CERTIFICATE OF LIABILITY INSURANCE (230)NOVAH -1
OP ID: GD
'`�� °R °� CERTIFICATE OF LIABILITY INSURANCE
DATE(MM /DD/YYYY)
08/28/2013
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 Phone:727- 447-6481
Bouchard - Clearwater Fax: 727 -449 -1267
101 Starcrest Drive
P e Box 6090
Clearwater, FL 33758 -6090
J Raymond Bouchard, CIC
NAMEACT
PHONE FAX No):
(ac, No, Ext):
,MM /DD/YYYY)
ADDRESS: cicerts @bouchardinsurance.com
INSURER(S) AFFORDING COVERAGE NAIC #
INSURER A : Valley Forge Insurance Co
INSURER B : Transportation Insurance Co
LIABILITY
COMMERCIAL GENERAL LIABILITY
INSURED NOVA Hotel Renovation &
Construction, LLC
601 South Lincoln Ave
Clearwater, FL 33756
INSURER C : National Fire Ins Co Hartford
" " r
C20834540001_ ,
INSURER D :
09/11/2014
INSURER E :
$ 1,000,000
INSURER F :
$ 100,000
•
ISION NUMBER:
NA v , • .
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.
ILTR
TYPE OF INSURANCE
INSR
WVD
POLICY NUMBER
(MM /DD/YYYY)
,MM /DD/YYYY)
LIMITS
C
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
X
" " r
C20834540001_ ,
09/11/2013
09/11/2014
EACH OCCURRENCE
$ 1,000,000
pR M sES(a oecu ante)
$ 100,000
MED EXP (Any one person)
$ 5,000
CLAIMS -MADE
X
OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP /OP AGG
$ 2,000,000
GEN'L AGGREGATE
7 POLICY
X
LIMIT APPLIES
FS:T
PER:
LOC
$
A
AUTOMOBILE
X
X
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
SCHEDULED
AUTOS
NON -OWNED
AUTOS
C5086465497
09/11/2013
09/11/2014
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
C 5086465502
09/11/2013
09/11/2014
EACH OCCURRENCE
$ 5,000,000
AGGREGATE
$ 5,000,000
$
DED
X
RETENTION$ 10,000
A
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
WC 5086465533
09/11/2013
09/11/2014
X
WC STATU-
TORY LIMITS
0TH -
ER
E.L. EACH ACCIDENT
$ 1,000,000
E.L. DISEASE - EA EMPLOYEE
$ 1,000 , 000
E.L. DISEASE - POLICY LIMIT
$ 1,000,000
C
Equipment Floater
C5086465516
09/11/2013
09/11/2014
Lsd /Rent 50,000
Deductibl 1,000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule If more space is required)
FAX: 727 - 443 -5508
CERTIFICATE HOLDER IS RECOGNIZED AS ADDITIONAL INSURED AS RESPECTS GENERAL
LIABILITY ONLY IF REQUIRED BY WRITTEN CONTRACT AND SUBJECT TO THE TERMS,
CONDITIONS, AND LIMITS AS SPECIFIED IN THE POLICY.
VCR I rriVM I L rI•LVLrl
CLEARWA
CITY OF CLEARWATER
100 SOUTH MYRTLE AVENUE
CLEARWATER, FL 33756
- • .. --__ -- -' -_ --
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
ACORD 25 (2010/05)
-2010 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD