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CERTIFICATE OF LIABILITY INSURANCE (15) CHICH-2 OP ID: S7 ACORC�"' CERTIFICATE OF LIABILITY INSURANCE DA02/06/201 Y) �►.--""' 02/06/2015 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). CONTACT PRODUCER Phone: 727-461-6044 NAME: Linda Waldorf Brown&Brown of Florida,Inc. Fax: 727-442-7695 PHONE 727.450-7055 FAX 83 Park Place Blvd.,Ste 101 A/c No Ext: (A/C,No): 727-450-3353 P.O.Box 2456(33757-2456) E-MAIL Clearwater,FL 33759 ADDRESS: Iwaldorf @bbpinellas.com Sean Tobe INSURER(S)AFFORDING COVERAGE NAIC# INSURERA:Zenith Insurance Company 13269 INSURED Chi Chi Rodriguez Youth INSURER B:National Casualty Company 11991 Foundation, Inc. 3030 McMullen Booth Rd INSURERC:National Casualty Company 11991 Clearwater, FL 33761 INSURER D: INSURER E: INSURER F: 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 TYPE OF INSURANCE DDL UBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 B X COMMERCIAL GENERAL LIABILITY X KK00000005115000 02/01/2015 02/01/2016 DAMAGE TO RENTED 3OO 000 PREMISES Ea occurrence $ , CLAIMS-MADE OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ None GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OPAGG $ 1,000,000 POLICY JECT LOC Emp Ben. $ 1,000,000 AUTOMOBILE LIABILITY (CEO, SINGLE LIMIT 1,000,000 Ea ident $ B X ANY AUTO KK00000005115000 02/01/2015 02/01/2016 BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Per accident X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1,000,000 B EXCESS LAB CLAIMS-MADE XK00000005115000 02/01/2015 02/01/2016 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY TORY LIMITS ER A ANY PROPRIETOR/PARTNER/EXECUTIVE Y/N Z836521214 02/01/2015 02/01/2016 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUDED? ❑ N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,000 C Equipment KK00000005115000 02/01/2015 02/01/2016 Equipment 743,748 Deductibl 1,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Certificate holder is an Additional Insured with respect to General Liability. CERTIFICATE HOLDER CANCELLATION CITYC-1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN y ACCORDANCE WITH THE POLICY PROVISIONS. P. O. Box 4748 Clearwater, FL 33756-5520 AUTHORIZED REPRESENTATIVE ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD