CERTIFICATE OF LIABILITY INSURANCE (4).� � DATE (MM/DD/YYYY)
, CERTIFICATE OF LIABILITY INSURANCE �vo���o,s
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
MARSH USA INC.
540 W. MADISON
CHICAGO, IL 60661
Attn: chicago.CertRequest(�Dmarsh.com
INSURED
CorVel Healthcare Corpora6on
Attn: Jay Villeda
2010 Main SVeet, Suite 600
Irvine, CA 92614
iNSUReR a: Travelers Property Casualty Company of America
iNSUReR a: XL Specially Insurance Company
iNSUReR c: Illinois Union Insurance Company
INSURER D :
INSURER E :
COVERAGES CERTIFICATE NUMBER: CHI-006039811-80 REVISION NUMBER:3
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTIMTHSTANDING 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 NUMBER MM/DD/YYYY MM/DD/YYYY LIMITS
LTR
A X COMMERCIAL GENERAL LIABILITY TJGLSA280K5095-16 0413012016 04I3O/2017 EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED
CLAIMS-MADE X OCCUR PREMISES Ea occurcence $ �,��0,���
MED EXP (Any one person) $ 10,00�
PERSONAL & ADV INJURY $ 1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERA� AGGREGATE $ 2,000,000
POLICY � PR� � LOC PRODUCTS - COMP/OP AGG $ 2,OOQ000
JECT
OTHER: $
A AUTOMOBILE LIABILITY TJCAP280K5102-16 0413012016 04130/2017 COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
X ANY AUTO BODILY INJURY (Per person) $
ALL OWNED SCHEDULED BODILY INJURY (Per accident) $
AUTOS AUTOS
X X NON-OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
Comp.IColl. Ded. $ 500
B X UMBRELLA LIAB X OCCUR US00067014LI16A 0413012016 04I3012017 EACH OCCURRENCE $ 1,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 'I,OOO,OOO
DED X RETENTION $1 O 000 $
A WORKERS COMPENSATION TC2JU6280K5071-16 (AOS) 04/30/2016 0413012017 X STATUTE �RH
AND EMPLOYERS' LIABILITY
A ANY PROPRIETOR/PARTNER/EXECUTIVE Y� N/ A TRJUB280K5083-16 (AZ, MA, NE, WI� 04/3012016 O4/3OI2O'I% E.L. EACH ACCIDENT $ 'I,OOO,OOO
OFFICER/MEMBER EXCLUDED?
(Mandatory in NH) E.L. DISEASE - EA EMPLOYE $ 1,0�0,���
If yes, describe under 1,000,000
DESCRIPTION OF OPERATIONS betow E L DISEASE - POLICY LIMIT $
C Managed Healthcare Prof. Liab. MSP G27108647 004 (SIR: $300,000) 10/31I2016 10/3112017 Per Claim 5,000,000
Retro date: 04-10-1987 Aggregate 5,OOQ000
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
City of Clearwater is Additional Insured with respect their interesl.
CERTIFICATE HOLDER
City of Clearwater
Attn: John Marcin
100 S. Myrtle Ave.
Clearvvater. FL 34616
ACORD 25 (2014/01)
CANCELLA
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
of Marsh USA Inc.
Manashi Mukherjee ..'�3�i.a.uaea�..: �..�-eR.
O 1988-2014 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD