CLEARWATER, FL 33758
Attention:
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLE_D BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTAT�VE
ACORD 25 (2010/05) OO 1988-201f
The ACORD name and logo are registered marks of ACORD