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CERTIFICATE OF LIABILITY INSURANCE (8) ACC? ® DATE(MM/DD/YYYY) CERTIFICATE OF LIABILITY INSURANCE 9/28/2017 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 Christina Hayes, CIC NAME: Stahl & Associates Insurance Inc. a/c NNo Ext: (813)818-5300 p/C No: (813)818-5396 3939 Tampa Road ADDRESS:christina.hayes @stahlinsurance.com INSURER(S)AFFORDING COVERAGE NAIC# Oldsmar FL 34677 INSURERA:FCCI Insurance Group INSURED INSURERB:National Trust Insurance Co Clearwater Golf Club LLC INSURERC:FUBA Workers' Comp 525 N Betty Ln INSURER D: INSURER E: Clearwater FL 33755 INSURER F: COVERAGES CERTIFICATE NUMBER:17-18 COI 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 ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 A CLAIMS-MADE 1X OCCUR PREMISES(E.occurrDence) $ 100,000 X CPP00117597 10/1/2017 10/1/2018 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 X POLICY ❑ PRO JECT [::] LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY (CEO,accMBINED ident SINGLE LIMIT $ 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ B ALL OWNED SCHEDULED AUTOS AUTOS X CA00170606 10/1/2017 10/1/2018 BODILY INJURY(Per accident) $ NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS APer accident Uninsured motorist combined $ 1,000,000 X UMBRELLA LAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LAB CLAIMS-MADE AGGREGATE $ 1,000,000 DED X RETENTION$ 0 UMB00114907 10/1/2017 10/1/2018 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 500,000 OFFICER/MEMBER EXCLUDED? ❑ N/A C (Mandatory in NH) 10653222 10/1/2017 10/1/2018 E.L.DISEASE-EA EMPLOYE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Clearwater is listed as additional insured with respect to general liability per form CG2011 (attached) subject to the terms, conditions and exclusions of the policy. City of Clearwater is listed as additional insured with respect to auto liability per form CAU001 (attached) , subject to policy terms, conditions, and exclusions. CERTIFICATE HOLDER CANCELLATION debbie.reid @myclearwater.c SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Parks & Recreation Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 100 So Myrtle Ave Clearwater, FL 33756 AUTHORIZED REPRESENTATIVE M Pagano, AAI/HAYES .. °° ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS025(201401) COMMERCIAL GENERAL LIABILITY CGL 026 (11 08) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - OWNERS, LESSEES OR CONTRACTORS - AUTOMATIC STATUS WHEN REQUIRED IN CONSTRUCTION AGREEMENT WITH YOU - LIABILITY FOR ACTIONS OF NAMED INSURED This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM This endorsement is subject to the terms, conditions, exclusions and any other provisions of the COMMERCIAL GENERAL LIABILITY COVERAGE FORM or any endorsement attached thereto unless changes or additions are indicated below. Section II - Who is an Insured is amended to include as an insured any person or organization for whom you are performing operations when you and such person or organization have agreed in writing in a contract or agreement that such person or organization be added as an additional insured on your policy. Such person or organization is an insured but only with respect to your negligent actions, which cause liability to be imposed on such person or organization without fault on the part of said person or organization, caused by "your work" performed for that insured. All policy exclusions relating to you in the Commercial General Liability Coverage Form, including any exclusions added by endorsement, shall apply to any additional insureds herein. With respect to the insurance afforded to these additional insureds, the following additional exclusion applies: This insurance does not apply to "Bodily injury", "property damage" or "personal and advertising injury" arising out of the rendering of, or the failure to render, any professional architectural, engineering or surveying services, including: 1. The preparing, approving, or failing to prepare or approve, maps, shop drawings, opinions, reports, surveys, field orders, change orders or drawings and specifications; or 2. Supervisory, inspection, architectural or engineering activities. This endorsement does not apply to any Additional Insureds scheduled on the CG 20 10, CG 20 37, CGL 005 or CGL 021 endorsements, when any of those endorsements are also attached to the Commercial General Liability Coverage Form. CGL 026 (11 08) Includes copyrighted material of the Insurance Services Office, Inc., with its permission. Page 1 of 1 Copyright 2008 FCCI Insurance Group. POLICY NUMBER: CA14(1045184 -02 COMMERCIAL AUTO CAU 001 (10-04) THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the faring: BUSINESS AUTO COVERAGE FORM Section HIA1. Who Is An Insured is amended to add paragraph d. d. Any person or organization designated in the schedule below but only to the extent of the negligent acts or omissions of an insured under paragraph a. or b. of Section II A.1 which cause liability to be imposed on such person or organization without fault on the part of such person or organization, during work performed by you or for you for the person or organization designated below. Person or Organization City of Clearwater Parks & Recreation Dept CAU 001 (10-04) Includes cop SCHEDULE of the Insurance S *ass cnur Offices. Inc. with Its permission. Page 1 of 1