CERTIFICATE OF LIABILITY INSURANCE (734)FLORI -6
OP ID: MS
'4� RL CERTIFICATE OF LIABILITY INSURANCE
DATE 07 /06DD/YYYY)
07106!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
Insurance and Risk Management
of Florida, LLC
755 W SR 434, Suite E
Longwood, FL 32750
David C Moss
CsaMNTEACT David C Moss or Marty Smith
PHONE FAX
A/C . E:d1; (A/C, No):
ADDRESS:
INSURERS) AFFORDING COVERAGE
NAIC #
INSURER A : Evanston Insurance Company
35378
INSURED Florida Playstructures &
Water Features, Inc.
1808 James Redman Pkwy, #178
Plant City, FL 33563
INSURER B: Old Dominion Insurance Company
40231
INSURER C
/0$/2017
{ '
INSURER D :
$ 1,000,000
INSURER E :
INSURER F :
X
ES
CERTIFICATE 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
LTR
TYPE OF INSURANCE
ADDL
HNSD
BUBR
WVD
POLICY NUMBER
POLICY EFF
JMMIDDIYYYI/1
POLICY EXP
(MMIDDIYYYYI
LIMITS
A
X
COMMERCIAL GENERAL LIABILITY
,_
3C07126
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/0$/2017
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EACH OCCURRENCE
$ 1,000,000
CLAIMS -MADE
X
OCCUR
PREMI MISE S o T rr
PREES ( (EE a a ocxiurenoe)
$ 100,000
MED EXP (Any one person)
$ 5,000
GE
PERSONAL& ADV INJURY
$ 1,000,000
'L AGGREGATE
POLICY
OTHER:
X
LIMIT APPLIES
JEC
PER:
LOC
GENERAL AGGREGATE
$ 2,000,000
PRODUCTS - COMP /OP AGG
$ 2,000,000
$
B
AUTOMOBILE
X
LIABILITY
ANY AUTO
AUTOOWNED
HIRED AUTOS
—
AUTOS EDDULED
NON -OWNED
AUTOS
J "
B1T0285W
51WCS DEPT
03/17/2016
03/17/2017
COMBINED DSINGLE LIMIT
accident)
$ 1,000,000
BODILY INJURY (Per person)
$
BODILY INJURY (Per accident)
$
PROPERTY DAMAGE
(Per accident)
$
$
A
X
UMBRELLA LIAR
EXCESS LIAR
X
OCCUR
CLAIMS -MADE
MKLV2OLE107874
04/29/2016
07/08/2017
EACH OCCURRENCE
$ 1,000,000
AGGREGATE
$ 1,000,000
DED RETENT ON $
$
WORKERS COMPENSATION
AND EMPLOYERS' LIABILITY Y / N
ANY PROPRIETOR/PARTNER/EXECUTIVE -
OFFICER/MEMBER EXCLUDED?
(Mandatory In NH)
If yyea deecnbe under
DESG�RIPTION OF OPERATIONS below
N ! A
PER
STATUTE
OTH-
ER
E.L. EACH ACCIDENT
$
E.L. DISEASE • EA EMPLOYEE
$
E.L. DISEASE - POLICY LIMIT
$
DESCRIPTION OF OPERATIONS I LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached If more space Is required)
CERTIFICATE HOLDER
I
CLEARWA
City of Clearwater
100 S. Myrtle Avenue
Clearwater, FL 33756
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
ACORD 25 (2014/01)
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