CERTIFICATE OF LIABILITY INSURANCE (13)
84/15/2007
ACORQM
PRODUCItR (727)442-0012
Sandbergen Insurancet Inc.
2121 N.E. Coachman Rd.
Clearwater, FL 33765-2616
13:12 7274459147
CERTIFICATE OF LIABILITY INSURANCE
SANDBERGEN
PAGE 02/03
AX (727)446-9147
INSURED Marina Restaurant
Thomas & Patrcia Wolkowsky
lS Causeway Boulevard
Clearwater Bea~h. FL 33767-2064
INSURERS AFFORDING COVERAGE
INSURE~A: Capaci'ty Insurance (0.
IN9URER B:
INSURER C:
III/SURER 0:
INSURIiR E:
NAIC#
COVERAGES
THE POLICIES 01" INSURANCE; LISTED BElOW HAVE BEEN Issueo TO THE INSUAED NAMED ABOVE FOR THe POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT 10 WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN. TI-tE INSURANCE AFFORD~D BY THE POLICIES OESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANO CONDITrONS OF SUCH
POLlCII:S.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDuceo BY PAID ClAIMS,
LT~ NSR~ TYPE OF INSURANCE pOLICY NUMIilER ClA TE (MMIODfYV) DATE rMMIDDlYYJ LIMITS
GENERAL LIABILITY ClPOO9277 04/01/2007 04/01/2008 F..ACH OCCURFlENce $ 1,OOO.OO~
X COMMERCIAL GeNERAL LIABILITY PR~M~Ea!~Booou~n~1 s 100.000
I CI.AIMS MADE 0 OCCUR MED EXP (My 0118 person) $ 5,000
A X PERSONAL. & AOV INJURV $ 1,000.000
i- GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES peR; PROOUCTS.COMP~PAGG $ 1,000.000
~ nPRO. n
POL.ICY JECT loe
AUTOMOBILI! UABILITY COMBINED SINGLE LIMIT S
"-- ANY AUTO rea accident)
- AI.1.. OWNED AUTOS
BODILY INJURY ilo
- SCHEDUU;:D AUTOS [Par p~"';l~n)
- HIRED AUTOS BODI\,Y INJURY
- [Per accklenl; $
NON-OWNED AUTOS
- F'~F'ERlY DAMAGE
- (F'ar scCi<lanl) $
GARAGf LIABILITY AUTO ON!.V - EA ACCIOeNT $
R ANY AlITO O'l'HER THAN EAACC S
AUTO Oll/L Y: AGG $
El<CI099/UMBRELLA L1ABILlTV EACH OCCURRENCe $
~ OCCUR o CLAIMS MADE AGGREGATE $
is
R DeOUCTIIlLE; $
RETENTION S $
WORKERS COMPENSATlOII/ AND . J TO'R-?' Li~Ns I jUER
eMPLOYERS' LIABILITY E.L. El\CM ACCIDeNT $
ANY PROPR'eTO~PARTNERlExeaJTIVF.
OFFIOER/t./IEMBER EXCLUDED? 1;,1., DISEASE - EA fMPLOY!!E $
if ~<J5, ~95Woa ~ndar e.L. DISEASE. POLICY I.IM1T $
S ECIAL PROVISIONS QQh;l1l,l
OTHER
DESCRIPTION OF OpeRATIONS / LOCATIONS I VEHI(;I.t;S I EOlICLUSIONS ADDED BV llNDORSEOIlllEONT J SPECIAL PROVlSIDNS
rertificate Holder is Landlord Additional Insured
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
Marine & Aviation Division
25 Causeway Boulevard
Clearwater Beach, FL 337~7
ACORD 25 (2001/08) FAX: (7l7)462-69S7
0~/15/2007 13:12
7274459147
SANDBERGEN
PAGE 03/03
....
IMPORTANT
If the certificata holder is an ADDITIONAL INSURED, the pollcy{ies) must be endorsed, A staternent
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUB~OGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may
require an endorsement. A statemant on this certificate does not confer rfghts to the certificate
holder in lieu of such endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse 5ide of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or altet the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)