CERTIFICATE OF LIABILITY INSURANCE (11)
Apr 13 06 09: 26a
SANDBERGEN INSURANCE
727-446-9147
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ACORD CERTIFICA _ E OF LIABILITY INSURJ.~_ JCE DATE (M::M/OO!YYYYj
TM 04/13/2006
PRODUCER (7Z7)44Z-0012 FAX (727)446-9147 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORIWIATION
Sandbergen Insurance, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTlFJCA.. TE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTENlD OR
2121 N.E. Coachman Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES ESELOW.
Clearwater, FL 33765-2616
INSURERS AFFORDING COVERAGE NAIC#
INSURED Marina Restaurant INSURER A: Capacity Insurance Co.
Thomas & Patrcia Wolkowsky IIJSURER B:
25 Causeway Boulevard IIJSURER c:
Clearwater Beach, FL 33767-2064 INSURER D:
INSURER E:
COVERAGES
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 ISSUEO 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 DATE (MMlDDIYYI -OATE rMM/~6WX1'I LIMITS
GENERAL LIABILITY CLP009Z77 04/01/2006 04/01/2007 EACH OCCURRENCE $ 1.000,00
X COMMERCIAL GENERAL '_lABILITY ~~~~~~s lEa occurence\ $ 100.00
I CLAIMS MADE 00 OCCUR MEO EXP (Anyone person) $ 5,00<
A X PERSONAL & ADV INJURY $ 1 ~OOO. 001
-
GENERAL AGGREGATE $ 2,,000, om
I--
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMPICP AGG $ 1,,000,001
h POLICY n j~ n lOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
f-- (Ea aCCident) $
ANY AUTO
I--
AlL OWNED AUTOS BODIL Y INJURY
- (Per person) $
SCHEDULED AUTOS
-
HIRWAUTOS BODILY IIJJURY
- (Per accidentl $
NorJeOWNED AUTOS
-
- PROPERTY DAMAGE $
{Per accidentl
GARAGE L1ABIUlY AUTO ONLY - EA ACCIDENT S
=i ANY AUTO OTHER THAN fA ACC S
AUTO ONlY: AGG S
EXCESSJUMBRElLA UABILITY EACH OCCURRENCE $
~ OCCUR o CLAIMS MADE AGGR:;GATE $
$
R DEDUCTIBLE $
RETENTION S $
WORKERS COMPENSATION AND I TOR'( LIMITS I IUdA'-
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $
If yes. describe under
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT S
OTHER
DESCRIPTION OF OPERATIONS I lOCATIONS I VEHICLES I 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