CERTIFICATE OF LIABILITY INSURANCE (3) CLEAR11 OP 113: KS
UATE III M1nr).rVYyY)
CERTIFICATE OF LIABILITY INSURANCE F 09f30113
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 fNSURFR(S4, 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(sl,,
PRODUCER NTACT
727-784-8554 CNAOM E:
Stahl&Associates insurance
PHONE FAX
3939 Tampa Road 727-789-2823 (A!QNp,ext): �A!C,No):
Oldsmar,,FL 34677 E-MA L
Michael Pagano,AAI ADDRESS:
INSURERJISI AFFORUNG t'OVERAGE NAIC#
INSURER,A•Naticinal Trust Ins,Co.
i INSURED Clearwater Golf Club LLC WSURER 8:FOCI
Greg or Rebecca McClimans
NSOA CU
Ii-P �FRA
525 N Betty Ln
Clearwater, FL 33755
INSURER D:
NSU RER
I E
'8U
INIURERF:
COVERAGES CERTIFICATE NUMBER: REVISION NUM ER
THIS IS T(,)CFRTIFY THAT TH.E POUC@ES OF INSURANCE LISTED BELOW HAVE B17 EN ISSUED TO THE ENSUIRE ' NAMED ADO`,,E—FORTHE
INDICATED- NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Wl- V%)HICH THiS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT rO ALL II HE TERMS
EXCLUSIONS AND CON D1 TIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID OLAJ ME
INSP, ADDL SUBW
LTR TYPE Or INSURANCE POLICY EFL POLICY EXP
—POLICY LIMPS
GFNERAL LIABILITY
FAGH O(.CURIRENCE I.000,00
A X CO�,4�0---,RC,[Al-f3ENERA[-LIABILI;Y x <CPPOOI 17691 10101113 10101114 DANIAGE TO REN"F0
PRk-401SES�Eaoccur�eric�) 100,00
C I-A!M S°PA,A f)E X OCCLP M FXV tAnv One P�rso-,n) $ 10,()0
IlHISONAL A AUV INJURY 'N 1,000,001
GENERAL AGGREGATE $ 200000
GEN'L AGGP EGAJ E UMIT APPLIES PER PRODUCTS-GONIP;(-W 1„ r, S 2:000:00
X PoItCL— I - ,
AUTOMOBILE LIABILITY COMBINED Sfl,4GI-E LINII-1-
,,Ea aCCI'Jeflt) a 1,000,000
B X A114Y AUTO CAU0170601 10101(13 101011,14 B(IDII-Y.N 1URY fPer S�
ALI,C4144ED SCHEI)LILED
AUTOS AUTOS 60D1I,Y INJURY i PPr S
HIRED AUTOS NON-OWNFI) PROPERTY DIAMAGE.
AUTOS (Pe,'r ijcc,�Im)
A
—------------ —-----------
X UMBRELLA LIAB X OCCUR EA C H 0 C C J R R EN',F, 1,000,000
B EXCESS LIAS CLAIMS-MADE UMB001 14901 10/01113 10001114 A err EGATI-H t 1,000,000
DED X RETENTONS 0 $
WORKERS COMPENSATION A'G STATU 1 1--I-
AND EMPLOYERS'LIABILITY X [ORYLONITS ER
C ANY PROPRIETOR.6PARTNER/EXFCU1 ivE YIN TSD 10101/13 10101114 El, FACHACCIDEW 9� 500,00
OFRCERWEMBER EX�"IILUDEn?
iMandatory in WH) Na A tA,1NV`t,,0YI'E, 5 500,00
ff yos,do soribe undef,
DESCRIPTION OF 0 P I-RKr I ONS F.-o low E D5SEASE-POLICYLIMIT 3 500,00�
------------
8 Inland Marine -CM00059011 10/01113 10101114 Grflf Cart 160,000
Ded 1,000
DESCRIPTION OF OPCRATIONS(LOCATIONS!VEHICLES (Altath AGO RD 10 Add ftiwm�R.mdd,,� it-- P.—i.
City of Clearwater is listed as additional insured with respect to general REC E I VEr-
liab,ility subject to the, terms, Conditions and exclusions of the-- policy,
P a r k s &
CERTIFICATE HOLDER CITYCLE CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE I
Ift hXPIRAIION DATE IHEREOF, NOTICE, WILL BE DELIVERED IN
City o lear ter ACCORDANCE WITH THE POLICY PROVISIONS,
f Cwa
Parks& Recreation Dept.
AUTHONZED REPRESENTATIVE
100 So Myrtle Ave
Clearwater, FL 33756
-stt
198P
3-2010 ACORD CORPORATION. AH rights reserved,
ACIORD 25(20101051 TVA p ACOPD narne artd Ioge are regNtered marks,of ACORD