CERTIFICATE OF LIABILITY INSURANCE (3) 0 DATE Il�rWDDIYYYYl
A
CC> CERTIFICATE OF LIABILITY INSURANCE 5r26/2015
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
'EPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
WPORTANT: 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 PR: 500-526-1375 FAX: 973-921-2876 CONTACT Amber Richards
RPS NAME:
ADDRESS!x#1 9pt1.Cr7 (AJC,NA:{4§13 5 22 9-27 95 FAX
Bollinger sorts & Leisure PHONE arichards @Nmewil ...
P.O. Box 390 INSURER(S)AFFORDING COVERAGE NAIL#
Short. Hills NJ 33823 �INSURER A:Markel 'Insurance Co 38970
INSURED NNSURER B
Florida Youth Soccer Association, Inc, INSURERC
2828 'Lake Myrtle Park. Road. INSURER D:
INSURER E:
Auburndale FL 33823 INSURER F
COVERAGES CERTIFICATE NUMBER:15/"16 All Lines REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO"I"FIE INSURED NAMED ABOVE FOR THIE 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 TYPE OF INSURANCE P{7LICY EFF POLICY EXP ..
LTR POLICY NUMBER' 'MM7DC1,YYY I' M,,,,YYYY LIMITS
• COMMERCIAL GENERAL LIABILITY OC.L 1,0001000
. I .....EACH OCCURRENCE $
r
DAMAGE TO RENTED
A CLAIMS MADE -X OCCUR i PREMNSEz,�'{Ea ocr.��,r„rance} ......$ 300,000
_....
• Participant Legal Liab. PIED E'XF (Any one person) $ 5,000
--- ' { 36U2Ati1243b4s 6J1/21715 6'J1J2p16 i P...
• Sexual...Abuse .& Moles. SexuaS. .Abuse and PERSONAL&ADV INJURY S 1,000,000
GENT PAGGREGATEPRAT APPLIESLPER. $11�s0�aN5Ot]nFer occurrence GENERAL AGGREGATE 5 5,000,000
PRO-
JECT PRODUC"" COM .OP AGG .S 2,000,000
_._.
OTHER. ; $2,000,000 Aggregate Abuse or Molestation S 1,000,000
AUTOMOBILE LIABILITY COMBINED SINGLE WAIT $ 1,000,000
ANY lea ecciEt,�n.J
1,C1L12ARODS385 6/1/2015 j 6/1/201.6 BODILY INJURY(Per accident) S
A AUTO BO[AI Y INJURY f a.
_......_
ALL OWNED SCHEDULED
i AUTOS AUTOS
aCCi ar'stl
_......—
PROPERTY DAMAGE
HIRED AUTOS X AU rOS WNEI)
UrOSWNENS (.{Pei,eu�ident} $.._
S
.. UMBRELLA LNAB ..?C..... OCCUR ' EACH OCCURRENCE .....:$ 1,000,000
A EXCESSLiAB CLAMS-MADE ... ....„AIE ,......S 1,00CS..e. '00
DED RkTFNI"IONS.. , ACGIdEt
7C 4�6CY2A1CCJ29104 6'/1/201 6J1J2p16 S
WORKERS COMPENSATION PER O"I H
AND EMPLOYERS'LIABILITY YIN .„„IT,$TA„TLITE ER :.......,,„,.
ANY PRI'APR%ETOR'IPARTNERIEXECUTIVE F t EACH ACCINJEN"T S
OFFICCERiPOF MBE R FX. N,DFD^l NIA'
(Mandatory in NH) ......... E.L.LASEASE-EA EMPLCiYLE $
ir es.describe Under
I'.)F'SCRIP rION OF OPERATIONS blow E I DISEASE-PrUl..lt„Y LIMIT S
A Participant Accident 4102AH243046 6/1/201.5 6/1/201.6 $50,000 E.xcessAcxident Max Per Claim
Medical Bxpense Limit $2.000 De&icbble Per Claim
C)ESCRN TION OF FERA7NO S I LOCATICSNS I VEHICLES {ACORL7 1t)i„Add tfonal Remarks Schedule mey be attached Nt more space Is rieuirsdj
All operations of the Florida Youth Sooner Assn, its teams, leagues & clubs. Coverage applies only to
official, sanctioned and supervised activities of FYSA, CERTIFICATE HOLDER IS NAMED AS ADDITIONAL
INSURED. This certificate is issued on behalf of: CkIARGERS SOCCER CLUB
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Athletics Office
WITH THE POLICY PROVISIONS.
746 N. Missouri Avenue
Clearwater, FL 33755 AUTHORIZED REPRESENTATIVE
Q 1988.2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD
INSOPS onlAoi?
L'I,
4C"� CERTIFICATE OF LIABILITY INSURANCE =/2 rq
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE. DOES NOT AFFIRMATIV'EL'Y' 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(les)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 PH: 800--526-1379 FAX,: 973-921--2876 CONTACT Amber Richards
NAME:
RPS Programs LPHOO,E EXt,. (813)349-2220 FAX�Q1 {8137229 2795
Bollinger Sports & Leisure E-MAIL ari.chards9mewil son.com
P.O. Box 3907 INSURERIS)AFFORDING COVERAGE. � NAIC#
" INSURER A Xark.e... ..
_ 23 I
l Insurance ,o 1389717...
Short H1,1 �^ NJ
Florida Youth Sooner Association,
INSURED IIINSURERC:NSURER B
w , Inc. .. „..�.µ..
2828 Lake Myrtle Park. Road INSURER D: T
INSURER E
Auburndale FL 33823 INSURER F:
COVERAGE'S CERTIFICATE NUMBER:15/16 All Lines REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEI:)AB'O'VE FOR THE POLICY PERIOD
INDICATED RO"TWI"THS'T'ANDDNG ANY REQUEREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER. DOCUMENT WITH RESPE'C'T TO WHICH THIS
CERTII-ICA'E MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE A17"ORDED BY "T'HE. 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 LNSR�..._.,.... TYPE OF INSURANCE APOL SWBRI POLICY NUMBER,... POLICY EFF....... POLICY EXP ..........._._....-----.--- ----._.. ,.
IMMMDIYYYYI LIMITS
X COMMERCIAL GENERAL LIABILITY
_ EACH f,3C;C:VrRNUE S 1 r 1700,U0o
AA GE TO FEN rEO
A µ�A VS MADE. X....OCCUR 5RIEVISES(Ea occurmnce) .5 500.. 000
X.. Participant Legg] 7 X 3Sf7 .AH'7 349 611/X715 6J112015 VEuEXP(Anyaneperson) S ,OOC1
y PERSONAL 8.ACV INJURY.. ........—...._.
'�' Sexual. Abu" & Moles. Sexual Abuse a:rs1 r,L..�, �.� ,, 1,000,000
'.GEh t':.r,d..;.A"'E r.IVIT A�-IES PER Molestation: ::Eh vnL:�„ISREC;ATE $ 5,004,000
C. (J; 1 Or, $1,000,000 Per occurrence PR"C"C, TS-COVI'MIPAG'C $ 2,000,1740....
.$2,000,000 Aggregate AbsearVVlestatiD- ._ S 1,044,040.....
AUTOMOBILE LIABILI"T"Y COVIRINFD S'NGL E��.IMIT
,Era accident S 1,000,000
. 1.002AII008385 � 6/1/2015 6/l/2016 OD, nt,;Y INJURY(Par node .,5
," ...... ......
A
n) S
7J �. S I�E7L1L.E10
A, 01 Auros
NON-O'ANED ',. :1n- PER 1"M DAMAGE
eE.,A:.`OS AUTOS i :Per,acadentJ .
$
..
".� X 5
UMBREL.L..A'LIAB X OCCUR EATS 0CC JRRENCE s ]. 000 400
X EXCESS LIAR T`.NTi^.h S CLAI.10 �DF
.+ A GG .- .-1,op
_ HE.GATE 5 l 400 000
X 4602AH029'104 5/'112015 6/112p1i" $
WORKERS COMPENSATION i Pr7,R
AND EMPLOYERS'LIABILITY Y f N - ...STATUTE_ 7,"5.., ...,.............
ANv PRCPR.F-CP PAR7NE.R %LC,J."...V= . ° .EACH ACC..DENT 5 ,_ .........
EXCLJGE5a II N fA
(Matdatory In NH) u$LASE•EA PAPWYEE S
...._
C]':"..SC"dIF Tlf;h C7 ,:-.RA�IC)N,�a belsw ` ?mm C7 Aa•E:-P:JLICY....IM" S
A 'Participant. Accident. 4102AH243046 6/l/2015 6/1/20.7.6 So,).X,'Excess Accidwit Max Per Claim
Medical Expense 'Limit $2,000 Clad„ctible Per Claim
DESCRIPTION OP OPERATIONS f LOCATIONS f VEHICLES ACORD 101 Additi.anal Remrks chegglfl rti
A'll 6perations iii the Florida Youth Soccer Assn, its teams, leagues & clubs. Coverage applies only to
official, sanctioned and supervised activities of FYSA. CERTIFICATE HOLDER IS NAMED AS ADDITIONAL
INSURED. This certificate is issued on behalf of. CHARGERS SOCCER. CL'U'B
EDDIE C. MOOREE COMPLEX - 3050 DREW ST. CLEARWATER FL 33759 - COUNTRYSIDE SPORTS PLE'X 30764 MCMULLEN BOOTH
RD CLEARWATER FL 33761 _ JOE DIMAGGIO FIELDS 2450 DREW ST CLEARWATER FL 33765 - GLEN OAKS PARK/DAVID
MARTIN FIELDS 1345 COURT ST CLEARWATER FL 33756
CERTIFICATE HOLDER CANCELLATION
.SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Clearwater THE EXPIRATION DATE. THEREOF, NOTICE WILL BE DELIVERED IN
Athletics Office ACCORDANCE WITH THE POLICY PROVISIONS,
706 N. Missouri Avenue
Clearwater, FL 33755 AUTHORIZEDREPRESENTA71VE
9888-2014 ACORD CORPORATION. Al rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
IN;;n25:a +.ei-