CERTIFICATE OF LIABILITY INSURANCE (377)ACG D®
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM/DD /YYYY)
6/11/2014
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the poiicy(ies) must be endorsed. 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).
PRODUCER
Adcock- Adcock Insurance Agency
315 W. Fletcher Ave.
Tampa FL 33612 -3414
INSURED
CGM Services Inc
1015 E Martin Luther King Blvd
Tampa FL 33603
1633
CONTACT
NAME: __._._.._...f�.BSjjid_.. one$_ ........ ............__.. ---°-- -..... - --
PHONE
...(NC No Ex081.3 -933 = 6691.__._...._......_.._....
E-MAII
AooRESS :Radhagpadcock- insurance.com
FAX
(A/C
INSURER(S) AFFORDING COVERAGE
INSURER A Southern-Owners ._.Insurance Co.
INSURER BiL_ Pa. 01 _F1re._$s-M.S.rirle...(nsurance C .
INSURER C :Bridgefield Employers Ins Co
INSURER o :Mercury Indemnity of America
INSURER E :
..__.._...__NAIC 0
10190
............
65306 -....
10701
11201
INSURER F :
COVERAGES
CERTIFICATE NUMBER: 1002873984
REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR
LTR
TYPE OF INSURANCE
ADM
INSR
SUBR
WVD
POLICY NUMBER
' POLICY EFF
' (MM/DD/YYYY)
POLICY EXP
(MM/DDIYYYY)
LIMITS
A
GENERAL
X
LIABILITY
COMMERCIAL GENERAL
LIABILITY
',IX OCCUR
20138579 - •F�*
F,
3 �f`
,
1L3,r/20J4
�� i .
;•..-
1/112015
EACH OCCURRENCE
$1,000,000
DAMAGE TO RENTED
PREMISES (Ea occurrence)
950,000
CLAIMS -MADE
MED EXP (Any one person)
PERSONAL & ADV INJURY
$5,000
$1,000,000
GENERAL. AGGREGATE
$2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER
—1 POLICY IX JcRCT LOG
PRODUCTS - COMP/OP AGG
$2,000,000
$
D
AUTOMOBILE
X
X
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
I SCHEDULED
...._. ; AUTOS
X._.,..' AUTOS
BA0900000�$$$� -
?22 ,
i
3/12/2015
40M1i3INED SINL,LE LIMI
Ea accid)
51,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
(Per DAMAGE
$
$
B
X
UMBRELLA UAB IX
EXCESS LIAR .
DED X I RETENTION $10,000
OCCUR
CLAIMS -MADE
ZUP15R7437314NF
1/1/2014
I
1/1/2015
EACH OCCURRENCE $5,000,000
AGGREGATE $5,000,000
$
C
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY YIN
ANY PROPRIETOR :PARTNER /EXECUTIVE' ' N
OFFICEPiMEMSER EXCLUDED2
(Mandatory in NH)
It yes, describe under
DESCRIPTION OF OPERATIONS beiOW
f A
0830.43595
1/1/2014
I
1/1/2015
X TORY T LIMITS 0T '
F.L. ACCIDENT ACCID NT $1,000,000
E L. DISEASE - EA EMPLOYEE $1,000,000
E.L. DISEASE - POLICY LIMIT I $1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required)
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
100 S Myrtle
Clearwater FL 33756
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
ACORD 25 (2010/05)
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