CERTIFICATE OF LIABILITY INSURANCE (280)A ®
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CERTIFICATE OF LIABILITY INSURANCE 10/25/2014
DATE (MM /DD(YYYY)
10/23/2013
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 LOCKTON COMPANIES, LLC-1 KANSAS CITY
444 W. 47TH STREET, SUITE 900
KANSAS CITY MO 64112 -1906
(816) 960 -9000
CONTACT
NAME -
ACC, N , EXt): I FAX No):
E-MAIL SS:
INSURER(SI AFFORDING COVERAGE
NAIC #
INSURER A : Zurich American Insurance Company
16535
INSURED SERVICE AMERICA ENTERPRISE, INC.
1343427 2755 NW 63RD COURT
FORT LAUDERDALE FL 33309
INSURER B: American Guarantee and Liab. Ins. Co.
26247
INSURER C : Pennsylvania Manufacturers' Assoc Ins Co
12262
INSURER D :
EACH OCCURRENCE
INSURER E :
DAMAGE TO RENTED
PREMISES (Ea occurrence)
INSURER F
$ 10,000
CERTIFICATE MI MBER• 11498795
•
LrV VGRMVCJ 1'11 \\iV 1✓ "-- -- .---- - - - - --
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
LTR
TYPE OF INSURANCE
ADDL
INSR
SUBR
WVD
POLICY NUMBER
POLICY EFF
(MM /DD/YYYY)
POLICY EXP
(MM(DD/YYYY)
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL LIABILITY
N
N
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EACH OCCURRENCE
$ 1,000,000
$ 1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
MED EXP (Any one person)
$ 10,000
CLAIMS -MADE X OCCUR
PERSONAL & ADV INJURY
$ 1,000,000
$ 5,000,000
$ 2,000,000
GENERAL AGGREGATE
PRODUCTS - COMP /OP AGG
GEN'L AGGREGATE LIMIT APPLIES PER:
f�''I j�
I l JE I 1 LOC
7 POLICY$
A
AUTOMOBILE
_
X
_
X
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
_
—
X
SCHEDULED
AUTOS
NONOWNED
AUTOS
N
N
L # ! ", c
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,
3,0/25/ 3
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10/25/2014
Ea BINEDtSINGLE LIMIT
r
$ 1,000,000
$ XXXXXXX
BODILY INJURY (Per person)
BODILY INJURY (Per accident
$ {XXXXX
PROPERTY DAMAGE
$ XXXXXXX
$ XXXXXXX
B
X
UMBRELLA LIAB
EXCESS LIAB
X
OCCUR
CLAIMS -MADE
N
N
AUC 6555463 -04
10/25/2013
10/25/2014
EACH OCCURRENCE
$ 5,000,000
AGGREGATE
$ 5,000,000
$ XXXXXXX
DED I X RETENTION so
CWORKERS
COMPENSATION Y / N
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE N
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH)
DESCRIPTION OF OPERATIONS below
N / A
N
201380 7650856
12/31/2013
10/25/2014
X (TORY LIMITSI IOFR
E.L. EACH ACCIDENT
$ 1,000,000
E . DISEASE - EA EMPLOYEE
$ 1,000,000
$ 1,000,000
E.L. DISEASE - POLICY LIMIT
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES /(Attach ACORD 101, Additional Remarks Schedule, if more space is required)
Evidence of Coverage
CERTIFICATE HOLDER
CANCELLATION
11498795
City of Clearwater
100 S. Myrtle Ave.
Clearwater FL 33756
ACORD 25 (2010/05)
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
(i18°/9 010 AC ORPORATION. All rights reserved
The ACORD name and logo are registered marks of ACORD