CERTIFICATE OF INSURANCE CERTIFICATE OF INSURANCE
SPECIAL EVENT LIABILITY GROUP INSURANCE TRUST,A RISK PURCHASING GROUP
REVlSED C I, 74BX
...............
AGILITY OWNER-Additionai InSUred: (if rinultiple,continued PRODUCER: CA License#0757776
on next page)
HUB International insurance Services Inc.
PaSCO COUnty.'227 Land O'Lai eF,Boulevatd,Lanal 0'1_aaes FIL 34638- P.O, Box 4047
2826 Concord,CA 94524-4047
PH:925 609 6600 FX:925 609 6550 sre c,i a reve i i t�c avobi otle rn all o n a co m
E 'EISkT HOLDER-Named llnsured°(it multiple,continued on EVENT INFORMATION
next page)
Tampa Bay Balle. TYPE OF EVENT: fnstnicloi,
1584", Martha Circle EVENT DATE(S): I/18-12/31/2017
Lutz,PL 33549
[EVENT LOCATION(S): Variou Pa,,ico,-oLinly 1 londa Scho,,-)!r;Poi thf,!,11o':Jo,d iV
ic
io oer°ry thal Me poiii-Jes of insurance lisle berow have,bpen y,5uP"d lo the amve forme evew ciatefs) nclicated above Notwithslandinq _ny requirement `emi or
Condition of umy oomra,",tur oltherdocunicrAl vAlh respec.to mrico,tlw�(,(nhftcare may br is.,Ued or nay P�uaiq,tile rusk ffanCO afto.,dc,,d by the frelicPos closcnihorS herein e subject to,V the tP.,rim-
exclusions and cond=iions of such Prlicips
This insurance is issued purswant to the 1 Jonda Surplus i nes t,a,, Person,,insured by Su,131us U110', dQH01,have[lie protection of the Florda lnsurapc.e Guopjwy Ao to It*ex era t of
,any right of recovery for Inc,-obligialion Lif an wsoiver[unl:censed n&jrer.
INSURER k COLONY INSURANCE COMPANY
INSR LTR Type of Insurance Policy Number Effective Expiration, Policy Linifts,
Each Occurrence $1,000,000
Ge.n e re 1 Ag g reg a to $2,000,000
......................
Porsonal&Advertising Injury $1,000,ODO
Prod uotsfComplouid operations $2,000,000
Commercial ----g re gate - -
A General Liability AR 6360147 11112017 1M12018 DarhagotoPrermies—Rentedto $500,000
1!!=211-111 I P 11 y"I I n—te $5,000
Liquor Liability Each Occurrence
(ggregate included in General NIA
Liability Aggregate)
COVERAGE TERMS
Occurrence Forrin(GG 0001)
Host Liquor la lily InClUded. The coverage afforded by this irisuranco is primary and Piet contributing with any insuriurice hold by the"ADDITIONAL INSURED".
WHEN REQUIRED BY wkiTrEN CONTRACT, The limits of insurance apply separately to each event insured by this policy as if a
separate policy of insurance has been issued too,that event, Who is an insured is aniorided to include as an additional insured the
`T acrIfty,Owner.-Add tonal Insured"above and any person or organ ization shown intho 5c had ule below, This insurance doess not
11
Full 1-squor Liability incloded when a apply to: any"PlCrmnince"which takes plaGo after Ole,event holder ceases to be a tenant in that premises. Thill insurance applies
sate pa rate ore ni I u ni,has tbe e n charmed. offlyte! an`occurrence"which takes place during the dates mdrated under"Event information"above.
All participants in athletic activities are
Etgjjjred to sign Release and Waiver of
Liability forms.
COVERAGE EXCLUSIONS:(REFER TO POLICY FOR COMPLETE LISTING OF EXCLUSIONS)
Sexual Abuse&MolestaUon Specific Events are excluded from coverage. Please see second page for list of excluded events.
Terrorism 1 On behalf of the Risk Purchasing Group and each Member,the Trustee has declined coverage for the Terrorism Risk
Insurance Act(TRIA).
Additional insureds, next page—
Second Page of Certificate erfificate RR 74830
OTHEP ADDITIONAL INSUREDS:
1 Woodland Elementary-38203 Henry Dr.,Zelonyrhills, FL.33542
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2 New River Eiernentaiy-47H0 River Glen Blvd-Wesley Chapel. FL 33545
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3 IMPLES(PAMye P, !-ocke)Elementary-4339 Evans Ave, New Port Richey,FL 34652
——-------- ....
4 Hudson Elementary-7229 Hudson Ave., Hudso r! 3466-7
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5 James M. Marlowe Elementary School-5642 Cecelia Dr- New Port Richey, FL 34652
................... .................
6 Gulfside Elementary-2329 Anclote Blvd.,Holkday, F:L 34691
7 Seven Sphngs Elementary-8025 1Mhtcheil Ranch Pd.,New Port,Richey, FL 34655
8 Cypress Elementary--10055 Sweet Bay Gt. New Per,,Richey,FL 34656
..............
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9 Longleaf Elementary, 3253 Town Avenue.New Port Richey FL 34655
10 Double Branch Elementary, 31500 Chancey Blvd. Wesley Chapel, FL 33545
11 Richey Elernenwry School,6850 AdarnsnStreet,New Port Richey,Fl-34652
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12 'Wesley Chapel Elementary,30243 Wells Road,Wesley Chapel,FL 33545
13 Sunray Elementary,4815&Mray Drive.Holiday,Fl-34690
.......... .......
14 Chasco Elementary,7906 Ridge Road,Port Richey, FL 34668
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15 Sunlake High School,3023 Sunlake Blvd.,Land O'Lakes, FL,34638
Additional Insureds,continue to next page-
Third Page of Certificate Certificate# 74830
OTHER ADDITtONAL INSUREDS�
16 Anclote Elementary,3610 Madison Streel New Port Richey FL 34652
17 Sari Antonio Elernentary, 32416 Darby Read,Dade City, Fl- 33525
..........
18 Northwest Elementary 14302 Cobra Way, Hudson. FL 34669
19 Veterans Elenerqary,26940 Progress Parkway.Wesley Chapel, FL 33544
20 Gulf]'race Elerneniary.3303 Gulf'rrace Blvd.,Holiday, FL,34691
21 Calusa Elen'ientary,7520 Orchid Lake Road, New Part Richey. FL 34654
22 CAV of Pinellas Park-Attr) risk Managernent, 5,141 78th Avenue N., Pinellas Park. FL 33781
23 Regency Park Branch -ibraij. 9701 Little Road,New Poll Ricl-iey, FL 34654
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24 I-ludson Regionat Ulbrary,8012 Library Road, Hudson,FL 34667
25 R,B,Stewart Middle School.38505 10th Avenue.ZephyrthiHs,FL 33542
26 Genesis School,8100 Mitchell Ranch Road, New Parl Richey, FL 34655
27 R'ClUb Sutherland, 3,150 IN Belcher Road, Palm Harbor, FL 34683
28 RVA)MILK 557 '10th Street North,St. Petersburg,Fl-33705,
29 Schrader Elementary School, 11041 Little Road, New Port Ritchey, FL,34654
Additional Insureds,contin
Fourth Page of Certificate Certificate 4 74830,
OTHER ADDITIONAL INSUREDS:
30 Tarpon Sprigs Library, 138 E Lemon Street Tarporr Springs, FL, 34689
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Sciiool Boatd of N mu
�i)ocih Gounty,901 E Kennedy 91vd, Tampa,"'L 3M02(Loctifi,,,,ris Frneriary, 3205 1,5 Ferfin-aixi Avt 7cimjpa,FL Hews Elenwnfaiy,
31 720,")sprvy F�dgt,, F 33547 Mom Fiementary 1806 L Beans Ave
FL Philp'Shore Ele 7,,i+' ''y L 2rd Ave,. FL 33605 ir�lark
Demenla,y''19002"A"aad Sage,Di,'ampa,F! 13647 H y�,t I--.!emontary 2006',1 1')oXAvomu(-,,.Plani Cqy,I-'],2,563j
32 Seven Oaks Elerinentary,27633 Mysflc Oak Blvd, Wesley Chapel, FL 33543
33' 1 he School Board of Polk County, F",0. Box 391. Barlow-FL 33831
34 GMS Delta Academy. Go!,"Middle Schom 6419 Louisiana Ave.,New Port Richey, FL 34653
35 RBS Delta AcaderrV,Raymond B.Stewart M.,iddle School, 338505 10th Ave.,New Port Richey. FL 33542
36 ;HMS Delta Acaderuy,1-tudson Middle Scl-lool. 14540 Cobra Way, Hudson, FIL 34669
37 Lake Myrfle Elementary School 22844 Weeks Blvd-Land 0 Lakes,FL 34639
38 Cypress Elementary-, 10055 Sweat Bay Court, New Port Richey, FL 34654
..........
39 Moor)Lake Elementary--'[2019 Tre(.�Breeze Drive-New Pan Richey, "134654
40 tAIjrrthro,o Charter School,(3204 Scholars Hill Lane,Riverview,FL 33578
41 Chester VV Taylor Elerrientary School, 3638 Morris Bridge Rd, Zejrhyr1hiIIS, 1`1 33543
42 City of Clearwater
43 CoarWater Public Libranj Systern
44 Trinity Elementary School 2209 Duck Slough Blvd.. New Port Richey,PL 34655
CA NCELLA FION should th o above des rfibe d policy(s)be caf i ce 7e(,t before fr,,a ta pra tfo 111'da tr-M L 01,of,Me 6suin 9 co ripa ny AM;e ri 08 a vo f to.71(1 i7 3D days vvntte n n o'rCe to the ms;77,7r 77
ti older and a ddition at 0 suneds hs fed,
AUTHORIZED REPRESENTATIVE:
DATE ISSUED: 1/18/2017
Fifth Page of Certificate Certificate
SPECIFIC EVENT EXCLUSIONS
The following types of events are specifically 2xcludqd and no coverage for them exists on the policies listed on the
front page of this Certificate of Insurance:
Aircraft/Aviation
All Terrain Boarding
Ballooning I Balloon Rides
Base JUrnping
Bouldering Events
Boxina
Bungee Jumping
Carnival Rides
Circuses
Concerts with performances exceeding 6 hours of performance time
Contact Karate I Martial Arts
Contact Sports
Diving
Dodgeball/Gaga Dodgeball
Football I Flag Football (except passing camps with no contact drills)
Gun Shows/Exhibitions
Hang Gliding
Hockey
Jousting
Kayaking, Rafting or Canoeing in greater than Class 3 rapids
Lacrosse/ Rugby
Mechanical Arnusernent Rides or Services
Motorized Sporting Equipment
Mash Pits
Mountain Biking
Power Boat Racing
Professional Sporting Activity; Games, Races, Contests of a professional nature
Pyrotechnics/ Explosives
Rap or HeaVyr Metal Concerts
Raves
Rock Climbing
Rodeo I Roping Events (includes practice)
Scuba Diving
Sky Diving
Tattoo Expos/Conventions
Tractor/Truck Pulls
Wrestling