CERTIFICATE OF LIABILITY INSURANCE (19) Client#:26072 FIELDSIN
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMfDDMfY1r)
o1/13l2017
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
Bouchard Insurance(CLM E
AIC xt
NE 727 447-6481 A/c Ne:727 449-1267
101 N Starcrest Dr. AD�: cicerts @bouchardinsurance.com
Clearwater,FL 33765
INSURER(S)AFFORDING COVERAGE NAlC 0
727 447-6481 INSURER A:United Specialty Insurance Co 12537
INSURED INSURER 0:
Fields Inc.dba Barefoot Beach House INSURER C:
332 S.Guffview Blvd.
Clearwater,FL 33767 INSURER o:
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. NOTWITHSTANDINQ 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 ADD UB POCK EFF POLIC EXP
LTR TYPE OF INSURANCE R D POLICY NUMBER M/0 M OLI LIMITS
A X COMMERCIAL GENERAL LIABILITY USI550222 1/14/2017 01/14201 FAACMHp�OECTCURppRENCE $1,000,000
CLAIMS-MADE EX OCCUR MEMO, $100000
MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE s2,000,000
X POLICY❑JECCT LOC PRODUCTS-COMP/OP AGO s2,000,000
OTHER: $
A AUTOMOBILE LIABILITY USIS50222 1/14/2017 01/14/201 C._ dd."SINGLE LIMIT 110001000
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(per accident) $
AUTOS AUTOS
X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $
AUTOS Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
OED RETENTION$ S
WORKERS COMPENSATION PER OTH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETORIPARTNERIEXECUTIVE Y/N EL EACH ACCIDENT $
OFFICERIMEMBEREXCLUDED? � NIA
(Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $
It yes,desci be under
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMB I$
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,AddMonal Remarks Schedule,may be attached if more space Is required)
(See Attached Descriptions)
CERTIFICATE HOLDER CANCELLATION
City of Clearwater,A Municipal SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
ty pa THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Corporation ACCORDANCE WITH THE POLICY PROVISIONS.
PO Box 4748
Clearwater,FL 33758 AUTHORIZED REPRESENTATIVE
®1888-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) 1 of 2 The ACORD name and logo are registered marks of ACORD
#S5882181M588217 VICDE
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.
Certificate holder is additional insured as respects to General Liability only if required by written
contract,and subject to the terms,conditions and limits as specified in the policy.
SAQ T rA 25.3(2014101) 2 of 2
#S588218/M588217