CERTIFICATE OF LIABILITY INSURANCE (176)ACOR�®
`+� CERTIFICATE OF LIABILITY INSURANCE
DATE (MM /DD/YYYY)
6/27/2013
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 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(s).
PRODUCER
Adcock - Adcock Property & Casualty Agency, Inc.
315 W. Fletcher Ave.
Tampa FL 33612 -3414
CONTACT Radha Jones
NAME:
IA / /c°Nro.Extt (813)933 -6691 I A/C. Not; (813)932 -6287
ADDRESS :radhaj @adcock- insurance.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURERA:Owners Insurance Co.
32700
INSURED
Smith & Hudson Interiors Inc
James Brownrigg
5003 N. 40th St. #101
Tampa FL 33610 -5237
INSURER B :Auto-Owners Insurance Co.
18 988
INSURERC:
7/1/2014
INSURER D :
$ 500,000
INSURERE:
$ 50,000
INSURERF:
$ 5,000
NUMBER:CL1362606257
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
LTR
TYPE OF INSURANCE
.DL
INSR
$UBR
WVD
POLICY NUMBER
POLICY EFF
(MM /DD/YYYY)
POLICY EXP
IMM /DD/YYYY)
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
20663654
vri
r.
7/1/2013
=f
7/1/2014
EACH OCCURRENCE
$ 500,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$ 50,000
MED EXP (Any one person)
$ 5,000
CLAIMS -MADE
X
OCCUR
PERSONAL &ADVINJURY
$ 500,000
GENERAL AGGREGATE
$ 1,000,000
PRODUCTS - COMP /OP AGG
$ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER:
X l POLICY n PF n LOC
$
B
AUTOMOBILE
X
X
—
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
X
SCHEDULED
AUTOS
NON -OWNED
AUTOS
•
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9541917800 ,
' `
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.20tS = y,'7'J1'
, F
/2014
COMBINED SINGLE LIMIT
(Ea accident)
$ 1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
PIP -Basic
$ 10,000
B
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
9541917801
7/1/2013
7/1/2014
EACH OCCURRENCE
$ 1,000,000
AGGREGATE
$ 1,000,000
$
DED
X
RETENTION $ 10,000
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR /PARTNER/EXECUTIVE
OFFICER /MEMBER EXCLUDED?
(Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below
Y / N
N / A
j TORY LIMITS t I 10TH-
D ER
E.L. EACH ACCIDENT
$
E.L. DISEASE - EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required)
City of Clearwater
100 S Myrtle
Clearwater, FL 34237
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Jeffrey Kemp, CIC /RRJ
ylr
•
/
---,--.P.-„,.
ACORD 25 (2010/05)
INS025 (201005).01
01988 -2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD