CERTIFICATE OF LIABILITY INSURANCE (225)ADD® CERTIFICATE OF LIABILITY INSURANCE
I DATE(MMIDDIYYYY)
08/22/2013
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 Mutual Insurance Inc
1900 1st Ave North ;,"
PO Box 12350
St Petersburg FL 33713
CONTACT
CONTACT Mitchell Marsh ext 2214
PHONE (727) 896 -0006 FAX
Nth vY +)• ) (A /C Noj:
(727) 821-7483
(vr,
ADDRLSS mmarsh @mutualinsuranceinc.com
INSURER(S) AFFORDING COVERAGE
NAIC #
INSURER A :Owners Ins Co
INSURER B 'Southern Owners Ins
32700
10190
INSURED
Victor C Owsley and Perry's Nursery Inc
4305 46th Ave N
St Petersburg FL 33714-
INSURER C
09/10/2013
INSURER D
EACH OCCURRENCE
INSURER E
DAMAGE TO RENTED nra
( )
INSURER F :
MED EXP (Any one person)
•
ION NUMBER:
WW1/ LI\l1•LV vr.. ". ...r.... ...............
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
TYPE OF INSURANCE
ADDL
!NCR
SUBR
wvn
POLICY NUMBER
POLICY EFF
IMM/DDIYYYY)
POLICY EXP
(MM /DDIYYYY)
LIMITS
B
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
20697993
09/10/2013
09/10/2014
EACH OCCURRENCE
$ 1,000,000
DAMAGE TO RENTED nra
( )
$ 50,000
MED EXP (Any one person)
$ 5,000
CLAIMS -MADE
X
OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
X
No deductible
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP /OP AGG
$ 2,000,000
GEN'L AGGREGATE
—)1( POLICY
LIMIT APPLIES
''Th T
PER:
LOC
$
A
AUTOMOBILE
X
X
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
X
SCHEDULED
AUTOS
NON -OWNED
AUTOS
4394820504
09/10/2013
09/10/2014
OMBINtEeDn9 INGLE LIMIT
Q 1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Pr r accident)
$
UMBRELLA LIAB
EXCESS LIAB
OCCUR
CLAIMS -MADE
EACH OCCURRENCE
$
AGGREGATE
$
$
DFD
RETENTION $
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
TORY WC
LIMITS -
0TH-
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)
Cancellation Terms: 30 Days notice of cancellation except 49rnys.aotIe pf..cancellation for non - payment of premium. License Holder: Victor Owsley
license number LC118130 E '' (I
.... _ nl /IA ennn
rn
IiCR I IrIVFi i C IlVLUCR •- .--.-
City of Clearwater
Brian & Renee
100 S Myrtle Ave
Clearwater
°•
FL
e
33756-
• ^E--- ..• —.-
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 t
ACORD 25 (2010/05)
- . .
The ACORD name and logo are registered marks of ACORD