Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
CERTIFICATE OF LIABILITY INSURANCE
PRIMA -1 OP ID: 25 A` CORE" 1/4.......--- CERTIFICATE OF LIABILITY INSURANCE DATE (MM /DD/YYYY) 07/22/2014 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 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 Bouchard I su ance 90 Bouchard Insurance CONTACT PHONE FAX (A/C. No. Ext): (A/C, No): E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A : Bridgefield Employers Ins Co 10701 INSURED Primary Structures, Inc. of Clearwater Inc. 18395 Gulf Blvd, Ste 104 Clearwater, FL 33785 INSURER B : Amerisure Mutual Insurance Co 23396 INSURER C : Amerisu re Insurance Company 19488 INSURER D : $ 1,000,000 INSURER E : $ 100,000 INSURER F : $ 5,000 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 ADDL INSR SUBR WVD POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP (MM /DD/YYYY) LIMITS B GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY GL2084336102 RECEII/ED JUL 2 52014 OFFICIAL RECORDS 2013 A AND 10/01/2014 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 CLAIMS -MADE X OCCUR PERSONAL & ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 PRODUCTS - COMP /OP AGG $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES 7 POLICY n pi PER LOC Emp Ben. $ 1,000,000 C AUTOMOBILE X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS X X SCHEDULED AUTOS NON -OWNED AUTOS LEGISLATIVE SRVCS CA13220011601 DEPT 10/01/2013 10/01/2014 COMBINED SINGLE LIMIT (Ea accident) $ 1 000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA UAB EXCESS LIAB X OCCUR CLAIMS -MADE CU13811901402 10/01/2013 10/01/2014 EACH OCCURRENCE $ 1,000,000 AGGREGATE $ 1,000,000 $ DED X RETENTION $ 0 A 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 083018871 07/07/2014 07/07/2015 X WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ 1,000,000 E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Addkional Remarks Schedule, If more space is required) RE: Marina Cantina 25 Causeway Blvd, Clearwater, FL 33767 CERTIFICATE HOLDER CANCELLATION City of Clearwater 100 S Myrtle Ave 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) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD