CERTIFICATE OF LIABILITY INSURANCE (12)
From: Diane Benoit At: Roger Bouchard Insurance, Inc. FaxlD: Bouchard Insurance To: EARL BARRETT
Date: 21912007 01 :47 PM Page: 1 of 2
....
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ACORD,.
CERTIFICATE OF LIABILITY INSURANCE
OP ID 01 DATE (MM/DDIYYYY)
S1LVEOl 02/09/07
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONL Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER
Bouchard-Clearwater
101 starcrest Drive
PO Box 6090
Clearwater FL 33758-6090
Phone:727-447-6481 Fax:727-449-1267
INSURED
INSURERS AFFORDING COVERAGE
Auto-owners Insurance Company
NAIC#
18988
Silver Dollar Trap' Club Inc
16316 Patterson Ra
Odessa FL 33556
INSURER A
INSURER B
INSUf<ER C
INSURER D
INSURER E:
COVERAGES
THE POLICieS Of INSUllANCE LISTED BelOW HAVB BeBN ISSUED TO THE INSURED NAMED ABr)VB FOR THE POLICY f'ERIOD INDICATBD NOTWITHSTANDING
ANY RECJUIREMErIT. TERM OR CONDiTICN OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY IOBllTAiN. THE INSU'lANCB .AI'fOl<UED BY THE POLICIES DESCRiBED HEREIN IS SUBJECT 10 ALL THEIERMS. EXCLUSIONS AND CONDITIONS ,)F SUCH
POLICIES AGGREGATE LIMITS SHOW~ fv<AY HAVE BEEI' REDUCED BY PAID CLAIMS
LTR NSR( TYPE OF INSURANCE POLICY NUMBER DATE (MMIDDIYY) I P8k~~{(MMlDDIYY) LIMITS
GENERAL LIABILITY EACH OCCURRENCE $300000
~ 01/29/07 01/29/08
A X COMMEIKIAL GE~lmAL L1ABILlIY BINDER 7088 PREWISES lEa occurence) $ 10000
~ =:J CLAiMS MADE [~ OCCUR
. MED EXP (Anyone person) $
~
PERSONAL & ADV INJURY $ 1000000
--- -----------."--.- ...-----..----- _._u.u,_______ -------
GENERAL AGGREGATE $ 3000000
GEN'L AGGREGATE LIMIT APPLIE:3 PER PROC:JCTS - COIvIP/OP AGG $ 1000000
x-I nl-V i-l f'HO- II LOC I
U l, I ~iECT i
AUTOMOBILE LIABILITY ~ rE l!: lElD \VIlE ... COMc.INED SINGLE LIMIT
~ lICe accident) $
NoIY AUTO
~ ! --
,\LL OWNED AUTOS DODIL ,(INJURY
~ $
SCHEDULED AUTOS -~ :., (F'er >.orson)
~ fEe -
HIRED AUTOS BODIt. Y INJURY
--- (Per E1ccident) $
NON, OWNED ,J-\UTO'::.
-'-
~ CITY OF C EARWATER PROPERTY DAMAGE $
NT (Per ecddent)
GARAGE LIABILITY AUTO ONL Y EA ACCIDENT $
=1 A~IY AUTO i i OTHER THAN EA ACC $
I AUTO ONL Y AGG $
I
EXCESS/UMBRELLA LIABILITY I EACH OCCURRENCE $
~ OCCUR D CI AIMS IvIADE i AGGRICGATE $
$
l DEcDUCTIBLE $
RETENTION $ $
WORKERS COMPENSATION AND ~l IV~~
EMPLOYERS' LIABILITY ,
, EL. Ec',CH ACCIDENT $
ANY PR(JP~:!ETOR/PAATNER/E;.:.ECUTIVE
OFFiCER/MEMBER E:<CLUDEDc EL DISEASE - EA EMPLOYEE $
If yes, df~scribe und",r I
SPE::.CIAL PI~OV(SION::; I)elow EL ['ISEASE - POLICY LIMIT $
OTHER I
:
i
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
re: vacant land - part of the Southeast 1/4 of Section 19, Township 27
south, Range 17 East Hillsborough County, FL.
Cert Holder is an additional insured with respect to General Liability
subject to the terms, conditions, and exclusions of the policy.
Fax: 727-562-4755
CERTIFICATE HOLDER
CANCELLATION
C1TYCLW
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Clearwater
Attn Earl Barrett
Engineering Department
PO Box 4748
Clearwater FL 33758-4748
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30
DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHOR PR SENTAT
@ACORD CORPORATION 19BB
ACORD 25 (2001/OB)