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CERTIFICATE OF LIABILITY INSURANCE (589)OP ID: 2Y Ac �RD CERTIFICATE OF LIABILITY INSURANCE October27,2014 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 800 - 678 -0361 Hylant Group Inc- Indianapolis 317 817 -5151 301 Pennsylvania Parkway, #201 Indianapolis, IN 46280 Donald J. Thompson Jr. CONTACT PHONE FAX (A/C. No. Extl: (A/C, No): ADDRESS: PRODUCER KIWAN25 CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED Kiwanis International ALL CLUBS & THEIR MEMBERS INSURED LOCAL CLUB: Kiwanis Club of Springtime City P.O Box 6142 Clearwater, FL 33758 Contact Jim Ewbank Ph 727 724 1779 INSURER A : Lexington Insurance Company 019437 INSURER B : 013136005 INSURER C 11/01/15 INSURER D : $ 2,000,000 INSURER E : PDREM SES (EaEN r ante) INSURER F: • 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 INSRWVD SUBR POLICY NUMBER POLICY EFF (MM /DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY OCCUR 013136005 11/01/14 11/01/15 EACH OCCURRENCE $ 2,000,000 X PDREM SES (EaEN r ante) $ 500,000 CLAIMS -MADE X MED EXP (Any one person) $ 5,000 X Liquor Liability PERSONAL & ADV INJURY $ 2,000,000 X Per District GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: POLICY n JEGPRO T 7 LOC PRODUCTS - COMP /OP AGG $ 2,000,000 Lqr Liab $ 1,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS $3,000,000 Aggreg 013136005 11/01/14 11/01/15 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ X X $ X $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER /EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ below E.L. DISEASE - POLICY LIMIT $ A SELF INSURED RETEN 013136005 11/01/14 11/01/15 ALL CLAIM 75,000 QESCinIgTJmON e O CQy E an s / LmCemTer / s V aI Lguestt wh.() CQRcD a 1n , edrc es Aerk . o had sh of m otre h e s p fao llwn eates: Saturday, November 8, 2014, Saturda y, January 10th, 2015, Saturday March 14, 2015, Saturday, May 9, 2015, Saturday July 11, 2015 and Saturday, September 12, 2015. The program is part of the City of Clearwater's Adopt A Street Program. The area to be cleaned is Hercules Ave. between Druid Rd on the south and Drew St. on the north. City of Clearwater ATTN: Nancy Lamonga 100 S. Myrtle Ave Clearwater, FL 33756 I ALLCERT 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 (2009/09) ©1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD 4 KIWANIS INTERNATIONAL - CERTIFICATE OF INSURANCE REQUEST WITH ADDITIONAL INSURED WORDING PLEASE COMPLETE BEFORE ORDERING!! We strive to meet a 24 hour turnaround Kiwanis Club Information(name of club). ' Springtime City Kiwanis Club Contact Name: Jim Ewbank Club or Contact Address: P.O. Box 6142 City: Clearwater State: Fl Zip: 33758 Contact Phone: 727 724 1779 Contact Fax: Contact Email: ewbankjl @tampaba .rr.com Send copy of certificate via: ]✓ Email ❑ Fax ❑ Mail 1) Additional Insured: Description of Event: Springtime Kiwanis members will clean a one mile stretch of Hercules Ave to help beautify Clearwater Add'l Insured Name: City of Clearwater Add'l Insured Address: Munciplal Building, 3rd Floor, 100 S. Myrtle Ave City: Largo State: FL Zip:33758 Attn: Nancy Lamonga Fax: Email: State: Send copy of certificate via: ✓ Email ❑ Fax ✓ Mail 2) Additional Insured: Description of Event: Springtime Kiwanis members will clean a one mile stretch of Hercules Ave to help beautify Clearwater Event Dates (include set up /tear down dates): November 8, 2014, Janaury 10, 2015. March 14, 2015, May 9, 2015, July 11, 2015, Sept 12, 2015 Event Location: Hercules Ave, between Druid Rd and Drew Street Add'! Insured Name: Add'l Insured Address: City: State: Zip: Attn: Fax: Contact Email: Send copy of certificate via: ❑ Email ❑ Fax ❑ Mail Kiwanis Event Information Description of Event: Springtime Kiwanis members will clean a one mile stretch of Hercules Ave to help beautify Clearwater Event Dates (include set up /tear down dates): November 8, 2014, Janaury 10, 2015. March 14, 2015, May 9, 2015, July 11, 2015, Sept 12, 2015 Event Location: Hercules Ave, between Druid Rd and Drew Street Special Instructions: Hylant, 301 Pennsylvania Parkway, Suite 201, Indianapolis, IN 46280 Phone: 800 - 678 -0361 Fax: 317- 817 -5151 Email: kiwaniscert @hylant.cgm 5 ACO O® CERTIFICATE OF LIABILITY INSURANCE DATE (MMIDDIYYYY) 10/28/2014 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 the terms and conditions of the policy, certain policies may require an certificate holder in lieu of such endorsement(s). policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to endorsement. A statement on this certificate does not confer rights to the PRODUCER Hylant Group Inc - Indianapolis 301 Pennsylvania Parkway, #201 Indianapolis IN 46280 NAME: Adam Reiff PHONE (A/C. No. Ext):317- 817 -5139 FAX No►:317- 817 -5151 ADDRESS:adam.reiff a( hylant.com INSURER(S) AFFORDING COVERAGE NAIC # INSURED KIWANO3 Kiwanis International, All Clubs and Their Members 3636 Woodview Trace Indianapolis IN 46268 INSURER A :Lexington Insurance Company INSURER B : 19437 INSURER C : INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 833502464 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 A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY Y 013136005 11/1/2014 11/1/2015 EACH OCCURRENCE $2,000,000 PRMMGE TO RENTED PREMISES (Ea occurrence) $500,000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $5,000 PERSONAL & ADV INJURY $2,000,000 X Liquor Liability GENERAL AGGREGATE $2,000,000 GEN'L AGGREGATE 7 POLICY LIMIT APPLIES PRO - JFS T PER: LOC PRODUCTS - COMP /OP AGG $2,000,000 Liquor Liability $1,000,000 A AUTOMOBILE LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS SCHEDULED AUTOS NON -OWNED AUTOS 013136005 11/1/2014 11/1/2015 COMBINED SINGLE LIMIT (Ea accident) $1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ Aggregate $3,000,000 UMBRELLA LIAR EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENT ON $ $ 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 I A WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A Self- Insured Retention 013136005 11/1/2014 11/1/2015 All Claims $75,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more space is required) Certificate Holder is named as Additional Insured as respects to General Liability only regarding the following Kiwanis event (setup, take down & rain date(s) during policy term are included): 11/8/2014, 1/10/2015, 3/14/2015, 5/9/2015, 7/11/2015 and 9/12/2015 or any future date(s) during the policy term - Cleaning a one mile stretch of Hercules Avenue between Druid Road and Drew Street (Springtime City Kiwanis Club) CERTIFICATE HOLDER CANCELLATION City of Clearwater Attn: Nancy Lamonga 100 S. Myrtle Avenue, 3rd Floor Largo 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 KIWANO3 OP ID: 53 A �_°RL CERTIFICATE OF LIABILITY INSURANCE DATE 10 /30DIYYYY) 10130/12 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 800 - 678 -0361 Hylant Group Inc- Indianapolis 301 Pennsylvania Parkway, #201 317 - 817 -5151 Indianapolis, IN 46280 Donald J. Thompson Jr. CONTACT PHONE FAX (AIC. No. Extl: (A /C, No): E -MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURER A: Lexington Insurance Company 019437 INSURED Kiwanis International All Clubs and Their Members Insured Local Club: SPRINGTIME CITY % Jim Ewbank PO Box 6142 Clearwater, FL 33758 INSURER B: 013136005 013136005 INSURER C : 11/01/13 11/01/13 INSURER D : $ 2,000,000 INSURER E : $ 500 000 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 ADDL INSR SUBR MD POLICY NUMBER POLICY EFF (MMIDD/YYYY) POLICY EXP (MMIDD/YYYY) LIMITS A A GENERAL X LIABILITY COMMERCIAL GENERAL LIABILITY X 013136005 013136005 11/01/12 11/01/12 11/01/13 11/01/13 EACH OCCURRENCE $ 2,000,000 DAMAGE TO RENTED PREMISES (Ea occurrence) $ 500 000 CLAIMS -MADE X OCCUR MED EXP (Any one person) $ 5,000 X X AGG PER DISTRICT PERSONAL 8 ADV INJURY $ 2,000,000 LIQUOR LIABILITY GENERAL AGGREGATE $ - 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: —1 POLICY PFD LOC PRODUCTS - COMP /OP AGG $ 2,000,000 LIQUOR LI $ 1,000,000 A AUTOMOBILE X X LIABILITY ANY AUTO ALL OWNED AUTOS HIRED AUTOS 3,000,000 X X SCHEDULED AUTOS NON -OWNED AUTOS AGGREGATE 013136005. 11/01/12 11/01/13 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ $ DED RETENT ON $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR /PARTNER /EXECUTIVE OFFICER /MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below YIN N I A WC STATU- TORY LIMITS OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A SELF - INSURED RETENTION 013136005 11/01/12 11/01/13 ALL CLAIM 75,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Certificate holder is named as Additional Insured as respects to General Liability regarding the following Kiwanis event: 11/17/12 or any other future date(s) during policy term - KC members & guests will pick up trash on Hercules Ave as part of the Adopt a Street program (Setup, take down and /or rain date(s) are included) CERTIFICATE HOLDER CANCELLATION ALLCERT City of Clearwater 100 S. Myrtle Ave. 3rd Floor Clearwater, FL 33756 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 ACORD 25 (2010/05) © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OP ID: 2Y AC°RO CERTIFICATE OF LIABILITY INSURANCE `. . 01/14/2012 YYY) 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 Hylant Group Inc- Indianapolis 800 -678 -0361 301 Pennsylvania Parkway, #201 317- 817 -5151 Indianapolis, IN 46280 Donald J. Thompson Jr. CONTACT PHONE FAX rac. No EXtI (A/C, No): E-MAIL ADDRESS: PRODUCER KIWAN25 ._CUSTOMER ID #: INSURER(S) AFFORDING COVERAGE NAIC # INSURED Kiwanis International ALL CLUBS & THEIR MEMBERS INSURED LOCAL CLUB: Springtime City Kiwanis Contact: Jim Ewbank P.O. Box 6142 Clearwater, FL 33758 INSURER A : Lexington Insurance Company 019437 INSURER B MED EXP (Any one person) $ 5,000 INSURER C : 1 PERSONAL BADVINJURY I $ 2,000,000 INSURER D : I GENERAL AGGREGATE $ 2,000,000 INSURER E : i PRODUCTS - COMP /OP AGG INSURER F : I POLICY PRO— r 1 LOC — 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 J TYPE OF INSURANCE ADDL INSR SUBR, WVD 1 POLICY NUMBER POLICY EFF 1 POLICY EXP (MM /DD/YYYY LIMITS }+(MM/DDlYYYY) i GENERAL LIABILITY COMMERCIAL GENERAL LIABILITY I ;013136005 ;013136005 1 11/01/11 11/01/11 11/01/12 11/01/12 EACH OCCURRENCE $ 2,000,000 A 1 X PREMISES Ea occur ante) f $ 500,000 1 CLAIMS -MADE 1 X I OCCUR MED EXP (Any one person) $ 5,000 X Liquor Liability 1 PERSONAL BADVINJURY I $ 2,000,000 X Per District I GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: i PRODUCTS - COMP /OP AGG $ 2,000,000 I POLICY PRO— r 1 LOC — ILqr Liab $ 2,000,000 1 AUTOMOBILE LIABILITY 1 ANY AUTO 1 ALL OWNED AUTOS I SCHEDULED AUTOS HIRED AUTOS I NON -OWNED AUTOS i $3,000,000 Aggreg .013136005 1 , 11/01/11 11/01/12 COMBINED SINGLE LIMIT (Ea accident) ! $ 1,000,000 A 1 BODILY INJURY (Per person) $ { BODILY INJURY (Per accident) $ f i PROPERTY DAMAGE (Per accident) $ X I I X $ 1 $ UMBRELLA LIAB OCCUR , EACH OCCURRENCE $ EXCESS LIAB 1 CLAIMS -MADE AGGREGATE $ DEDUCTIBLE RETENTION $ I $ I I $ WORKERS AND ANY OFFICER (Mandatory ! If yes, 1 DESCRIPTION COMPENSATION EMPLOYERS' LIABILITY Y/ N N / A 1 WC STATU- T OTH -I I TORY LIMITS I ER 1 1 E.L. EACH ACCIDENT $ PROPRIETOR /PARTNER /EXECUTIVE /MEMBER EXCLUDED? i E.L. DISEASE - EA EMPLOYEE $ in NH) describe under OF OPERATIONS below 1 E.L. DISEASE - POLICY LIMIT I $ A !SELF INSURED RETEN ; I ( 013136005 11/01/11 11/01/12 'ALL CLAIM 75,000 1 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Springtime City Kiwanis members and volunteers will clean up Hercules Ave. between Druid Road and Drew Street on January 14, 2012 CERTIFICATE HOLDER CANCELLATION ALLCERT City of Clearwater Y Municipal Services Building, 1st Floor 100 S. Myrtle Avenue 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 (2009/09) © 1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD OP ID: 2Y A... --- CERTIFICATE OF LIABILITY INSURANCE � Mayo, 012 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(les) 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 800-678 -0361 Hylant Group Inc- Indianapolis 317 - 817 -5151 301 Pennsylvania Parkway, #201 Indianapolis, IN 46280 Donald J. Thompson Jr. CONTACT \ PHONE FAX (ac. No. Extt: (NC. No): E-MAIL ADDRESS: PRODUCER KIWAN25 CUSTOMER ID #. INSURER(S) AFFORDING COVERAGE NAIC # INSURED Kiwanis International ALL CLUBS & THEIR MEMBERS INSURED LOCAL CLUB: Springtime City P.O. Box 6142 Clearwater, FL 33758 contact Jim Ewbank 727 724 1779 INSURER A : Lexington Insurance Company 019437 INSURER B : 013136005 013136005 INSURER C: 11/01/12 11/01/12 INSURER D : $ 2,000,000 INSURER E : $ 500,000 INSURER F : CLAIMS -MADE COVERAGES CERTIFICATE NUMBER: • THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY 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 ADOL INSR SUER WVD POLICY NUMBER POLICY EFF (MM/OD/YYYY) POUCY EXP (MMIDO/YYYY) LIMITS A GENERAL X LIABILITY COMMERCIALGENERALUABIUTY X OCCUR MAY 2 1 2012 HOORIZZEED REPRESENTATIVE 013136005 013136005 11/01/11 11/01/11 11/01/12 11/01/12 EACH OCCURRENCE $ 2,000,000 DEMGS DNwltrrO e rce) $ 500,000 CLAIMS -MADE MED EXP (Any one person) $ 5,000 X X GEN'L Liquor Liability PERSONAL BADVINJURY $ 2,000,000 Per District GENERAL AGGREGATE $ 2,000,000 AGGREGATE LIMIT APPLIES PER: POLICY JECT LOC PRODUCTS - COMP/OP AGG $ 2,000,000 Lqr Liab $ 2,000,000 A AUTOMOBILE X X X UABIUTY ANY AUTO ALL OWNED AUTOS SCHEDULED AUTOS HIRED AUTOS NON -OWNED AUTOS $3,000,000 Aggreg 013136005 11/01/11 11/01/12 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ $ UMBRELLA UAB EXCESS LIAR OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DEDUCTIBLE RETENTION $ $ $ WORKERS COMPENSATION AND EMPLOYERS' UABIUTY ANY PROPRIETOR/PARTNEEXECUTNE R/ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS Y / N N / A WC STATU- OTH- TORY LIMITS ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ below E.L. DISEASE - POLICY LIMIT $ A SELF INSURED RETEN 013136005 11/01/11 11/01/12 ALL CLAIM 75,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) Springtime City Kiwanis members and guest will clean trash on Hercules Ave between Druid Road and Drew Street on Saturday, May 5 2012 CERTIFICATE HOLDER CANCELLATION ACORD 25 (2009/09) © 1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ALLCERT City of Clearwater ty RECEIVED SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Municipal Service Building, 1st Floor CITY OF CLEARWATER ACCORDANCE WITH THE POLICY PROVISIONS. 100 S. Myrtle Ave Clearwater, FL 33756 MAY 2 1 2012 HOORIZZEED REPRESENTATIVE RISK MANAGEMENT .AUNT- V ` ' ACORD 25 (2009/09) © 1988 -2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD