CERTIFICATE OF LIABILITY INSURANCE (373)�uent�: �iu4a�yy r�iarwrc�
DATE (MM/DD/YYYY)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE 06/23/2015
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:
USI Insurance Services, LLC, PHONE g13 321-7500 aC, No ; 813 321-7525
AIC No Ext :
1715 N. Westshore Blvd. Suite 700 E-MAII
ADDRESS:
Tampa, FL 33607 INSURER(S) AFFORDING COVERAGE NAIC #
INSURED
Plisko Architecture, P.A., AIA
800 Drew St
Clearwater, FL 33755
iNSUReRn: Phoenix Insurance Company 25623
iNSUReR s: Travelers Casualty and Surety C 19038
iNSUReR c: XL Specialty Insurance Company 37885
INSURER D :
� � INSURER F: I 1
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.
LTR �PE OF INSURANCE NSRL YWD POLICY NUMBER MM/DDY� MM/DDY EXP LIMITS
A GENERAL LIABILITY X X 6602432R749 6/18/2015 06/18/201 EACH OCCURRENCE $1 000 000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea oNcu ence $1 OOO OOO
CLAIMS-MADE � OCCUR MED EXP (Any one person) $ � 0 0��
PERSONAL & ADV INJURY $ � ,OOO,OOO
GENERALAGGREGATE $Z�OOO,OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $Z,OOO,OOO
POLICY PR� LOC $
JECT
A AUTOMOBILE LIABILITY X X 6602432R749 6/18/2015 06/18/201 COMBINED SINGLE LIMIT ,�,000,000
Ea accident $
ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X HIREDAUTOS X NON-OWNED Per�acc,denDAMAGE $
AUTOS
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
B WORKERSCOMPENSATION X UB7080Y545 9/01/2014 09/01/201 X W RYTATU- OTH-
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N E.L. EACH ACCIDENT $� OO OOO
OFFICER/MEMBER EXCLUDED? � N / A
(Mandatory In NH) E.L. DISEASE - EA EMPLOYEE $'I OO OOO
If yes, describe under
DESCR!PTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $�JOO,OOO
C Professional DPS9719401 9/11/2014 09/11/201 $1,000,000 per claim
Liability $1,000,000 annl aggr.
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (AtWch ACORD 707, Addltional Remarks Schedule, if more space is requlred)
Professional liability is written on a claims made basis.
The certificate holder is an additional insured with respect to the general liability coverage where
required by written contract.
Clt of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
y THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Ellglflee�lflg D@pt. ACCORDANCE WITH THE POLICY PROVISIONS.
100 S. Myrtle Ave., #220
Clearwater, FL 33756 AUTHORIZED REPRESENTATIVE
0�� '� O�--OL.A .�•--�---
O 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25 (2010/05) 1 of 1 The ACORD name and logo are registered marks of ACORD
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