CERTIFICATE OF LIABILITY INSURANCE (8) CERTIFICATE OF LIABILITY INSURANCE WDDVYYYYa
0312/12017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIR'MATIV'ELY 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 INSURER?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 endors'ement(s
PRODUCER NAQM ACr Sam Muiradyan.....�....r..
Liberty United Insurance Services,Inc. PHONE 8)688-3788 rAx 888 '
X6005 Vineland Avenue, Suite 203 gNzfatl � ) 1 s�uses
ADDRr ss Smlb nsurance.com dNOith Hollywood,CA 91606
License : OF89841 __ it?sI�RE s A�RIYENf3COYrERA E �.. __ NAIL#
_- _ .. ..._......
—. _INSkiRERa�1 Ini r�.+_ Mte Fire rIS.R t 1I1r a
INSURED INSURER a
All Around Amusements INSURERC-
4001 Willow Hills Ct. INSURER D:
Plano,TX 76024 INSURER
INSURER F
COVERAGES CERTIFICATE NUMBER: 00000000-0 REVISION NUMBER: 109
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTER)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.
II ..-..
.. MYNCE 7p]l SUS R M RY a YY'
" ..."
"URA . POLCY NUYBER MDDIY`YY MLQI?YYI LIMITS
A MERCIAL GENERAL LIABILITY Y I ___ ._...,..
SRPGP-101-07116 0311612017 0311612018 EACH OCCURRENCE $ ...1,000,!Ol�,@,_.
b&MitiO Y5 Nro._ .m,.. -
CLAIMS-MADE � �.�OCCUR P ML FS.S Par[ ce ..... ..._...._. ,(, ,000
_.. _ .. ...... ME EXP(Any. p l $ 5 000
PERSONAL_IIADVINJURY $ ____IJ000'1000
E ..�C..AT LIMIT A IPLGES PER, ........_.
O. POLICY JE L C PROCI�LICTS _
N L AH GREGAT �c GENERAL ERAL AGGREGATE----__P O--A s... 41Qi I, "
00 _
OTHER': S
AUTOMOBILE UABIUTY COMBINED SINGLE LIMIT' -S
ANY AUTO ...,.. BODILY dINJURY(Per person)
;s
�........... .... _�,,,�, .,........ .._..n,...,.,,�..
OWNED, SCHEOULELS BODILY INJURY[Per accident S
.... AUTO'S CdNLY _.�. AUTOS _... R .._ ..__......
AUTOAU7NON-OWNED S LY -PRiyPERTM'IaAMAC.E .....
AUTOS ONLY AUTOS ONLY r-t� -�c��9 � ...., $
I � S
A ',.m UMaBRELLALL LIAB �___[CLAIMSWADE OCCUR TBI 0311.612017 03116/2018 F6C!j qqG y WREN E S 4x000_,000
EXCESS LIAR AGGREGATE .. $ . 4,000 990
GIEO RETENTIONS $
WORKERS COMPENSATION I'�ER C1"I'HI-
AND EMPLOYERS'UABIUTY 'YIN _,�. STATU,T.,.... ER_. ........................ '.....
ANY PROPMETORIPARTNEPiEXEGUTIVE E L.EACH ArCCIgENT $
OPFICER)MEMBER EXCLUDED? � NIA
'. 'm........^ _-
RMandatrrry In NHI E L,DISEASE-EA LMPLOYE $
It yyes descriLra und�3t
... .........
DESCRIPTION OF OPERATIONS Geivaa E.G..DISEASE-POLICY I.I'MIIT $
I
DESCRIPTION OF OPERATIONS)LOCATIONS I VEHICLES(ACORD 101,Additianal Remarks Schadute,may be attached IM mom space Is required)
Certificate Holder Is An Additional Insured
Scheduled activities exclusion endorsement applies:Mechanical Bucking Devices:including Multi Bide Attachments,Zip Line,
Trampolines,&Permanent Rock Wall Structure.
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
Parks& Recreation ACCORDANCE WITH THE POLICY PROVISIONS,
PC) Box 4748
Clearwater, FL 33758 AUTHORIZED RERRESENTAT7VE
11 K__ ____ ,,, SMS
1988-2015 ACORD CORPORATION, All rights reserved.
ACORD 25('2016103) The ACORD name and logo are registered marks of ACORD
Printed by SMS on March 21,201'7 at 11:1 SAM
ACm.:M �.... .... ..
~. CERTIFICATE OF LIABILITY INSURANCE DATE i o/YYYY)
THIS CERTIEICATEISISSUEDAS AMIATtf R OF INFORMATION ONLYANDCON. � �. C - THIS CERTIFICATE DOE ELY NEGATIVELY
. CONFERS NO _. ��..._DOES
AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING I NS U RER('S)„
AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT1If the certificate holder is an ADDITIONAL INSURED,the policy(,res)must have ADDITIONAL INSURED provisions or be endorsed.IISUBRO GAT]ON IS WAIVED,sutr,lect 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 1 Ileu of such endorsement(s).
PRODUCER CONTACT
NAME:.
12655 N Central Campbell(355231J)
Ex23 Ste 425 (A/C ND,EXT) 214-42Q_75CICl w __. _.., L(4/C,PHONE py NO):214-420-7501 .._
E-MAIL
Callas TX 75243-3747 ADDRESS: tcamphe112 @farmersagent.com
INSURERS)AFFORDING COVERAGE NAIC WI
_......... . ._.. mm..__._..._ww.. w.__ .__..._w _._..... .
INSURED INSURER A: Truck Insurance Exchange 21709
NNSURER.B: Farmers Insurance Exchange 21652
ALL AROUND AMUSEMENTS LLC -.... - __..
INSURER c Mid Century Insurance Company 21687
4001 WILLOW HILL'S OT ..-.. .___.- _..... .
INSURER D: Farmers Texas County Mutual Insurance Company 24392
._. ._
—INSURER E:
PLANO TX 75024 ._ ...__._.._ _._._..�.. _..m
INSURER R
COVERAGES CERTIFICATE NUMBER: REVISION'NUMBER:
I HIS 15 TO,CERTIFYTHATIHiE POLICIES OF INSURANCE.LISrED BELOW HAVE BEEN ISSUED TOIHE INSURED NAME ABOVE FOR THE:POLICY PE.RIW WITHSTANDING �
N I I i STAN DI NG ANY
REQUIREMENT,TERM OR CONDI"TION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BF 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 SHAWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
NNSR ADDTL SUBR POLIC
NSURANCE YEFF POLICY'EXP LIMITS
ETR TYPEOFI' INSD WVO POLICY (MM/DD/YY-YY) (MM/DD/YYYY)
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
.
CLAIMS MADE OCCUR DAMAGE TO RENTED -
PREMISES(Ea Occurrence)
MEDF-KP(Anyoneperson) S
PERSONAIITBWADVINJURY
CEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $
POLICY PROJECT LOC PRODUCTS-COMP/OPAGG $
AUTOMOBILE LIABILITY COMBINED'SINGLE LIMIT uW W $
(Ea accident) 1 1Jt1O,041
ANY AUTO) BODILY INJURY(Per person) $
OWNEDAUTOS x SCHEDULED
D ONLY AUTO'S y 605828159 04/0212017 04/021'201$ BODILYIN)URY(Perac orient)
HIRLDAUT05 NOS N-OWNED PROPERTY DAMAGE $
ONLY AUTOS ONLY (Per accident)
�.._....... $ .._..
..._........... �. .�..... ..._... ._..,.... ...__........._., ................... ...........�,,.,., ..........._._. .........�..�........
UMBRELLALIAS OCCUR. EACHOCCURRENCE '$
ExCESSt.lAB CLAIMS-.MADE AGGREGATE $
...
DED- - RETENTIONS $
WORKERS COMPENSATION PER OTHER
AND EMPLOYERS'LIABILITY SIATUTEi
ANY PROPRIETOR/PARTNIER/ YIN E.L.EACH ACCIDENT $
EXECUTIVE OFFICER'/MEMBER NIA _.
EXCLUDED?(Mandatoryin NH) F E.L.DISEASE-EAEMPI.OYEE
If yes,descdbe under DESCRIPTION OF
OPERATIONS below EA DISEASE-POLICY LIMIT $
m. _...._ —. __...._. _... .. _. _..._...... _.
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached If more space is required)
2008 DODGE RAM 3500 G;'VIN:3D7MX48AX8G161745
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION �
PARKS AND RECREATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITHTHE POLICY PROVISIONS.
PO BOX 4748 AUiTHORIZEDREPRESENTATIVE MAGGIE KIRK
--Ci-EARWATEFI. ......_. _ '.t, 33Z5.&— _ ... ... ....... _ _.... ... ...... -
ACORD 25(2016/03) (F)1988-2.015 ACORD CORPORATION,All Rights Reserved
31-1769 11-15 The ACORD name and lorao are Ireaistered marks of ACORD