CERTIFICATE OF LIABILITY INSURANCE (2)
A CORDnA CERTIFICATE OF LIABILITY INSURANCE I DATE (MMIDDIYY)
12/29/2005
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
JOHN L. WORTHAM & SON, L.P. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
P.O. BOX 1388 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
HOUSTON, TEXAS 77251-1388 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
068386-303-491 - tprentic INSURERS AFFORDING COVERAGE
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INSURED INSURER A:. Liberty Insurance Corporation
CROWN CASTLE ATLANTIC LLC
2000 CORPORATE DRIVE INSURER B: Liberty Mutual Fire Insurance CO.
CANONSBURG, PA 15317 INSURER C: Liberty Mutual Insurance Company
INSURER 0:
I 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.
I~~: TYPE OF INSURANCE POLICY NUMBER PR}~~Y EFFECTIVE POLICY EXPIRATION LIMITS
nATF
c- ~NERAlllABIt:fP(.' ,- .-. Ea1~14400990' --- --"-.--- . -, o 1/Oft2006 '9f/01f2OfJ7'- ..., EACH eGGIJRRENCE. .. -$-" " , ., .1.000,000-
!II COMMERCIAL GENERAL LIABILITY FIRE DAMAGE (Anyone flrel $ 100,000
I CLAIMS MADE W OCCUR MED EXP (Anyone Dersonl $ 5,000
PERSONAL & ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
~'L AGGRnE LIMIT AnS PER: PRODUCTS. COM PlOP AGG $ 2.000,000
!II POLICY p'~Rr LOC
B ~TOMOBILE LIABILITY AS26914400990 01/01/2006 01/01/2007 COMBINED SINGLE LIMIT 1,000,000
$
~ 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)
RRAGE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN EAACC $
AUTO ONLY: AGG $
:5ESS LIABILITY EACH OCCURRENCE $
OCCUR 0 CLAIMS MADE AGGREGATE $
$
==1 DEDUCTIBLE $
RETENTION $ $
.".., A WORKERSCOMPENS.AlION A/lID-- - WAZS9D4400990 - ,- -DUO 112006 01/01/2001.- .. V ! i"~~~Iffi"gs I !OJ~. i:----- ... -- -,.-. -------
EMPLOYERS' LIABILITY $ 1,000 000
E.L. EACH ACCIDENT
E.L. DISEASE. EA EMPLOYE $ 1,000,000
E.L. DISEASE. POLICY LIMIT $ 1 000,000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER IS INCLUDED AS AN ADDITIONAL INSURED UNDER GENERAL AND AUTOMOBILE LIABILITY POLICIES WHEN REQUIRED BY
WRITTEN CONTRACT BUT ONLY WITH RESPECT TO: COUNTRYSIDElBU#814424
CERTIFICATE HOLDER I I ADDITIONAL INSURED' INSURER LETTER: CANCELLATION (BELOW & SEE REVERSE)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO
MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
CITY OF CLEARWATER LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
ATTN:EARLBARRETT ANY KIND UPON THE ISSUER, ITS AGENTS OR REPRESENTATIVES.
GENERAL SERVICES DEPARTMENT
PO BOX 4748 AUTHORIZED REPRESENTATIVE
CLEARWAT1ER, FL 33758-4748 JOHN L WORTHAM & SON, L.P.
ACORD 25-S (7/97)
@ACORDCORPORATION 1988
Cert. # 068386-303-491
CITY OF CLEARWATER
IMPORTANT
If the certificate holder isan 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.
CANCELLATION NOTICE
The CANCELLATION NOTICE on the CERTIFICATE OF INSURANCE is amended to include the
following additional wording: The Insurance Company may cancel the described policy(ies) by mailing
or delivering ten (10) days written notice of cancellation to the Certificate Holder for:
(1) Non Payment of premium or (2) any other circumstance permitted by state law or policy conditions.
ACORD 25-5 (7/97)
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