CERTIFICATE OF LIABILITY INSURANCE (13) Client#:22073 RUTHECKE
DATE(MM/DD/YYYY)
ACORDIM CERTIFICATE OF LIABILITY INSURANCE 5/31/2016
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 CONTACT
NAME:
Bouchard Insurance(CLW) PHONE 727 447-6481 FAX 727 449-1267
A/C,No,Ex1: A/C,No
101 N Starcrest Dr. E-MAIL cicerts @bouchardinsurance.com
Clearwater, FL 33765 INSURER(S)AFFORDING COVERAGE NAIC#
727 447-6481 INSURER A:Zurich American Insurance Co 16535
INSURED INSURER B:American Guarantee&Liability 26247
Ruth Eckerd Hall,Inc. INSURER C:RetailFirst Insurance Company 10700
1111 McMullen Booth Rd
INSURER D:
Clearwater, FL 33759
INSURER E
INSURER F
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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
• GENERAL LIABILITY Y Y CP0017156801 5/31/2016 05/31/201 EACH OCCURRENCE $1,0005000
X COMMERCIAL GENERAL LIABILITY PREMISESOEa oNcurrDence $100,000
CLAIMS-MADE �OCCUR MED EXP(Any one person) $10,000
X BI PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000
POLICY PRO- LOC $
JECT
• AUTOMOBILE LIABILITY Y Y CP0017156801 5/31/2016 05/31/201 C Ea M accidenO .iden t S INGLE LIMIT $1,000,000
Ix ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
HIRED AUTOS X NON-OWNED PROP ERTY DAMAGE $
AUTOS Per accident
B X UMBRELLA LIAB X OCCUR AUC967294107 5/31/2016 05/31/201 EACH OCCURRENCE $105000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000
DED I X RETENTION$O $
WC STATU
C WORKERS COMPENSATION 052046229 1/01/2016 01/01/201 X T RYII ER"
AND EMPLOYERS'LIABILITY
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? �
N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
A Abuse/Molestation GLCO17156901 05/31/2016 05/31/2017 $1,000,000/$1,000,000
RET RO: 05/31/2013
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
(See Attached Descriptions)
CERTIFICATE HOLDER CANCELLATION
CITY OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX 4748 ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater, FL 33758-4748
AUTHORIZED REPRESENTATIVE
@ 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S459898/M459890 KIMCA
DESCRIPTIONS (Continued from Page 1)
NOTICE:
Bouchard Insurance is required to comply with the licensing agreement we hold with ACORD.
ACORD, in conjunction with the Department of Insurance,creates and enforces the rules and regulations
pertaining to proper use of the Certificate of Liability Insurance form.
We are required to mark a Y next to the line of business in which the Additional Insured or Waiver of
Subrogation coverage applies.According to ACORD,the Description of Operations section must be limited
to describing information necessary to identify the operations, locations and vehicles for which the
certificate was issued. Please note the Description of Operations section of the Certificate cannot be
used to add additional information except as just described. Marking a Y next to the line of business
adequately documents coverage. Equally important, it satisfies the rules and regulations governing the
proper use of the Certificate of Liability Insurance form.
Certificate is a reflection of the current coverages provided for the insured. Limits and coverages are
afforded to the certificate holder only if required by written contract.
Owner of Land
Loc#1 -1111 McMullen Booth Rd; Clearwater,FL
Building#1 Theatre&Education Wing
Building#2 Utility Building and Cooling Tower
Building#3 Studios
SAGITTA 25.3(2010/05) 2 of 2
#S459898/M459890
Client#:22073 RUTHECKE
DATE(MM/DD/YYYY)
ACORDIM CERTIFICATE OF LIABILITY INSURANCE 5/31/2016
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 CONTACT
NAME:
Bouchard Insurance(CLW) PHONE 727 447-6481 FAX 727 449-1267
A/C,No,Ex1: A/C,No
101 N Starcrest Dr. E-MAIL cicerts @bouchardinsurance.com
Clearwater, FL 33765 INSURER(S)AFFORDING COVERAGE NAIC#
727 447-6481 INSURER A:Zurich American Insurance Co 16535
INSURED INSURER B:American Guarantee&Liability 26247
Ruth Eckerd Hall,Inc. INSURER C:RetailFirst Insurance Company 10700
1111 McMullen Booth Rd
INSURER D:
Clearwater, FL 33759
INSURER E
INSURER F
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 CONTRACTOR 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSR WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
• GENERAL LIABILITY Y Y CP0017156801 5/31/2016 05/31/201 EACH OCCURRENCE $1,0005000
X COMMERCIAL GENERAL LIABILITY PREMISESOEa oNcurrDence $100,000
CLAIMS-MADE �OCCUR MED EXP(Any one person) $10,000
X BI PERSONAL&ADV INJURY $1,000,000
GENERAL AGGREGATE $2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $2,000,000
POLICY PRO- LOC $
JECT
• AUTOMOBILE LIABILITY Y Y CP0017156801 5/31/2016 05/31/201 C Ea M accidenO .iden t S INGLE LIMIT $1,000,000
Ix ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
HIRED AUTOS X NON-OWNED PROP ERTY DAMAGE $
AUTOS Per accident
B X UMBRELLA LIAB X OCCUR AUC967294107 5/31/2016 05/31/201 EACH OCCURRENCE $105000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $10,000,000
DED I X RETENTION$O $
WC STATU
C WORKERS COMPENSATION 052046229 1/01/2016 01/01/201 X T RYII ER"
AND EMPLOYERS'LIABILITY
Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $1,000,000
OFFICER/MEMBER EXCLUDED? �
N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
A Liquor Liability CP0017156801 05/31/2016 05/31/2017 $1,000,000/$25000,000
A Abuse/Molestation GLCO17156901 05/31/2016 05/31/201 $1,000,000/$1,000,000
RET RO: 05/31/2013
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required)
(See Attached Descriptions)
CERTIFICATE HOLDER CANCELLATION
CITY OF CLEARWATER SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
PO BOX 4748 ACCORDANCE WITH THE POLICY PROVISIONS.
Clearwater, FL 33758-4748
AUTHORIZED REPRESENTATIVE
@ 1988-2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010105) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S459904/M459892 KIMCA
DESCRIPTIONS (Continued from Page 1)
NOTICE:
Bouchard Insurance is required to comply with the licensing agreement we hold with ACORD.
ACORD, in conjunction with the Department of Insurance,creates and enforces the rules and regulations
pertaining to proper use of the Certificate of Liability Insurance form.
We are required to mark a Y next to the line of business in which the Additional Insured or Waiver of
Subrogation coverage applies.According to ACORD,the Description of Operations section must be limited
to describing information necessary to identify the operations, locations and vehicles for which the
certificate was issued. Please note the Description of Operations section of the Certificate cannot be
used to add additional information except as just described. Marking a Y next to the line of business
adequately documents coverage. Equally important, it satisfies the rules and regulations governing the
proper use of the Certificate of Liability Insurance form.
Certificate is a reflection of the current coverages provided for the insured. Limits and coverages are
afforded to the certificate holder only if required by written contract.
Four parking spaces in#49-52 in City Owned Parking Lot
Loc#2-405 Cleveland Street; Clearwater, FL
Building#1 Capital Theater
Loc#4-112 Osceola Ave; Clearwater, FL
SAGITTA 25.3(2010/05) 2 of 2
#S459904/M459892