CERTIFICATE OF LIABILITY INSURANCE ® DATE(MM/DD/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 8/7/2017
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 She rry Wilt
NAME:
Lancaster Insurance PHONE x27 461-3704 FAX
Q N b (7 ) _ I.(A/C No);_.(727)491-3298
510 Druid Rd E. , Ste. #C ADDRIESS•Sherry@ lanci.ns.COM
P O Box 2856 INSURER(S)AFFORDING COVERAGE NAIC#
Clearwater FL 33757 INSURER A:S outhern-Owners Insurance 10190
INSURED
INSURER B
Clearwater Historical Society Inc INSURER C:
P O BOX 175 INSURER D:
INSURER E:
Clearwater FL 33757-0175 INSURER F:
COVERAGES CERTIFICATE NUMBER:CL148707469 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 ADDL SUBR'.. POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR MVP POLICY NUMBER IM /DD/YYYYI MM/DD/YYYY LIMITS
GENERAL LIABILITY
EACH OCCURRENCE $ 1,000,000'..
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED-
PREMISES(Ea ccturrarw $ 50,000
A CLAIMS-MADEI OCCUR X 20954975 8/7/2018 8/7/2019 MED EXP(Any one perscr) $ 10,000
PERSONAL&ADV INJURY $ 1'0 '00
GENERAL AGGREGATE $ 2,000,000
GGEEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 2,000,000
X I POLICY F-]PRo F__] LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea accident) $
_ ANY AUTO BODILY INJURY(Per Person) $
ALL OWNEDSCHEDULED
AUTOS AUTOS BODILY INJURY Peraccicleni) $
NON-OWNED PROPERTY DAMAGE
'.. HIRED AUTOS AUTOS ..(Per accident) $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB HCLAIMS-MADE AGGREGATE '$
DED I I RETENTION$ $
WORKERS COMPENSATION I T C I IAMITF I ICTR
AND EMPLOYERS'LIABILITY Y/N
ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? ❑ N/A
E L EACH ACCIDENT $
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under _--_--
'.. DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required)
The certifcate holder is listed as additional insured with respect to the general laibility insurance.
610 S Fort Harrison Ave
Clearwater, FL 33757-0175
1380 South Martin Luther King Ave
Clearwater, FL 33756
CERTIFICATE HOLDER CANCELLATION
chri s topher.hubbardmyclear SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Clearwater ACCORDANCE WITH THE POLICY PROVISIONS.
100 S. Myrtle Ave.
Clearwater, FL 33756 AUTHORIZED REPRESENTATIVE
. t a
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ACORD 25(2010/05) Q 19$#L2010 ACORD CORPORATION. All rights reserved.
INS025(201005)01 The ACORD name and logo are registered marks of ACORD