CERTIFICATE OF LIABILITY INSURANCE (3) Client#: 16741 INTERCUL
DATE(MMlDDrYYYY)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE 6/10/2015
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).
PRODUCER CONTACT
NAME: _
Bouchard Insurance(CLW) PHONE —T27 447-6481_
AX
Arc No): T27 449-1267--
101 N Starcrest Dr, MAIL
° ,
ADDRESS: cicertsftmyers @bouchardinsurance.com
Clearwater,FL 33765
INSURER(S)AFFORDING COVERAGE NAIC
727 447-6481 Arch Insurance Company 11150
INSURER A:
INSURED . INSURERS:Guarantee Insurance Company 11398
InterCuitural Advocacy ----- ---'--�--�°—��--- —
INSURER C:
InstituteInc --------.............---..................__.-.-._._.....__....-.-_--.--.._......__.__..._____.__ _....._...--
612 Franklin Street INSURER
Clearwater,FL 33756 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.
Irv$R -------- ADOL SUBR _.. POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE - INSR WVD POLICY NUMBER -_ iMM/DD/YYYY MMrDD/YYYY ---' LIMITS _.._. ._.------
A GENERAL LIABILITY NCPKGO128105 3/15/2015 03115/201 EACH OCCURRENCE $1 000 000
X COMMERCIAL GENERAL LIABILITY PRREMIISES(RENTED
urnce_ $10%000
000
CLAIMS-MADE �OCCUR MED EXP(Any one person) $2p pp0
PERSONAL&ADV INJURY $1,000,000 _
GENERAL AGGREGATE $3,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: -- PRODUCTS-COMP/OP AGG $3,000,000
z POLICY 1 PRO- I LOC $
---. _-__� ___L�
A AUTOMOBILE LIABILITY NCAUT0128105 3/15/2015 03/15/201 COMBINED SINGLE LIMIT
(Ea accidence--.__�_.. 1,000,000
X ANY AUTO BODILY INJURY(Per person) $ _
ALL OWNED SCHEDULED ..... ._...-.......
—
AUTOS AUTOS BODILY INJURY(Per accident) $
}( NON OWNED PROPERTY DAMAGE
X HIRED AUTOS accident) $ -
AUTOS Per
$
A X UMBRELLA Ll B X OCCUR NCFXS0128102 3/15/2015 03/15/2016 EACH OCCURRENCE $1 000 000
EXCESS LIAR CLAIMS-MADE AGGREGATE - $1 000 000
DED RETENTION$ $
WC B WORKERS COMPENSATION WCP100339105GIC 1/01/2015 01/01/201 TORYLI IT OTH-
AND EMPLOYERS'LIABILITY - -----ANY PROPRIETOR/PARTNER/EXECUTIVE YIN E.L.EACH ACCIDENT $1 pp ppp
OFFICER/MEMBER EXCLUDED? NIA ---_
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $100,000
If yes,describe under '..
DESCRIPTION OF OPERATIONS below ^_ ._�._ ._._ —----- E.L.DISEASE-POLICY LIMIT $500,000
A Directors& NFP008664902 3115/2015 03/15/2016 $1,000,000 —
DESCRIPTION OF OPERATIONS r LOCATIONS r VEHICLES(Attach ACORD 101,Additional Remarks Schedule,it more space is required)
1
(See Attached Descriptions)
CERTIFICATE HOLDER CANCELLATION
CCTV OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY MANAGER ACCORDANCE WITH THE POLICY PROVISIONS.
P.O.BOX 4748
CLEARWATER, FL 33758-4748 AUTHORIZED REPRESENTATIVE '
i
CJ 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010/05) 1 of 2 The ACORD name and logo are registered marks of ACORD
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DESCRIPTIONS (Continued from Page 1)
NOTICE:
Bouchard Insurance is required to comply with the licensing agreement we hold with ACORD.
ACORD, in conjunction with the Department of Insurance,creates and enforces the rules and regulations
pertaining to proper use of the Certificate of Liability Insurance form.
We are required to mark a Y next to the line of business in which the Additional Insured or Waiver of
Subrogation coverage applies.According to ACORD,the Description of Operations section must be limited
to describing information necessary to identify the operations,locations and vehicles for which the
certificate was issued.Please note the Description of Operations section of the Certificate cannot be
used to add additional information except as just described. Marking a Y next to the line of business
adequately documents coverage. Equally important, it satisfies the rules and regulations governing the
proper use of the Certificate of Liability Insurance form,
Certificate is a reflection of the current coverages provided for the insured. Limits and coverages are
afforded to the certificate holder only if required by written contract.
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