CERTIFICATE OF LIABILITY INSURANCE (3)DATE (MM/DDIYYYY)
ACORO� CERTIFICATE OF LIABILITY INSURANCE
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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 NAMEACT Shelley Bryant
Coleman Insurance Agency, Inc AHoNNo Ext :(727) 441-9911 A�� Na :(727) 441-9566
E-MAIL
1255 Belcher Road ���o�«. Shellev(c�ColemanAaencvFL.com
Dunedin
INSURED
FL 34698
Clearwater For Youth Inc
1501 N Belcher Rd
Suite 236
Clearwater FL 33765
COVERAGES CERTIFICATE NUMBER:
INSURER(S) AFFORDING COVERAGE
iNsuReRn: MT. VERNON FIRE INS CO
iNsuReR e: TECHNOLOGY INS CO
iNsuReRc: UNITED STATES LIABILITY INSURANCE CO
INSURER D :
REVISION NUMBER:
NAIC #
42376
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 MMIDD MM/DDIYYYY
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $'I ,OOO,OOO
CLAIMS-MADE � DAMAGE TO RENTED '� OO,OOO
X OCCUR PREMISES Ea occurrence $
MED EXP (Any one person) $ rJ,��O
A NPP2556717D 01/15/2017 01/15/2018 PERSONAL&ADVINJURY g Excluded
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $?,OOO,OOO
X POLICY � PR� � LOC PRODUCTS -COMP/OP AGG � Excluded
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accident
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
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION $ $
WORKERS COMPENSATION X STATUTE �ERH
AND EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE Y' N E.L. EACH ACCIDENT $ rJOO,OOO
B OFFICER/MEMBER EXCLUDED? �N N� E+ TWC3635556 06/16/2017 06/16/2018
(Mandatary in NH) E.L. DISEASE - EA EMPLOYEE $ 5��,0�0
If yes, describe under
DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT $ SOO,OOO
Directors and Officers -
C N D01054775K 11 /01 /2016 11 /01 /2017
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)
Certificate holder is listed as Additional Insured with respect to General Liability.
TE HOLDER
City of Clearwater
Po Box 4748
Clearwater
ACORD 25 (2016/03)
LA
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
�- i
FL 33758-4745 l `"�`"`" -"� `
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