CERTIFICATE OF LIABILITY INSURANCE (4) I
AC<>RbP CERTIFICATE OF LIABILITY INSU CEDATE(MMIDDIYYYY)
107/12/2018
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(Sl, 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
NAME: Colleen B.Burke__.
Burke Insurance services, Inc r'N°N .. II 727-441-3094 4 C No: 727-449-0102
._..
P C Box 1134 E-MAIL colburlt hotmail.com
Dunedin, FL 34697 A&P _ _.
INSURER{S)AFFORDING COVERAGE NAlC#
INSURES A_ United StatesLlability Insurance Corrlpany
INSURED INS€IRER B _F1orlda Worker Cornpensati2n_49Iq!E,Incferwritin
Youth Development Initiatives, Inc
900 Martin Luther}tine Avenue
INSURER D
Clearwater, FL 33755 - _—....
INStiRER E
INSURER :
COVERAGES CERTIFICATE NUMBER: 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 4111TH 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 SUS ...,..._ .....�. P[3LI Y�EFF POLICY EXP ..., .....m,,..,,,w.. .......W.:..
LTR TYPE OF INSURANCE WVO POLICY NUMBER MMIDDIYYYY MMIDDNYYY L#MrrS
A COMMERCIAL GENERAL LIABILITY X NPP1 s06973C 0810112018 0810112019 EACH OCCURRENCE $ 1,000,000
CLAIMS MADE OCCUR l
DAMAGE ro RE
PRI=M,I, , S, PeGC' a1 s 200.00(1
Sexual Abuse Molestation MED�xPt�v-0 Ism-i $ 5,000
Each{`.elarlTl 1,000,000 PERSONAL 8 ADV INJURY $ 1 00CI,000
l_-.. - __. ---- l.v.. _ ...._._
GEN'L AGGREGATE LIMIT APPLIES PER. ( GENERAL AGGREGATE S 2,000 000
�l POLICY[ ECCT 1-1 LOC
PRODUCTS-CC7MPIt}P AGG S 1,000 000 .
:.OTHER: (, $$
A AUTOMOBILE LIABILITY �X NPP1 b00973C 08/0112018 10810112019 COMBINED SINGLE LIMIT S
i a accident
ANY AUTO BODILY INJURY(Per person) $
ALL OWNED
m. ,...
AUTOS F AUTOSULEI3 BODILY IN (PeracaderA) $
HIRED AUTOS $
C NON-OWNED
AU'fCISI�[}PE I rACNAdI Ynit,--,.
OAAhfAGE
Included in Aggregate $ 2,000„000
UMBRELLA UAB OCCUR EACH OCCURRENCE $..
EXCESS LIAR CLAIMS-MAOHI AGGREGATE
_. _
.....,..,..,......Fv.....,._.__ .�..._ ..,.,.._
DED RETENTION$ $
B
WORKERS COMPENSATION 6F13UB-7017154 6-6-18 03/2612018 0312612019 ( S ATUTE RH
AND€M€�I,4YFR:S I_IARIL�ITY
----
ANY PROPRIETd]RIPARTNERIEXECUTIVE TIN E L EACH ACCIDENT $ 00,000
OFFICERIMEMBER EXCLUDED? NIA _..-..
IMandet®ry in NN) E t.DISEASE-EA EMPLOYE $ 100,000
If es, Ieschbe under
- --.....–..•. ..•.......
C}mdSCRIPTION OF OPERATIONS beIow E.L..DISEASE-POLICY LIMIT $ 500,1100
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may be allached if more space Is required)
Certificate Holder Listed below is Additional Insured with respects to Commercial General Liablity and Commercial Auto Liability.
CERTIFICATE HOLDER CANCELLATION
City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
100 S. Myrtle Avenue t CCDNC ' DAPCYPROVISIONS.E WILL BE DELIVERED INAORA °IITHTH THEREOF,
Clearwater, FL 33756
AUTHORIZED REPRESENTATIVE
Colleen B.Burke
I
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(201.4101) The ACORD name and logo are registered marks of ACORD