CERTIFICATE OF LIABILITY INSURANCE (10)
Apr 13 06 09:26a
SANDBERGEN INSURANCE
727-446-9147
p. 1
.
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MMIODIYYVY)
n, 04/13/2006
PRODUCER (7Z7)442-00lZ FAX (727)446-9147 THIS CERTIFICATE IS ISSUED AS A MATTER CF INFORMATION
Sandbergen Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
2121 N.E. Coachman Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Clearwater, Fl 33765-2616 INSURERS AFFORDING COVERAGE NAIC#
INSURED Marina Restaurant INSURER A: Capacity Insurance Co.
Thomas & Patrcia Wolkowsky 1~ISURER B:
25 Causeway Boulevard 1~ISURER c:
Clearwater Beach, FL 33767-2064 INSURER D:
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HIl,VE 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,
LTR NSR TYPE OF INSURANCE POLICY NUMBER OA rE ',i.U-NODNYl DATE IMMlB@.gN LIMITS
GENERAL LIABILITY CLPOO9277 04/01/2006 04/01/2007 EACH OCCURRENCE $ 1,000,000
-
X COMMERCIAL GENERAL '_lABILITY PREMISES lEa occurencel $ 100,000
-.J CLAIMS MADE 00 OCCUR MED EXP (Anyone person) $ 5,000
I--
A X PERSONAL & ADV INJURY $ 1,000,000
-
GENERAL AGGREGATE $ 2,000,000
-
GEN'l AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMPIGP AGG $ 1,000,000
I nPRO. n
POLICY JECT LaC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
- $
ANY AUTO (Ea accident)
-
ALL OWNED AUTOS BODilY INJURY
- $
SCHEDULED AUTOS (Per person)
-
HIR=DAUTOS BODILY ItlJURY
- $
NOt/-OWNED AUTOS (Per acoldenll
~
~ PROPERTY DAMAGE $
[Per accidentl
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT S
R ANY AUTO OTHER THAN EA ACC S
AUrO ONLY: AGG S
EXCESSJUMBRELLA LIABILITY EACH OCCURRENCE $
=:J OCCUR o CLAIMS MADE AGGR=.GATE $
$
~ DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION AND I TORY L1MIIST IUd~-
EMPLOYERS' liABILITY
ANY PROPRIETORlPARTNERlEXECUTIVE E.L. EACH ACCIDENT $
OFFICERlMEMBER EXCLUDED? E.l. DISEASE - EA EMPLOYEE $
If yes, describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LllAr, S
OTHER
DESCRIPTION OF OPERATIONS! LOCATIONS! VEHICLES! EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
ertificate Holder is landlord Additional Insured
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Marine & Aviation Division
25 Causeway Boulevard
Clearwater Beach, Fl 33767
Steven Sandbe
ACORD 25 (2001/08} FAX: (727)462-6957
_ A~p: ",13 06 09 ;'-26 a
SANDBERGEN INSURANCE
727-446-9147
p.2
IMPORTANT
If the certificate holder is an 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, subjectto 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.
ACORD 25 (2()01108)