CERTIFICATE OF LIABILITY INSURANCE
ACORD.. CERTIFICATE OF LIABILITY INSURANCE OP IDHN I DATEfMMIDDIYYYY)
USLAC-2 03/10/06
PP lllUCER THIS CERTIFICATE IS ISSUED AS A MA TIER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Bollinger, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
101 JFK Parkway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
S' ~ Hills NJ 07078-5000
i-. .8: 800-526-1379 Fax: 973-921-2876 INSURERS AFFORDING COVERAGE NAIC t#
INeUREO ......... " Markel Insurance Company 119
IoeSlRER B: AJ:G Life
US Lacrosse, Inc. IN5lRER c:
113 W. University Pky ......... l>
Baltimore MD 21210
......... E.
COVERAGES
TiE POUClES OF INSURANCE USTeD BELOW HAVE BEEN ISSUED TO 1lE ~ PW.IED ABOVE FOR n1E POLICY PERIOD INOtCATED. frt01'Y<<THST~
Nf( REQUIREMENT. TERM OR CONDJTION OF AN( CONTRACT OR OTHER bOCutENT \\fnf RESPECT TO 'MtICH 1KS CERTlACATE MAV BE tsStED OR
MAY PERTAIN. THE INSURANCE AFFOftOS) BY nE POUCles DESCRIElB) IEREIN IS ~TTO ALL llE TaWS. EXCLUSIONS 1rHD COHDI11ONS OF 6VCH
POUCIES. AGGREGATE UMI'fS SHOVlIN MAY HAVE BEEN REDUCED BY PM) Cl.AtM5.
- IlD'l ~.=:;;." ~='
LT1< N80Il TYPE OF INBURANCI! POUCY ....... UMIT8
GENERAL UAIlIUTY EACH OCCURRENCE 11,000,000
f-- _TORefTED
A X X COMMERC1AL GENatAL lJABILrrY 8502AH221369 01/01/06 01/01/07 PREMSE$ (Eat oca.nrme) I 100,000
I C1.AIMS MADE ~ acc.... MEn EJCP (My one perwotI) 15,000
X Inc! Participants PERSONAL & RN INJURY 11,000,000
GENERALAGGREGATE 15,000,000
I---
GENt. AGGREGATE UMIT NJPlJES PeR: PRODUCTS ~ COMPIOP AGG $ 2,000,000
II POUCY nPRo. nLOC
JECT
AUTOMOBILE UABlUTY ,
f-- CQIBoED ~ UMIT $
""" AUTO tEo_
f--
All 0V\1'IE0 AUTOS OQOLY IfWRY
I--- $
SCHEDUlED AUTOS (Pw...-l
f--
HIRED AUTOS BOOLY INJURY
- $
NON-OVVNED AUTOS (Pw_l
-
- PROI'ER'TY _ I
(Pw_
-
GARAGE UAIlIUTY AUTO ONlY . Ell ACCIDENT $
~"""AUTO OlliER T>WI EA ACC $
AUTO ONlY: AGG .
EXCESSlUMBREllA UAIIIUTY EACH OCCUIlllEHCE . 1,000,000
A X i!:J OCCUR D ClAIMS MADE 4602AH221370 01/01/06 01/01/07 _""TE $ 1,000,000
$
R OEOOCnBLE $
RETENTlON $ $
WONCERS COMPEMSA11ON AND 1 we STATU- 1 10TH-
TORY UMITS ER
EWlDVERS' .....uTY
Nf'( PROPRIETORIPARlNERIEXECUllVE E.L E.-cH ACCIDENT I
OFACERJMEMBER EXCLUDf:D? E.L. DISEASE - EA BPLOYEE $
.)"11II. cteeaiH ~
SPEctAL PROVIstONS below E.L DtSEASE. - POUCY l.IMIT I
011<ER
B Acqident Insurance SRG9029306 01/01/06 01/01/07 Acc Limit $25,000
Catastrophic Accid SRG9026291 01/01/06 01/01/07 Cat Acc $1,000,000
DeSCRIPtION OF 0PERA1IONS I 1.OCA11ON8 IYIHCI.ES I ~ ADOEIIBY ENDORaEIIENT IIPECIM. PAitMIKJN8
Coverage app~ies to .-bars and member teams of US Lacrosse whi.~e
participating in schedul.ed and supervised activities. The Certificate Ho~der
is named as an additional insured, only with respect to the activities of
C~earwater Youth Lacrosse.
CERTIFICATE HOLDER
CANCELLATION
CLEAFLl sttDIUJ IMt Of 11E ABOVE DbiCMED POUCIEB IE CAHCELLED BEFORE THE ~11ON
DATE TIEREDf. TIE_INSURER WLL ENDEAVOR 10 MAL 30 DAYSWIUTTEN
-
City of C~earwater tIOTICElO 11IE CIR1WICAlE MOLDER IMMEl) 10 lIE LEFT, BUT FALURE TO DO eo 8HAU
Attn: Bob Carpenter
1501 N BeJ.cher Road ..-olE" 08lJGA1IOII OR 1MBIJTY OF ANY laND UPON 11fE INS~ If8 AGENT8 OR
C~earwater FL 33759 _A1l\/ElI.
AU1'IM)NZB) IlEPMBSlTA
(.,-" .
ACORD 25 (2001108)
@ ACORD CORPORATION 1988
/~COBD~ CERTIFICA TE OF LIABILITY INSURANCE OP IDRN I DATEfMMIDIlIYYYY)
USLAC-2 03/10/06
.... >IltJCER THIS CERTIFICATE IS ISSUED AS A MA TIER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Bollinger, I:nc. HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
101 JFK Parkway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
S' '-, Hills NJ 07078-5000
~. .e: 800-526-1379 Fax: 973-921-2876 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A:. Markel I:nsurance Company 119
INSURER B: AIG Life
US Lacrosse, Inc. INSURER c:
113 W. University Pky INSlRER 0:
Baltimore He 21210
INSlRER E'
COVERAGES
nE POUClES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO lME INSURED HAMED ABOVE FOR THE POUCY PERIOD INDfCATEO. NOlWITliSTANDfNG
/IN'( REQUIREMENT, TERM OR CONDmON OF ANY CONmACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTlACATE ~y BE ISSueD OR
MAY PERTAIN, THE INSURANCE. AFFOROEQ BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALl THE TERMS, EXCLUSIONS AND CONllTIONS OF SUCH
POUCIES. AGGREGATE UMlTS SHOWN MAY HAVE BEEN REDUCED BY PAID ClAIMS.
INSR llD'L POUCY EFFEC11VE "'::,;,=:::
LTR Itwm TYPE OF INSURANCE POUCY NUMBER DATE.-xlIYYI UMITS
GENERAL UABIUTY EACH OCCURRENCE .1,000,000
- DAMAGE TO RENTED
A X X COMMERCIAL GENERAL UABIUTY 8502AH221369 01/01/06 01/01/07 PREMISES (Ell ooeurence) .100,000
I ClAIMS MADE [!:] OCCUR MEO EXP (Any one person) .5,000
~ I:ncl Participants PERSONAL & fJ.DV INJURY .1,000,000
GENERAl AGGREGATE .5,000,000
I---
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMPJOP AGG .2,000,000
h POLICY n ~ n loe
AUTOMOBILE UABtUTY COMBINED SINGLE LIMIT
- .
N<<AUTO (&eocident)
-
AU O't'VNED AUTOS BODtl. Y INJURY
- .
SCHEDUlED AUTOS (1'0<...-1
-
HIRED AUTOS BOOtlY INJURY
- .
NON-OWNED AUTOS (1'0<-)
I---
f-- PROPERTY DAMAGE $
(Per.x:idenl:)
-
GARAGE UABlUTY AlJTO ONl Y ~ EA ACCIDENT .
=i - A~O OTHER THAN EAACC $
AUTO ONLY: AGG .
EXCE8BlUMBRElLA UABIlJTY EACH OCCURRENCE $ 1,000,000
A X U OCCUR D ClAIMS MADE 4602AB221370 01/01/06 01/01/07 AGGREGATE $ 1,000,000
.
R oroocn~ $
RETENTlON . .
I. WCSTATlJ... I 10TH-
WORICER8 COMPENSATION AND TORY UMITS ER
EWI.OYERS' UABlUTY
E.L EACH ACCIDENT $
ANY PROPRlETORIPARTNERlEXECUTlVE
OFFICERINEMBER EXCLUDED? E.L. OtSEASE. EA EMPlOYEE .
" Y'K. desaibe Wlder
; SPECIAl PROVISIONS below EL DISEASE. POUCY UMIT .
011ft!R
B Accident I:nsurance SRG9029306 01/01/06 01/01/07 Ace Limit $25,000
Catastrophic Accid SRG9026291 01/01/06 01/01/07 Cat Acc $1,000,000
DE8CRIP11ON OF OPERATktNS IlOCA1tONSI VEtlCLE81 EXClUSK>N8 ACGED BY ENDORSEMENT 1 SPECIAL fIItc7tI8ON8
Coverage applies to members and member teams of US Lacrosse while
participating in scheduled and supervised activities. The Certificate Bolder
is named as an additional insured, only with respect to the activities of
Clearwater Youth Lacrosse.
CERTIFICATE HOLDER
CANCELLATION
CLEAFL1
attOI.UJ ANT Of TIlE ABOVE DESCReED POlICIES BE CANCEI...l.S) BEFORE UtE EXPIRATION
~TE THEREOF, THE I8SUINQ INSURER WILL. ENDEAVOR TO MAli.
30
DAYS WRmEN
City of Clearwater
Attn: Bob Carpenter
1501 N Belcher Road
Clearwater FL 33759
NOTICE TO 11IE CER11ACATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO 80 SHAU
MIOSE NO O8I.JGAllON OR UABlUTY Of ANY KIND UPON ntE INSURER, rrs AGENTS OR
A.CORD 25 (2001108)
_Al1VES.
AU1JtORIZB) AEPltESENTA
CTJ/
@ ACORD CORPORATION 1988
IMPORTANT
Ifthe 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, 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).
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 (2001108)