CERTIFICATE OF LIABILITY INSURANCE
01 Rug 2006 14:47
...
Cessie Insurance Rgenc~
864-688-0138
p.2
ACORD 1M
CERTIFICATE OF LIABILITY INSURANCE
DATE (MMlDDIYY)
8/1/2006
Hls'-CeRffFrCATEo'iSIssuED A5"A.'~iATTi~R--oF'-IN'F.O'RMA Ti6.N._._....__........._.~...._........
IONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND. EXTEND OR ALTER THE
COVERAGE AFFORDED BY THE POLICIES BELOW
INSURERS AFFORDING COVERAGE J
I iN"SuREDA:-jThe Burllngton"-lnsura'nee'Com"pany ~ - -- -- . - -.- - .... '.':
-------..-- 1-. -. -.- .---.-.... ------ .. - -- --- -.._..._.. _____.. .. .
INSURED B: I --'--1
i'NSUREci"c~+--'-" .. ....... ---.--....-..----.----... .....--.-..--.............-----.-.,
~~~lTR~~j_~.~~~.~..~~..:==~=:.:_~._~__:_-.:_.-----_:-:.:~~:::~:=::......------...:::-~--1
INSU~~D _E: _1_ ___.____..__._..______. .. .. ....__...__________.____..___...... ../
PRODUCER
Cosslo Insurance Agency
PO Box 1304
Fountain Inn, Se 29644
(864) 862-2838
INSURED
Ultimate Bounce,LLC
3300 11th Ave N
st. Petersburg. FL 33704
9qy;B.AGE.~____.__.__..__ _ _ .._____..____________.._._ _ .. ._.....___._.._.___.__.____________ .... .. ........____.___._.....___....._.._..__.... .. .. ...___.__.._......_.____.._.__................
iTHE POLICIES OF INSURANCE lISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY''''
11~~~~~l:rAF~:E'b~~~~~~lg~~~~=H~~:I~~i~~~~~~L~T~E ~:freigL~~:g~::oc~~~~~~~Ys~~~~~~~~~~~~i~r~~u:~s !
SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS i
I~: TYPE DF POLICY POLiCY-NUMBER" . p~~y EFFEcTiVE-' P~~:~~~N"I LIMITS
---............-..........-........... ..... ... -.-...........-.."/'- .....-....-...--...- ... ..
1~~~H.D~~~~1A~~ne-iiie)..+--~.~~~:~~g~.:~~...]
I~~~' EXP.la~y..~~ep~T!~~}--..Jr..:____..~.?~~~(iO?-.l
11~~~~~C~~~~~~~i~RY ....t-..~~:~~~:.~~~~~:.j
------.-...-.--..-------...-.-....... . - ......r....------..--. 1
f~~~~~.<?_"!:~~.c:oMP l~'=..'\~~,--~~~-o..~~~.q~_O~~?::j
'IDEDUCTIBLE EACH I' $5,000.00 I
.OCCURRENCE [
i .
GENERAL LIABILITY
!Xl COMMERCIAL GENERAL LIABILITY
DO CLAIMS MADE [Xl OCCUR
o
o
HGL0013506
7/2512006
7/2512007
A
GEN'LAGGREGATE LIMIT APPLIES PE
IX] POLICY 0 PRO- 0 LOC
JECT
AUTOMOBILE LIABILITY
o ANY AUTO
o ALL OWNED AUTOS
o SCHEDULED AUTOS
o HIRED AUTOS
o NON~WNEOAUTOS
o
o
COMBINED SINGLE LIMIT
(Ea aoeiClent)
BODILY INJURY
(Per Person)
BODILY INJURY
(per a<lCIdent)
$
$
$
PROPERlY DAMAGE
(per ac:cidenl)
$
GARAGE UABILITY
o ANY AUTO
o
$
., ......--.....-.... .............
~..t____._._..........1
$ i
$
$
$
$
__..__....If.~R.i~!.~~~~[]~~~.... ...........__.._........_.........
E.L. EACH ACCIDENT is ;
......._....__...._......._......-.--......____.._._.m..._....... I
j~t-~~~~~~~gt~~t~~-;~--_....:~..---...~:l
AUTO ONLY - EA ACCIDENT
OrnER THAN EA ACe
AUTO ONLY. AGG
EACH OCCURRENCE
AGGREGATE
EXCESS LIABILl1Y
o OCCUR 0 CLAIMS MADE
o DEDUCTIBLE
o RETENTION $
WORKERS COMPENSATION AND
EMPLOYER'S LIABILITY
OTHER
l
DESCRlF7TION OF OPERATlONSILOCATlONSNEHICLESlEXCLUSIONS ADDEO BY ENDDRSEMENT/$PECIAl PROVISION
Amusement devices on file with company for special events dated thoughout policy period.
Certificale holder named as additional insured.
CERTIFICATE HOLDER
~ ADDITIONAL INSURED, INSURER LETTER [] CANCELLATION
I~~~g~~~ ~:P;:~~~~~f~~~~Wtf~~i~I~I~~-~~3~~E~L~-1
I\:ENDEAVOR TO MAIL 10 DAYS WRtTTEN NOTICE TO THE CERTIFICATE I
HOLDER NAMED TO THE LEFT, BUT F~~I E TO DO SO SHALL IMPOSE NO ,
',OBLIGATION OR LIABILITY OF ANY KI U ~OM THE INSURER, IT'S AGENTS !
OR REPRESNETATlVES ./r / I
,AUTHORIZED REPRESENTATIVE ~X,__ . '=1
I
A /1 ~ 2J \
City of Clearwater
P.O. Box 4748
Clearwater, FL 33758
ACORD 25-5 7197