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CERTIFICATE OF LIABILITY INSURANCE (421)FASTO -1 OP ID: GD '4�0RET CERTIFICATE OF LIABILITY INSURANCE DATE(MM /DD/YYYY) 12/18/2013 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 policy(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 Phone: 727 -447 -6481 Bouchard - Clearwater Fax: 727 -449 -1267 101 Starcrest Drive P 0 Box 6090 Clearwater, FL 33758 -6090 J Raymond Bouchard, CIC CONTACT NAME: PHONE FAX (A/C, No. Ext): (A/C, No): E-MAIL ESS: cicerts @bouchardinsurance.com INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Ohio Casualty Insurance Co 24074 INSURED Fast of Florida, Inc. 13003 US 19 N Clearwater, FL 33764 -7224 INSURER B :Southern Owners Insurance Co 10190 INSURER C :Amerisure Insurance Company 19488 INSURER D: FFVA Mutual Insurance Company 10385 INSURER E : Amerisure Mutual Insurance Co 23396 INSURER F : $ 10,000 COVERAGES CERTIFICATE NUMBER: 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 .. INSR SUBR WVD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP (MM /DD/YYYY) LIMITS B GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY X TPP747056 RECEW E 23 2013 I >'" ' ,l I°RF tv'N' 12/28/2013 -^� \ii O:J 12/28/2014 OCCURRENCE EACH OCCURRENCE $ 1,000,000 DAMAGETORENTED PREMISES occurrence) $ 300,000 MED EXP (Any one person) $ 10,000 CLAIMS -MADE X OCCUR PERSONAL 8 ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 GE 'L AGGREGATE POLICY LIMIT APPLIES PRO- JECT PER: LOC $ C AUTOMOBILE X X LIABIUTY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS €€°°t'Y°'a E'- u�:3"1 U �,� . g CA2050451 r X8/2013 12/28/2014 Ea acwl dentSINGLE LIMIT $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ A X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE 00055375207 12/28/2013 12/28/2014 EACH OCCURRENCE $ 3,000,000 AGGREGATE $ 3,000,000 $ DED X RETENTION $ 0 D WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A BINDER 12/28/2013 12/28/2014 X WC STATU- TORY LIMITS 0TH - ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 E Equipment Floater IM2050477 12/28/2013 12/28/2014 Lsd /Rent 100,000 Deductibl 2 %subj 1000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule If more space is required) CERTIFICATE HOLDER IS ADDITIONAL INSURED WITH RESPECTS TO GENERAL LIABILITY SUBJECT TO ALL TERMS, CONDITIONS AND EXCLUSIONS OF THE POLICY. CERTIFICATE HOLDER CANCELLATION CITYCLW CITY OF CLEARWATER 100 S MYRTLE AVE CLEARWATER, FL 33758 -4748 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) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD