CERTIFICATE OF LIABILITY INSURANCE (3)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE
I DATE
12-21-2005
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ACORDIA SOUTHEAST-CLEARWATER/PHS ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
224347 P: (866)467-8730 F: (877)538-8526 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PO BOX 29611 INSURERS AFFORDING COVERAGE
CHARLOTTE NC 28229
INSURED INSURER A: Hart ford Fire Ins CO
INSURER B:
LE-AZON TECHNOLOGY INSTITUTE INC. INSURER c:
PO BOX 4097 INSURER D:
CLEARWATER FL 33758 INSURER E:
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE POLICY NUMBER r:i~rM~~~J.:.~~ ~k!fEY/:J,~~J.J~~ LIMITS
LTR
~ERAL LIABILITY EACH OCCURRENCE $1,000,000
A COMMERCIAL GENERAL LIABILITY 21 SBA NVOO05 02/18/06 02/18/07 FIRE DAMAGE (Anyone fire) s300,000
f-- ~ CLAIMS MADE lKJ OCCUR MED EXP (Anyone person) $10,000
X Business Liab PERSONAL & ADV INJURY $1,000,000
GENERAL AGGREGATE $2 , 000 , 000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMPIOP AGG $2 , 000 , 000
I I-I PRO II
POLICY JEcT X LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
-
- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS (Per person)
-
- HIRED AUTOS BODILY INJURY
$
NON-OWNED AUTOS (Per accident)
-
- PROPERTY DAMAGE $
(Per accident I
~AGE LIABILITY AUTO ONLY - EA ACCIDENT $
=l ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $
~ OCCUR U CLAIMS MADE AGGREGATE $
==l DEDUCTIBLE $
$
RETENTION $ $
WORKERS COMPENSATION AND I T~~,n~~s t IOl~-
EMPLOYERS' LIABILITY
E.L. EACH ACCIDENT $
E.L. DISEASE - EA EMPLOYEE $
.. -"--..--- --.
E.L. DISEASE. POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Those usual to the Insured's Operations. Certificate holder is also an
Additional Insured per the Business Liability Coverage Form SSOO08.
CERTIFICATE HOLDER I X I ADDITIONAL INSURED; INSURER lETTER: A CANCELLATION
Ic' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE I
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
lty of Clearwater 30 DAYS WRITTEN NOTICE (10 DAYS FOR NON.PAYMENT) TO THE CERTIFICATE
Earl Barrett/Engineering Dept. HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO
OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
P.O. Box 4748 REPRESENT A TIVES.
Clearwater, FL 33758-4748
A~ee~- -
ACORD 25-S /7/971
'" ACORD CORPORATION 1988
ACORDIA SOUTHEAST-CLEARWATER/PHS
PO BOX 29611
CHARLOTTE NC, 28229
City of Clearwater
Earl Barrett/Engineering Dept.
P.O. Box 4748
Clearwater, FL 33758-4748
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IMPORT ANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate
does not confer rights to the certificate holder in lieu of such endorsement(s)
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s),
authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or
alter the coverage afforded by the policies listed thereon.
ACORD 25-5 17/97)