CERTIFICATE OF LIABILITY INSURANCE (663)' l � DATE �MM/DDIYYYY)
A�� ° CERTIFICATE OF LIABILITY INSURANCE
9/21/2015
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 NAMEACT AL1dTd Browder
CGB Insurance, LLC PHONE .(g13) 749-7948 ac No: �eis�zoo-Zizo
2531 Green Forest Lane nDOR�ess:audracgbinsurance.com
�'� # 1 O 1 INSURER S AFfORDING COVERAGE NAIC #
Lutz FL 33558 INSURERA:FCCI Insurance Co (WC) 10178
INSURED R���_hardo . inc & INSURER B:FCCI Commercial Insurance Com an 33472
St Petersburg FL 33742
COVERAGES CERTIFICATE NUMBER2015-2016 Master 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 7ypE OF INSURANCE ADDL SUBR pOLICY NUMBER M� DDY� MMIDD/YYYY LIMITS
LTR
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1, 000 , 000
DAMA E TO RENTED 100 , 000
A CLAIMS-MADE ❑X OCCUR PREMISES Ea occurrence $
GL00014707-4 10/1/2015 10/1/2016 MED EXP (Any one person) $ 5, 000
PERSONALBADVINJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2, 000 , 000
POLICY PRO PRODUCTS - COMPIOP AGG $
included
X JECT LOC Employee Benefits 8 1, 000 , 000
OTHER:
AUTOMOBILE LIABILITY Ea aBc tleDtSINGLE LIMIT $
X ANY AUTO BODILY INJURY (Per person) $
B ALL OWNED SCHEDULED
AUTOS AUTOS CM00072G7-4 10/1/2015 10/1/2016 BODILY INJURY (Peraccident) $
NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS
Per accident
$
X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 5 000 000
A EXCESS LIAB CLAIMS-MADE AGGREGATE S 5 000 000
DED X RETENTION$ 10 000 [7HID0015459-4 10/1/2015 10/1/2016 $
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS' LIABILITY STATUTE ER
Y I N E.L. EACH ACCIDENT $ 500 , 000
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ N � A
OFFICER/MEMBER EXCLUDED? 001-WC15A-69461 10/1/2015 10/1/2016 E.L. DISEASE - EA EMPLOYE $ 500 000
B (Mandatory in NH)
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ 500 000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101, Additlonal Remarks Schedule, may be attached if more space is required)
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CATE HOLDER
City,!of Clearwa�er
Building Dept
100 South Myrtle Ave
C-110
Clearwater, FL 33756
ACORD 25 (2014/01)
INS025 r�o�ann
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEPORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
Kraig Blancher/AMANDA �� A �~ ~
O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
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