CERTIFICATE OF LIABILITY INSURANCE (11)� DATE (MM/DD/YYYY)
��u,�
8/7/2017
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFI�ATE HOLDER. THIS
CERTIFICA7E DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER 7HE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSU��R(S}, AUTHORIZED
F2EPRESENTATIVE OR PRODUCER, AND TNE CERTIFICATE HOLDER.
IMPORTANT: ff the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION I� WAIVED, subject to
the terms and conditions of the poficy, certain policies may require an endorsement. A statement on this certificate does w��t confer rights ta the
certificate holder in lieu of such endorsement(s).
PF20DUCER � �� NAMEA SYle2'x'y W11.t
Lancaster Insurance P"o"E (727)461-3704 FAx
�� � �,(727)441-3298
510 Druid Rd E., Ste .#C E-MA�� . Sherry@lancins . com
P O BOX 2 8 5 6 INSURER(Sl AFFORDING COVERAGE �� NAIC #
'Clearwater FL 33757 iNSUReRa:Southern-Owners Insurance 10190
i INSURED
INSURER B :
�'�, Clearwater Historical S'OC12ty IRC INSURERC:
�����, P O BOX 1% S . INSURER D:
Clearwater FL 33757-0175 INSLIRERF•
COVERAGES ������,���� CERTIFICATE�NUfViBER..����� ��..��.�������.�„�,����������,� � ���,��
� �����������������u �� •CL148707469 REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE F�Df� THE POLICY PERIOD
IIINDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RE'SPCCT 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 IADDL SUBR POLICY EFF POLICY EXP
LTR '����.. TYPE OF INSURANCE IN . R WV PQIICY NUM6EB� / ., y LIMITS
���. GENERALLIABILITY EACH OCCURRENCE $ 1, OOO, OOO
..A A ... . . 5�����
A,� ����G�kV,I��SM���FERaOCCUR X 20954975 B/�/2017 8/7/2018 MEDEXPSAnyoneuu�smy) $YAAA 10,000
PERSONAL&ADVINJUk�"� $ 1,000,000
I GENERALAGGREGATE $ 2, OOO, OOO
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP �+,,��� $ 2, 000 , 00 O
X POLICY PR� LOC ' $
AUTOMOBILE LIABILITY � IN 'I �� L �I ��.
IEa accident) '���. $
� ANY AUTO BODILY INJURY (Per �r�ror�s�;cr��r) � ��''.... $
ALL OWNED SCHEDULED BODILY INJURY (Per �ac�r��1�n0) �'���... $
I_ AUTOS AUTOS
NON-OWNED PROPERTY DAMAGE ....... $
._ HIRED AUTOS AUTOS (Per accidentl ���.
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE !$
.,_ . ...... ..._ ...... ..
EXCESS LIAB CLAIMS-MADE AGGREGATE �,�I $
� �.��.....,,���� .... .........�,.�����..�......
DED RETENTION $ �''���. $
WORKERS COMPENSATION WC STATU- 4�YTH �
�' AND EMPLOYERS' LIABILITY T(l I S FR '���.
ANY PROPRIETOR/PARTNER/EXECUTIVE ❑ E L EACH ACCIDENT I$ ��
OFFICER/MEMBER EXCWDED? N � A � �� � � � � �
�(Mandatory in NH) E L DISEASE - EA EMPLt;rYEE �'�� $ I
� If yes, describe under � ��
DESCRIPTION dF OPERATIONS below E,L. DISEASE - POLICY L�MIT $
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES (Attach ACORD 107, Additional Remarks Schedule, if more space is required)
The certifcate holder is listed as additional insured with respect to the general laibilaty insurance.
610 S Fort Harrison Ave
Clearwater, FL 33757-0175
1380 South Martin Luther King Ave
Clearwater, FL 33756
christopher . hubbdY'dlriyClH3r' ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES &�� CANCELLED BEFORE
' THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater
Attn: Christopher Hubbard
AUTHORIZED REPRESENTATIVE .
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ACORD 25 2010/05 p" 1588-2010 q�
( ) CORD CORPORATI�}N. Afl rights reserved.
INS025 (zoioos� oi The ACORD name and logo are registered marks of ACORD