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CERTIFICATE OF LIABILITY INSURANCE 14C CERTIFICATE OF LIABILITY INSURANCE °A 411 0D015 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 BELOYY_ 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 paticy(ies)must be endorsed. It 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 endomement(s). PRODUCER CONTACT Program Support .'� --- =FAX Veracity Insurance Solutions,LLC. ""E (8$$)56$-054$ — _ 260 South 2500 West,Suite 303 a OGRESS infaCtliprogram.com PleasantGrove UT $4062 U1gUR(S)AFFORDINGCOVERAGE NAICa INSMERA: GreatAmencan Allience insurance Go. 26832 INSUREO INSURER B: ..-- .. ,_...... Edward Bates,DBA Kinney's Kitchen INSURERC: 1450 Carolyn Ln INSURER D: Clearwater FL 33755 INSURER E' INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE USTED BELOW HAVE SEEN ISSUED'TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY RECIUIREMENT,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. LgR $DLSUBR - TPOIJ -EFF POLICI'1=71P LyM� TYPE OF pISLI@ANCE POLICY NUMBER I D NMlD GENERAL UAa1LIfY EACH OCCURRENCE .�_5__._. 1,D00,0O0 'DAMAGETOFRENTEI— 30 0,000 ]C COMMERaALGENERALLIABILITe ! x I PREMWESJEa tcwrrencaj..IS..__—_—_.. - .,.-MADE 1 x OCCUR �� ` MED EXPIAm one rasanl 1 S ___ 5,00D A =CLA _ I PL3305436-1`009172 !1H117120t5 64117r2a16 PERSONAL&ADVINJURe — s 1,000,000 GENERAL AGGREGATE i S 2,000,000 GrWLAGGREGATELRAFTAPPLIESPER ?RODUCTS-Gq.�10PAGG IS 2,000,00D PCLICY PRP 1 LCC PAUTOMOB"UABILITY CON131NEOSUVGLE LI I I S ANY AUTO ALLOWNED SCHEDULED I BODILY WJURY per accident)IS AUTOS -AUTOS NCW OWNED PROPER Y DAMAGE :3 :IIREOAUTOS AUTOS -- I UMBRELLA LtAa OCCUR _ EACH OCCURRENCE .__ S .__.._ EXCESS Wt6 CLAF.ISMAQE 'AGGREGATE S DED .RI:TENiIONS S WORIGERS W C STA 1-.!.. iOTH- ANDEMPLOYE LLgBR W ._.TORY ��R _._-_... AND ROPPIEHI3'LU981LSM ANY PROFIiIE;pRJPARTN°_RIEX£CUTNE YJN EL.EACH ACCIDENT S _ OFFICFMEMBEREXCU1DE6? ED NrA`1 EL >:MPLOY DISEASE-EAEE_5._.__—__--____-- ...__- (Mendato�YInNHI r-- ___...... byes,d—e,a finder EL.OW"SE-POLICY 4MIr:S I F I I 1 DESCRFTION OF OPERATIONS I LOCATIONS!VEHICLES(ANxh AGORD101,Additional Ransts Schedule.It MOM spew is Mg fired) Certificate holder had been added as additional insured regarding the above mentioned policy per attached Additional Insured-Designated Person or-Organization(CG20 25,EO-04 13) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED IIEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Clearwater ACCORDANCE WITH THE POLICY PROVISIONS. 299$Drew St. Clearwater FL 33759 AUTHORIMD REPRWEWATi4E algae-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2040105} The ACORD name and logo are registered marks of ACORD j d Z89e-ztt-LZL S81e8 PA I1 —' FOOD GKL-'A L4IERAC:-N /l LIABILITY 111SURMCE GROUP ADMINISTRATED 8Y INSURANCE Great American Alliance Insurance Company Veracity Insurance Solutions.LLC PROGRAM 260 South 2504 We st Suite 303 301 E.Fourth Street,25 S Pleasant Grove Utah 84052 htte"1hv�w.fliorearatn-cnm Cincinnati.OH 45202-42D1 888-56"548 513579.6300 'nfo Ce 0io ro gram.eom COMMERCIAL GENERAL LIABILITY COVERAGE PART -OCCURRENCE FORM CERTIFICATE PAGE IT IS AGREED THAT THIS CER77FICATE I5 ISSUED TO THE CERTIFICATE HOLDER LISTED BELOW TO CERTIFY COVERAGE UNDER THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY LISTED BELOW. INSURANCE COMPANY: GREAT AMERICAN ALLIANCE INSURANCE COMPANY POLICY NUMBER: NAMED INSURED:BEAUTY HEALTH$,TRADE ALLIANCE PL3305436 CERTIFICATE HOLDER:Edward Bates,DBAKinney's Kitchen CERTIFICATE NUMBER: ADDRESS: 1450 Caroiyn Ln.Clearwater,Florida 33755 F009172 POLICY PERIOD.,04n M015 to 0411712015 1291 A.M.Stand arn nma a tha Ad draas afThe Certificate Holder LIMITS OF INSURANCE General Aggregate Limit(Other than Products-Completed Operations) $ 2,000,000 Products-Completed Operations Aggregate Limit $ 2,000,000 Personal and Advertising Injury limit $ 1,000,000 General Each Occurrence Urn It $ 1,000,000 Damage to Premises Rented to You Limit S 300,000 Any One Premises Medical Expense Limit S 5,000 Any One Person Professional Coverage Extension $ Not Purchased Each Claim $ Not Purchased Aggregate Professional Coverage Deductible S Not Purchased Each Claim Liability Deductible None Identity Recovery Coverage Aggregate Limit $ 15,000 Identity Recovery Coverage Deductible $ 250 FORM OF BUSINESS:Sole ProprietDdIndividual TOTAL_COST OF INSURANCE: $ 399 (The cost is 100% earned/non refundable) CODE NUMBER: 11168 PREMIUM BASIS:Gross Sales EXPOSURE:$50,001-$100,000 CLASSIFICATION:CDnaessionaries THIS INSURANCE IS SUBJECTTO ALL THETERMS AND CONDITIONS.INCLUDING APPLICABLE ENDORSEMENTS,OF THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY.A COPY OF THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY ACCOMPANIES THIS CERTIFICATE.ADDITIONAL COPIES WILL BE PROVIDED TO THE CERTIFICATE HOLDER.PLEASE READ THE POLICY AND ALL ENDORSEMENTS. NO ADMISSION OF LIABILITY MAYBE MADE EITHER VERBALLY OR IN WRITING FULL DETAIL OF ANY INCIDENT SHOULD BE SENT IMMEDIATELY BY EMAIL TO CLAIMSa.VERACITYINS.0 M OR BY LETTER TO VERACITY INSURANCE SOLUTIONS LLC 260 SOUTH 2500 WEST SUITE 303,PLEASANT GROVE,UT 84062. FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part of this Policy at time of issue are listed on the attached Fortes and Endorsements Schedule IL 88 01 (11185). ADMINISTRATOR'S SIGNATURE: Z-d Z89C-Zbb-LZL sa}e8 PA FOOT? GIU a�L�tFxr�-{ti' // LIABILITY IUSURANCE GIWUP ADMINISTRATED BY INSURANCE Great American Alliance Insurance Company Veracity Insurance Solutions,LLC PROGRAM 260 South 2500 WeSt Sulte 303 4 301 E.Fourth Street,25 S Pleasant Grove Utah 84062 htto'RANva.1inroeratn.corn Cincinnati,OH 45202-4201 888,568-0546 513.579-8300 info RDBiorcaram.cnrn COMMERCIAL GENERAL LIABILITY COVERAGE PART—OCCURRENCE FORM CERTIFICATE PAGE iT ISAGREED THATTHIS CERTIFICATE IS ISSUED TO THE CERTIFICATE HOLDER LISTED BELOWTO CERTIFY COVERAGE CINDER THE COMMERCIAL GENERAL LIABILITY INSURANCE MASTER POLICY LISTED BELOW. INSURANCE COMPANY:GREAT AMERICAN ALLIANCE INSURANCE COMPANY POLICY NUMBER: CERTIFICATE HOLDER:Edward Bales,DBAKinney's Kitchen PL3305436 ADDRESS: 1450 Carolyn Ln,Clearwater,Florida 33755 CERTIFICATE NUMBER: POLICY PERIOD:04117!2015 to 04/1772046 12:01 A.M.Standard Time at the Address of The Certificate Holder F009172 LIMITS OF INSURANCE Business Personal Pro perty4niand Marine Limit $3,000 Maximum payoutfor anyone article $10,000 Annual Aggregate Property described in the poiicythat you own, or is in yo ur care,custody orcontrol Business Personal Prope"Inland Marine Deductible $250 Per Occurrence FULL DETAIL_OF ANY INCIDENT SHOULD BE SENTIMMEDIATELY BY EMAIL TO CLAIMSCa VERACITYlNS.CONI OR BY LETTER TO VERACITY INSURANCE SOLUTIONS,LLC 260 SOUTH 2500 WEST SUITE 303,PLEASANTGROVE,UT 84062. FORMS AND ENDORSEMENTS applicable to all Coverage Parts and made part ofthis Policy at time of issue are listed on the atfached Forms and Endorsements Schedule CAM 88 01 (Ed.11 85). ADMINISTRATOR'S SIGNATURE: E'd Z89P-ZVi7-LZZ s91I38 PA