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CERTIFICATE OF LIABILITY INSURANCE (17) DATE(M A�" CERTIFICATE OF LIABILITY INSURANCE M/DD/YYYY) 2/DATE(M 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 have ADDITIONAL INSURED provisions or 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 NAME: Linda Waldorf Brown &Brown Insurance-Clearwater 727-461-6044 FAX 83 Park Place Blvd., Suite 101 M20%, A/c N°: 727-442-7695 Clearwater FL 33759-3925 ADDRESS:Iwaldorf @bbpinellas.com INSURER(S)AFFORDING COVERAGE NAIC# INSURER A:National Casualty Company 11991 INSURED CHICHIR-01 INSURERB:Zenith Insurance Company 13269 Chi Chi Rodriguez Youth Foundation, Inc. INSURERC: 3030 McMullen Booth Rd. Clearwater FL 33761 INSURER D7 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 742786688 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 POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYY MM/DD/YYY A X COMMERCIAL GENERAL LIABILITY KK00000006058400 2/1/2017 2/1/2018 EACH OCCURRENCE $1,000,000 IX OCCUR PREMISES TORENTED CLAIMS-MADE PREMISES Ea occurrence) $300,000 MED EXP(Any one person) $5,000 PERSONAL&ADV INJURY $1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $None POLICY ❑ PRO JECT [::] LOC PRODUCTS-COMP/OPAGG $1,000,000 OTHER: $ A AUTOMOBILE LIABILITY KK00000006058400 2/1/2017 2/1/2018 COMBINED SINGLE LIMIT $ (Ea accident) 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY (Per accident) X PIP$10,000 $ A X UMBRELLA LAB X OCCUR XK00000006058500 2/1/2017 2/1/2018 EACH OCCURRENCE $1,000,000 EXCESS LIAB CLAIMS-MADE AGGREGATE $1,000,000 DED X RETENTION$0 $ B WORKERS COMPENSATION Z836521216 2/1/2017 2/1/2018 X PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER 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 KK00000006058400 2/1/2017 2/1/2018 Per Occurrence 1,000,000 Aggregate 1,000,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe attached if more space is required) Certificate holder is an Additional Insured with respect to General Liability if required by written contract. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P. O. Box 4748 ACCORDANCE WITH THE POLICY PROVISIONS. Clearwater FL 33756-5520 AUTHORIZED REPRESENTATIVE ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD