CERTIFICATE OF LIABILITY INSURANCE (12)„------I .
•�► CERTIFICATE OF LIABILITY INSURANCE
DATE (MM1D0/YYYY)
06/26/2013
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
MARSH USA Inc.
1717 Arch Street
Philadelphia, PA 19103
Attn: Healt hcare .AccountsCSS@marsh.com /FAX: 212 948 -1307
100607 - CIGNA- CAS -13 -14
CONTACT
NAME:
PHONE
(A/C. No. Ext); (A/C, No):
POLICY EXP
(MIWD /YYYY)
E -MAIL
ADDRESS:
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A : ACE American Insurance Company
22667
INSURED
CIGNA CORPORATION
900 COTTAGE GROVE ROAD
BLOOMFIELD, CT 06002
INSURER B : American Guarantee & Liability Ins Co
26247
INSURER C : Indemnity Ins Co Of North America
43575
INSURER D :
DAMAGE TO RENTED
PREMISES (Ea occurrence)
INSURER E :
MED EXP (Any one person)
INSURER F :
R:
CLE- 003505580 -15
REVISION NUMBER:1
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
ADDL
INSR
SUBR
SW
VD
POLICY NUMBER
POLICY EFF
(MMO(LDD/YYYY)
POLICY EXP
(MIWD /YYYY)
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
HDOG27018385
yea
�°
07/01/2013
ft
) ,-
V V
aatie ,r9 .. .
07/01/2014
EACH OCCURRENCE
$ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
1,000,000
$
MED EXP (Any one person)
$ 5,000
CLAIMS -MADE
X
OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 3,000,000
PRODUCTS - COMP /OP AGG
$ 1,000,000
GEN'L AGGREGATE
iii POLICY
LIMIT APPLIES PER:
PRO- ri LOC
JECT
$
A
AUTOMOBILE
X
LIABILITY
ANY AUTO
ALL OWNED
HIiREDSAUTOS
SCHEDULED
NON OWNED
AUTOS
ISAH08718957 ^'I h y `w,(
.v; _Jr,.
6 1$,._ "
07/01/2014
COMBINED SINGLE LIMIT
(Ea accident)
$ 1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
B
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
AUC967096605
07/01/2013
01/01/2014
EACH OCCURRENCE
$ 10,000,000
AGGREGATE
$ 10,000,000
$
DED
RETENT ON $
C
A
A
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below
Y/N
N
N / A
WLRC47317599 (AOS)
SCFC47317605 (WI)
WLRC47317587 (CA & MA)
WLRC47317575 (WV)
07/01/2013
07/0112013
07/01/2013
07/01/2013
07/01/2014
07101/2014
07/01/2014
07/0112014
X
WC STATU-
TORY LIMITS
OTH-
ER
E.L. EACH ACCIDENT
$ 1,000,000
-
E.L. DISEASE EA EMPLOYEE
1,000,000
$
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
A
EXCESS
WORKERS COMPENSATION
WCUC47317617 (OH Only)
07/01/2013
07/01/2014
LIMIT $1,000,000
SIR $1,000,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CANCELLATION
CITY OF CLEARWATER
ATTN: CITY CLERK
PO BOX 4748
CLEARWATER, FL 33758
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
of Marsh USA Inc.
Manashi Mukherjee wb C.6.4.4u-
ACORD 25 (2010/05)
@ 1988 -2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
0000484 SP 0198 - C01- P00484 -I
CITY OF CLEARWATER
ATTN: CITY CLERK
PO BOX 4748
CLEARWATER, FL 33758