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CERTIFICATE OF LIABILITY INSURANCE (7) ACC? ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 10/4/2016 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 Christina Hayes, CIC NAME: Stahl & Associates Insurance Inc. a/CNNo Ext: (813)818-5300 p/C No: (813)818-5396 3939 Tampa Road ADDRESS:christina.hayes @stahlinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Oldsmar FL 34677 INSURERA:FCCI Insurance Group INSURED INSURERB:National Trust Insurance Co Clearwater Golf Club LLC INSURERC:FUBA Workers' Comp 525 N Betty Ln INSURER D: INSURER E: Clearwater FL 33755 INSURER F: COVERAGES CERTIFICATE NUMBER:16-17 COI 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 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 INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMS-MADE 1X OCCUR PREMISES(E.oc ",.nce) $ 100,000 X CPP00117597 10/1/2016 10/1/2017 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY ❑ PRO JECT [::] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (CEO,accMBINED ident SINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS AUTOS X CA00170606 10/1/2016 10/1/2017 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS APer accident Uninsured motorist combined $ 1,000,000 X UMBRELLA LAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED X RETENTION$ 0 UMB00114906 10/1/2016 10/1/2017 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ N/A C (Mandatory in NH) 10653222 10/1/2016 10/1/2017 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Clearwater is listed as additional insured with respect to general liability per form CG2011 (attached) subject to the terms, conditions and exclusions of the policy. City of Clearwater is listed as additional insured with respect to auto liability per form CAU001 (Sample Attached) , subject to policy terms, conditions, and exclusions. CERTIFICATE HOLDER CANCELLATION debbie.reid @myclearwater.c SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Parks & Recreation Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 100 So Myrtle Ave Clearwater, FL 33756 AUTHORIZED REPRESENTATIVE M Pagano, AAI/HAYES �" ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025 r201401i POLICY NUMBER: CPP0011759 6 SUMMARY OF ENDORSEMENTS APPLICABLE TO ALL COVERAGES 1-UNGL-9512-MU-04, 04/04 Commercial General Liability Coverage Part Declarations IL 09 85(01 08)-Disclosure Pursuant To Terrorism Risk Insurance Act Premium: $98 APPLICABLE TO SPECIFIC STATES STATE: FL CG 00 01 (12/07)Commercial General Liability Coverage CG 00 99(11/85)-Changes in General Liability Forms for CPP CG 02 20 (03/12)-Florida Changes-Cancellation and Nonrenewal CG 20 28(07/04)-Additional Insured-Lessor of Leased Equipment Premium: $25 CG 21 49(09/99)-Total Pollution Exclusion CG 21 67(12/04)-Fungi Or Bacteria Exclusion CG 21 70 (01 08)-Cap on Losses From Certified Acts of Terrorism CG 21 86(12/04)-Exclusion-Exterior Insulation and Finish Systems CGL 026 (11/08)-Addl Ins-Owners,Lessees,Contractors-Automatic Status Premium: $100 CGL 064 (11/08)-Employment Related Practices Exclusion CGL070(07/06)-Golf Course General Liability Enhancement Endt The information that follows completes the schedule portion of this endorsement. This endorsement modifies your coverage. Please refer to the above numbered endorsement(attached)for details. Premium: $250 Number of Locations: 1 IL 00 03(09/07)-Calculation of Premium IL 00 17(11/98)-Common Policy Conditions IL 00 21 (07/02)-Nuclear Energy Exclusion (Broad Form) IL 008 (11/08)-Total Lead Exclusion IL 009 (11/08)-Total Asbestos Exclusion IL 013 (12/06)-Two Or More Coverage Forms Or Policies Issued By Us APPLICABLE TO SPECIFIC PREMISES/COVERAGES LOCATION: 1 525 N Betty Ln Clearwater, FL 33755-4799 CG 20 11 (01/96)-Additional Insured-Managers or Lessors of Premises The information that follows completes the schedule portion of this endorsement. This endorsement modifies your coverage. Please refer to the above numbered endorsement(attached)for details. Premium: $25 Name and Address:City of Clearwater 100 S Myrtle Ave Clearwater, FL 33756-5520 CG 20 02 (11/85)-Additional Insured-Club Members CG 20 08(11/85)-Additional Insured-Users of Golfmobiles CG 24 07(01/96)-Products/Completed Operations Hazard Redefined The information that follows completes the schedule portion of this endorsement. This endorsement modifies your coverage. Please refer to the above numbered endorsement(attached)for details. Description of Premises and Operations: Restaurant 1-UNGL-9512-MU-04, 04/04 PREPARED:08-27-2015 PAGE 3 OF 3 Includes copyrighted material of Insurance Services Office, Inc.with its permission. POLICY NUMBER: COMMERCIAL GENERAL LIABILITY CG 20 11 01 96 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE 1.Designation of Premises (Part Leased to You): 2.Name of Person or Organization (Additional Insured): 3. Additional Premium: (If no entry appears above, the information required to complete this endorsement will be shown in the Declara- tions as applicable to this endorsement.) WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the Schedule but only with respect to liability arising out of the ownership, maintenance or use of that part of the prem- ises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any 'occurrence"which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person or organization shown in the Schedule. CG 20 11 01 96 Copyright, Insurance Services Office, Inc., 1994 Page 1 of 1 ❑ COMMERCIAL AUTO CAU 001 (10-04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: BUSINESS AUTO COVERAGE FORM Section I I.A.1. Who Is An Insured is amended to add paragraph d. d. Any person or organization designated in the schedule below but only to the extent of the negligent acts or omissions of an "insured" under paragraph a. or b. of Section II.A.1 which cause liability to be imposed on such person or organization without fault on the part of such person or organization, during work performed by you or for you for the person or organization designated below. SCHEDULE' Person or Organization CAU 001 (10-04) Includes copyrighted material of the Insurance Services Offices, Inc. with its permission. Page 1 of 1