CERTIFICATE OF LIABILITY INSURANCE (3) f/19I20'15 CerfificatesN!ovi tTy Ebix BPO
;d,/r0r9l'A(/t United.States Swimming, Inc, CLEARWATER AQUATIC TEAM
Risk Management Services, Inc,
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS i
CERTIFICATE DOES NOT AF'F'IRMATIVELY 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 he endorsed. If SUBROGATION IS WAIVED,
subject to the terms and conditions of the policy, certain policies may require an end'orse'ment.A.statement on this certificate does
not confer rights to the certificate holder in lieu of such endorsement(s),
PRODUCER P; 1-602-540°3234 CON FACT
P.O. Management 3271 Services�, Inc. (A/C, No. Exk): (C�T2) 640-3 234 .:
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P.O. L3r�r 3271.7 FAX..
QA/C, Nta1:
Phoenix, Al 85064..2M2 E-MAIL
�ADORESS. Info(c,thC rlrakpeople,corn
INSURED INSURER(S) AFFORDING COVERAGE NAIL#
CLFARWATE;R AC)UATiC TEAM INSURED A: NATIONAL CAS CO I1H111
USA SMmminy, Inc dba USA Sviumrrning --
1,5101 N BELCHER ROAD, SUITE 229 INSURED 13; MUTUAL OF OMAHA, INS CO 71412
INSURED C:
C:L.EARWATEi�R, FIL 33165-13:35 _
INSURED D:
INSURED E:
p INSURED F;
TIFICATE NUMBER; REVISION NUMBER:
COVERAGES CImR.__._..._�__. ... �..� ......__.._... __._._.m . ...._. i
Tt4I5 IS iO CERTIFY THAI ]HE POL.ICIIES UF' XN$UFRANCE LISTED EEIrQV' HAVE BEEN ISSUED TO THE INsUI IED NAMED AF3C?'VE F3Ff, Itl91i'':. P'cJLfCI' E�E_F�IICJC) IN'..I'.7
N'O1'M`w TH S I J"rNJING ANY RLUUIRLMENT,TERM OR CONDITION OF ANY(CON RAC'd OR O f HE F DOCUMEN"I"W'I fE ITESF LC".B I O VIRICH PHIS CE RnFICATE:MAY P1 ISS'UFI a i,10 j
MAY F'F RTAIN,THE INSURANCE Af"FORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,F::XCL.USIONS AND CONDITION'S 01 SLJC H f'GLICAI.S.
LlhJlrTS S'HC7V`e+N MAY f9AVIL BEEN FZEGt.ICEp BY PAID CLAIMS.
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NNSR TYPE OF INSURANCE 7138PRLD SUE3R F OLICY Ij BER POLICY EPF POLICY EXR LIMITS
L.."6"l'F XD kKC�C CJCC?iltl F 4�6Q3,1ML9 ,1n tLl f.ID Ar"�'"c'Yt _.
A GENERAL.LIABILITY / / EACH- OCCURRENCE= F,
Xl RENTED 1 47OO,I17iL
1 � COMMERCIAL LIABILITY DAMAGE TO __.
I9 CLAIMS-MADE jXj OCCUR PREMISES (Ea
IXI Abu>,e/MOEesta Lion y.. :.: h�ss.Y'FXFS2 11-L-0 0[9 CDtl
j pant a
POLICY PRO.]
N L.ACICIREGATE tIM1I "Af�l)t.9L.S PER.
,. � ( PROJECT jX L..O�C �A� one C,rwcs� $ s,4JUC:
T PERSONAL&ADV
! CbT'HEP: INJURY
$ 1 u0u rJ01l1 i
GENERAL.AGGRE GAT F° 4 NO1 IMII'mm m
PRC)I7UCTS . COMP/OP
G .._ Y 1t)O,C l9[Y
AUTOMOBILE LIABILITY COMLINFU SINGL..E
T ANY AUTO 1..11111
ALL OWNED AUTOS R 'SCHEDULED AUTOS
HIRED AUTOS I I I NON-OW NED AUTOS BODILY INAjRY
jI 81 (Per ersan) ...�....W�...
f
BODILY INSIIRM�
(Per accident) $
PROPERTY DAMAGE"
A [I UMBRELLA IxI OCCUR X X XR00000005847700 01/01/16 01/01/17
EACH OCCURRENCE
LIAR CLAIMS $
jXl EXCESS LIAB 1I MAD
j AGGREGATE, $
�I DED RETEN'fION
m . _._.._.... ..... ...
I8 :
EMPLOYERS'COMPENSATION AND
PER _j.
�.... _.._._
WORKERS RS"LIABILITY STATUTE R
(G �iOTHF:
ANY Y/N E.L., EACH ACCIDENT .w._._.
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7,r19/2016 Certificates'Now by Ebix BPC
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PROP RIETOR/PARTNER/EXFCUTIVF}
OFFICER/MEMBER EXCLUDED? E.L. DISEASE- EA
(,Mandatory in NH) EMPLOYEE
� E.LDISEASE- POLICY .._...._.�._ ..
If yes, describe under DESCRIP"f'ION OF E.L.
LIMIT
OPERATIONS below $
R OTHER 41/01,/16 01/01/1I Maximum Ur nit $ 1 ju)
XS Accident-Medical SR2414M0-P-435454
DESCRIPTION OF OPERATIONS/LOCATIONS/"VEHICLES(Attach ACORD 101, Additional Remarks Schedule, If more space Is required).m
Verification of General Liability, Excess Liability &Abuse,/Molestation coverage for COVERED ACTIVITIES,
Abuse/Molestation Aggregate on the General Liability Policy is $5,000,000, Abuse/Molestation is excluded in the
Excess(Liability Policy. Excess Medical/Dental Accident coverage Provided for members only. The Certificate
Holder is included as Addidonal Insured per attached ADDITIONAL INSURED ENDORSEMENT EFFECTIVE CERTIFICATE ISSUE DATE..
134 DAY CANCEL LAfION PER POLICY PROVISIONS*
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLIC:IES BE CANCELLED BEFORF,
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Clearwater ACCORDANCE WITH THE IfPOLICY PROVISIONS.
C/O Athietics Office Authorized Representative
Gary Brokaw Carolyn I dlumt �__._y__- ._ .�1
745 N fMlissriorl Ave �..,. „....y... .. w-o _._..
Clearwvatcr FL,33755-4321
LISA
C> Lg88-2EuL4�ACORD CORPORATION. All rights reserved.
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ACORD 2.5 (2014/01)The ACORD name and logo are registered marks of ACORt2
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