CERTIFICATE OF LIABILITY INSURANCE (12)
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ACOBQM CERTIFICATE OF LIABILITY INSURANCE I DA 1'1; (M MJDDNVVY)
06/14/2006
~ODUCliI'l (727)44~-OO12 FAX (727)446-9147 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
iandbergen Insurance, Inc;:. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR
2111 N.E. Coachman Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
[1 earwater'. FL 33765-2616
INSURERS AFFORDING COVERAGE NAlC#
SU~ED Patrlcla & Thomas Wolkowsky INSURI:R A~ Granada Insurance Co.
25 Causeway 81vd INSURER B~
Suite 4 IN$URER c:
Clear'water Beachj FL 33767-2000 INSURER c;
INSURER E:
THE POLICIES OF INSURANC!: LISTED BELOW HAVE BEEN IssuED TO THE INSUREO NAMED ABOVE FO~ THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM O~ CONDITION OF ANY CONTRACT O~ OTHER DOGUMIONi WITH ~ESPECT TO WHICH THIS CERTI FICA TE MAYBE ISSUED O~
MAY PERTAIN, THE INSURANCE AFFOROED BY THE POUC1ES DESCRlaED HEREIN 1$ SUBJECT TO ALL THE TERMS, E;XCLUSIONS AND CONDITIONS OF SUCH
POLICIES. AGGRE(jATE LIMITS SHOWN MAY HAVE 8E.EN REDUCED BY PAID CLAIMS.
~! ~~~~ TIPt: OF IIlSVIlANCE I'OI,ICY NUMa!!R POI.ICY E~FECT1Vl! POLICY t:Xp'R..rION 1.IMITS
l;Iliil'lt:RAL L1AaILlTY CP13 n91 06/07/Z006 06/07/2007 EACH OCCURRENCE s 1,000.000
I---..,.- D^MAG~ TO ~~~~~~'d'
X COMMERCIAL GENERAL I,IAElII.ITY $ 50,000
I CI,AIMS MliDE m oCCUR MED EX!> (Anyone person) $ l,OOC
1\ peRSONAL & ADV INJURY $ 1,000 , ooe
- 1,000,000
G5NF,RALAGGREGATE $
- INCLUOEC
GEiN'I. AGGREGATE LIMit APPLIES PER PRODUCTS. COMPIOP AGG $
I .nPRO- n
POI,ICY JECT LOC
~TOMOalll! L1ABI1.ITI COMBINl':D SING1." I.IMIT S
ANY AUTO (En aCCIdent)
-
ALL OWNED AUTOS BODilY INJURY
I-- (P~. prn'Ml~) $
SCHEOUlED AUTOS
I--
HIRED AuTOS BODILY INJURY $
~ (Par 9ccldent)
NON.OWNED AUTOS
I--
i---- PROI"ERTv OAMAGE $
(Per 3CCldenl)
r;.1I1l.6.GE L1ABILlTI AUTO ONLY. EA AccIDENT $
~ N--rf AUTO otHER THAr>i EAACC; ,$
AUTO ONL V: AGG $
I!XCESS/UMBRIO;LI..I\ LIABILITY IOACH OC;CURRE\lCI; $
:j-OCCUR D ClAIMSMAOe AGGR~GATE $
$
~ DEDUCTIBLE S
RETENTION $ $
WORKt:R' CoMPENSATION AND I T~~H~I,~;.1 IllJ~.
EMP~OYERS' L1.6.BI~ITY E.1.. EACH ACCIDENT $
ANY PROPRIETORIPAIHNERJEXECUTIVE
OFFICER/MEMBER E)(CI.UDED? E.L DISEASe . ~A EMPLOYEI ~
~~~lMtSW~bb~s18rNS balOW E.L. DISEASE - ,"Olley LIMIT ~
Ol~fJh CP131991 06/07/2006 06/07/2007 AGGREGATE $500jOOO
A L Q R LIABILITY EACH COMMON CAUSE $500,000
)ESCRIPTION OF OPEIlIITIONS f LOCATIONS! VEHICll!S r EXC1.USIONS ADDED BY ENDORSENENT I SPECIA1. PROVISIONS
ERTIFlCATE HOLDER IS NAMED AS AN ADDITIONAL INSURED- LANDLORD.
C
OL.D
StlOULD ANY OF THE AIilQV~ DESCRIBED POLICIU ;'1; CANcelLED BEFOFlIi, THE
eXPIRATION DAn, THI;REOF, THE ISSUINI3INSl,J~ER WILL ENDEAVOR TQ MAIL
~ DAYS WRlliEfII NOTICE TO THE CERTIFICATE HOLDER NAMED TO TIll, I.E~T.
61fT ~.6.llURE: TO M.6.l1. Suelt NOTICE SH.6.ll IMPOSE (110 OBLIGATION OR L1ABILli'I'
OF NIY KIND Ui>ON THE INSURER.IT$ AGEiNTS OR REPRESENT^TIVI;S.
~~
RO CORPORATION 1988
CITY OF CLEARWATER
ATTN: CATHERINE
25 CAUSE:WAV BLVD
CLEA~WATER BEACH. FL 33767
ACORD 25 (2001/08) FAX: 462-6957
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,
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(les) must be endorsed, A statement
on this certificate does riot 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 st~tElment 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 Oil 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)