CERTIFICATE OF LIABILITY INSURANCE
ACORD",
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DDIYY)
12/20/2006
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER
JOHN L. WORTHAM & SON, L.P.
P.O. BOX 1388
HOUSTON, TEXAS 77251-1388
INSURERS AFFORDING COVERAGE
068386-489-451
gwp - Iwright
INSURED
CROWN CASTLE ATLANTIC LLC
2000 CORPORATE DRIVE
CANONSBURG, PA 15317
INSURER Po: Liberty Mutual Insurance Company
INSURER B: Liberty Insurance Corporation
INSURER C: Liberty Mutual Fire Insurance CO.
INSURER 0:
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 MAYBE 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.
II~~: TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
A ~NERAl LIABILITY TB2691440099066 01/01/2006 04/01/2007 EACH OCCURRENCE $ 1,000,000
t/ COMMERCIAL GENERAl LIABILITY FIRE DAMAGE IAnv one firel $ 100,000
.1 CLAIMS MADE [;] OCCUR MED EXP (Anv one personl $ 5,000
- PERSONAL & ADV INJURY $ 1,000,000
- GENERAl AGGREGATE $ 2,000,000
~'L AGGRnE LIMIT AnS PER: PRODUCTS - COMP/OP AGG $ 2,000,000
t/ POLICY ~~R;. LOC
C ~TOMOBILE LIABILITY AS2691440099016 01/01/2006 04/01/2007 COMBINED SINGLE LIMIT 1,000,000
$
~ ANY AUTO (Ea accident)
~ ALL OWNED AUTOS BODILY INJURY
(Per person) $
I-- SCHEDULED AUTOS
~ HIRED AUTOS BODILY INJURY
$
~ NON..QWNED AUTOS (Per accident)
PROPERTY DAMAGE $
(Per accident)
~GE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
~ESS LIABILITY EACH OCCURRENCE $
OCCUR D CLAIMS MADE AGGREGATE $
$
==i DEDUCTIBLE $
RETENTION $ $
B WORKERS COMPENSATION AND "..' VVA769D440099037 - 01LQ1/?007 ....... 04/01/2007 . _J/TJY~.~!~T.I!:..I IOJ~-is: .. 1-..
EMPLOYERS' LIABilITY --,-
E.L EACH ACCIDENT $ 1,000,000
E.L. DISEASE - EA EMPLOYE $ 1,000,000
E.L. DISEASE - POLICY LIMIT $ 1,000,000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER IS INCLUDED AS AN ADDITIONAL INSURED UNDER GENERAL AND AUTOMOBILE LIABILITY POLICIES WHEN REQUIRED BY
WRITTEN CONTRACT BUT ONLY WITH RESPECT TO: COUNTRYSIDElBU#814424
CERTIFICATE HOLDER I I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION (BELOW & SEE REVERSE)
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, THE ISSUING INSURER VVILL ENDEAVORTO
MAIL 30 DAYS VVRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
CITY OF CLEARWATER LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
ATTN:EARLBARRETT ANY KIND UPON THE ISSUER, ITS AGENTS OR REPRESENTATIVES.
GENERAL SERVICES DEPARTMENT
PO BOX 4748 I q;z;~ :w:.:.~~;TA~I:~ /..1
CLEARWATER, FL33758-4748
I
ACORD 25-S (7/97) , @ACORDCORPORATION 1988
Cert. # 068386-489-451
CITY OF CLEARWATER
...
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, 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-arter thifcoverage afforded bythe-poficies listedthereon~
CANCELLATION NOTICE
The CANCELLATION NOTICE on the CERTIFICATE OF INSURANCE is amended to include the
following additional wording: The Insurance Company may cancel the described policy(ies) by mailing
or delivering ten (10) days written notice of cancellation to the Certificate Holder for:
(1) Non Payment of premium or (2) any other circumstance permitted by state law or policy conditions.
ACORD 25-8 (7/97)