CERTIFICATE OF LIABILITY INSURANCE (7)DATE (MM/DDNYYY)
A� �� CERTIFICATE OF LIABILITY INSURANCE 1/15/2016
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 NTA T
NAME: M D V
Greene-Hazel Insurance Group a"N E� :904-446-31 6 Fvc No : 4- -74 2
10739 Deerwood Park Bivd Ste 200 E-MAIL
Jacksonville FL 32256 a�oRess:mrd reen h zel.c m
INSURER S AFFORDING COVERAGE NAIC #
INSURER A :I7AfWl11 �P.�PI:t �f1Sl1t'9IlCe CORlD91'1
INSURED NORTH 18
Northeast II, Inc. dba TC
Delivers; TC Specialties Co.
5911 Philips Hwy
Jacksonvil�e FL 32216
INSURER C
E:
COVERAGES CERTIFICATE NUMBER: 2005328511 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 SUBJEC7 TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PA�D CLAIMS.
INSR TypE OF INSURANCE ADD SU POLICY EFP POLICY EXP
LTR INSR WV POLICY NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
D GENERAL LIABILiTY CPP0021858 1/15/2016 1/15/2017 EACH OCCURRENCE $1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence 51,000,000
CLAIMS-MADE � OCCUR MED EXP (Any one person) $10,000
�
GEN'L AGGREGATE LIMIT APPLIES PER:
� POLICY n jE � � LOC
AUTOMOBILE LIABILITY
� ANY AUTO
ALLOWNED e SCHEDULED
AUTOS AUTOS
NON-OWNED
HIRED AUTOS AUTOS
UMBRELLALIAB IX I OCCUR
EXCESS LIAB h —1
I i CLAIMS-MADE
C WORKERS COMPENSATION
AND EMPLOYERS' UABILITY Y/ N
ANY PROPRIETOR/PARTNER/EXECUTIVE �
OFFICER/MEMBER EXCLUDED? N � A
CA0031819
UM60022753
WC84000321362015A
1 /15/2016 I 1 /15/2017
PERSONAL 8 ADV INJURY $1
GENERALAGGREGATE $2
PRODUCTS - COMPIOP AGG $2
$
BODILY INJURY (Per persan) $
BODILY INJURV (Per accident) $
PROPERTY DAMAGE $
Per accident
$
1/15/2016 1/15/2017 EACH OCCURRENCE
AGGREGATE
12/31 /2015 I 12/31l2016
A Prof Liability 03040680 8114/2015 8/14l2016
B Crime 82095695 1/15/2016 1l15/2017
DESCRIPTtON OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule, ii more space is required)
City of Clearwater
100 South Myrtle Avenue
Ciearwater FL 33756
CANCELLATION
E.L. EACH ACCIDENT
E.L. DISEASE - EA EMPLOYE
E.L. DISEASE - POLICY LIMIT
Prof Liab Limit
Crime Limit
$5,000,000
$
$1, 000,000
$1.000.000
3000000
1000000
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
_ ����_
O 1988-2010 ACORD CORPORATION. All rights reserved.
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