CERTIFICATE OF LIABILITY INSURANCE (427)ACCPREP
11762
CERTIFICATE OF LIABILITY INSURANCE
DATE (MM /DD/YYYY)
12/19/2013
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
Commercial Lines - (813) 639 -3000
Wells Fargo Insurance Services USA, Inc.
2502 N. Rocky Point Drive, Suite 400
Tampa, FL 33607
INSURED
Image One Corporation, Lencor LLC
6206 Benjamin Rd #301
Tampa FL 33634
CONTACT ry
Ch stal Hatcher
NAME:
PHONE 813.639.3019
(A /C, No, E_41:
E-MAIL
chr stal.hatcher wellsfar .com
ADDRESS: - - - -.y. @ g o_
INSURER(S) AFFORDING COVERAGE
INSURER A : Hartford Fire Insurance Company
INSURER B : Zenith Insurance Company
INSURER C
INSURER D :
INSURER E :
INSURER F
FA 813.639.7198
I. LAICX No
- -..-
NAIC If
19682
13269
COVERAGES
CERTIFICATE NUMBER: 7016308
REVISION NUMBER: See below
THIS
INDICATED.
CERTIFICATE
EXCLUSIONS
INSR
LTR
IS TO CERTIFY THAT THE POLICIES
NOTWITHSTANDING ANY REQUIREMENT,
MAY BE ISSUED OR MAY
AND CONDITIONS OF SUCH
_.___ __ - -- ----- _- _- - - - - --
TYPE OF INSURANCE
OF INSURANCE
PERTAIN,
POLICIES.
ADDL
INSR
SUBR
WVD
LISTED BELOW HAVE BEEN
TERM OR CONDITION OF ANY
THE INSURANCE AFFORDED BY
LIMITS SHOWN MAY HAVE BEEN REDUCED
POLICY NUMBER
ISSUED TO
CONTRACT
THE POLICIES
BY
, POLICY EFF- _-
(MM /DD/YYYY)
THE INSURED
OR OTHER
DESCRIBED
PAID CLAIMS.
..
.. POLICY EXP
(MM /DD/YYYY)
NAMED ABOVE FOR THE POLICY PERIOD
DOCUMENT WITH RESPECT TO WHICH THIS
HEREIN IS SUBJECT TO ALL THE TERMS,
-_ - - - --
LIMITS
A
GENERAL
r-
X
LIABILITY
COMMERCIAL GENERAL
1 CLAIMS -MADE
LIABILITY
X
OCCUR
21SBALI1614
�
L "¢r�;1
tt��ss
- - �{
1/1/2014
1/1/2015
EACH OCCURRENCE
DAMAGE EMI SO RENTED occur e
PREMISES tEa occurrence)
MED EXP (Any one person)
PERSONAL 8 ADV INJURY
GENERAL AGGREGATE
PRODUCTS - COMP /OP AGG
$ 1,000,000
$ 300,000
$ _- 10,000
$ 1,000,000
$ 2,000,000
$ 2,000,000
GEN'L
X
AGGREGATE LIMIT APPLIES PER'
PRO- l
POLICY [ LOC
1
A
AUTOMOBILE
X
X
LIABILITY
ANY AUTO
ALL OWNED
AUTOS
HIRED AUTOS
—
X
SCHEDULED
AUTOS
NON -OWNED
AUTOS
21 UECL Ig9p�,,,, _
y P. 1
f r ,...�.r'', r •� u , �,;
01/01/2014
, F r , . '
01/01/2015
COMBINED SINGLE LIMIT
(Ea accident/
BODILY INJURY (Per person)
BODILY INJURY (Per accident)
PROPERTY DAMAGE
(Per accident)
1,000,000
$
$
$
$
A
X
UMBRELLA LIAB
EXCESS LIAB
DED 1 X [ RETENT
X
ON $
OCCUR
CLAIMS -MADE
10,000
21SBALI1614
1/1/2014
1/1/2015
EACH OCCURRENCE
AGGREGATE
$ 3,000,000
$ 3,000,000
$
B
WORKERS COMPENSATION
AND
Z072426002
1/1/2014
1/1/2015
x WC STATU- II � OTH-
1 TORY LIMITSJ ' ER
t
$ 1,000,000
- - - _ -- -
$ 1,000,000
-_. -- -._ -_— -..-__
$ 1 000,000
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
It yes, describe under
DESCRIPTION OF OPERATIONS below
YIN
N/A
E L EACH ACCIDENT
- -- -- - --- -- - -- - - --
E.L DISEASE - EA EMPLOYEE
___ -- --- -. - -__
E DISEASE POLICY LIMIT
J
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule if more space is required)
CERTIFICATE HOLDER is named as additional insured as it relates to general liability in accordance with the terms and conditions of the policy.
CERTIFICATE HOLDER
CANCELLATION
CITY OF CLEARWATER
ATTN: CITY CLERK
P 0 BOX 4748
CLEARWATER FL 33758
I
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
003064
ACORD 25 (2010/05)
The ACORD name and logo are registered marks of ACORD
1988 2010 ACORD CORPORATION. All rights reserved.
l Hill Hi iHI iW 1101 HI lI
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Commercial Lines - (813) 639 -3000
Wells Fargo Insurance Services USA, Inc.
2502 N. Rocky Point Drive, Suite 400
Tampa, FL 33607
CITY OF CLEARWATER
ATTN: CITY CLERK
P 0 BOX 4748
CLEARWATER FL 33758
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