CERTIFICATE OF LIABILITY INSURANCE (3) DAT E(M WD D!YYYY)
CERTIFICATE OF LIABILITY INSURANCE 9/18/2016
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 have ADDITIONAL INSURED provisions or be endorsed,
If SUBROGATION IS WAIVED, subject to the terms and conditions of the poticy, certain policies may require an endorsement. A statement on
this certificate does not confer rights to the certificate holder in lieu of such endorsementlsl.
PRODUCER CNAONTACT
____— --------
Gagliardi Insurance Services, Inc.. PHONE 1(800) -995-9768 FAx N (408) 414-8199
1315 Walnut Street, Suite 1101 E-MAILfi .sa esCgsportsinsurance.com
ADDRE
Philadelphia, PA 19107 INSURER(SI AFFORDING COVERAGE NAIC#
# 809840 INSURLRA Scottsdale Insurance 41297
INSURED Suncoast Youth Football INSURER B. QBE Insurance Corporation 11515
Conference, Inc.
P.O. Box 6313 INSURER€D_:
Clearwater, FL 33758
727-642-0497
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 CONTRACTOR 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 CONDITIONSOF SUCH POLICIES.LIMITS SHOWN MAYHAVE.BEEN REDUCED BY PAID CLAIMS.
INS POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE LIMITS
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,0009000
I"s'I'C FFt I __
CLAIMS-MADE OCCUR $ 300,000
X Abuse & Molestation KRS--00000073653-00 5/l/20185/l/2019 MED EXP An ane egon $ 0
A X Y PERSONAL&ADV INJURY $ 1,000,000
GEN L AGGREGATE LIMIT APPLIES PER: GENERAL. AGGREGATE $ NONE
X POLICY El PROCT LOC: PRODUCTS....COMPlOP AGG s 1,000,000
JE
AUTOMOBILE LIABILITY C'-OMBINED`.TINGLE LIM IT` $
ANYAUTO BODILY I.NJURY(Per Person) $..
OWNED SCHEDULED BODILY INJURY Ire,ac adem) $..
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE
AUTOS ONLY AUTOS ONLY I EgE aiggen 11 11
--..
UMBRELLA LIABOCCUR EACH OCCURRENCE $
EXCESS LIAR HCLAIMS-MADE AGGREGATE. $
RETENTION ---___ _____
WORKERS COM1IIPENSA.TIOM'. PE.R 7H-
AND EMPLOYERS LIABILITY
ANY PROPRIETGRIFAR-FNERIEXE.CUTIVE EA..EACH ACCIDENT --. S
OFFICEWMEMBER EXCLUDED? 14.,.�.J) NFA
(Mandatory In NH) E.L..DISEASE-EA EMPLOYEE 5
If yes,describe under
Accident Medical GAH000001 5/l/20185/l/2019Limit $100K Ded $250
AD&D $25
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORO141,Additional RemarKsScheWe,rnay lse artacnadif more space is required)
The Certificate holder is included as an additional insured, but only with
respect to the liability arising out of the negligence of the named insured.
All policy terms and conditions apply.
For use by associations of Countryside Junior Cougars.
City of Clearwater
3060 McMullen Booth Road ,SHOULD ANY OF THE ABOVE DESCRIBED POUCIEwS BE CANCELLED BEFORE
Clearwater, FL 33761 THE EXPIRATION DATE THEREOF, NOTICE WILL SE DELIVERED IN
ACCORDANCE.WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTA IVE.
i
D 7088-207 RD CORPC7RATIO All rig7s reserved.
ACORD25(tat 6103) The ACORD name and logo are registered marks of ACORD
COUNTRYSIDE JUNIOR
COUGARS , INC .
P.O. Box 169134
Clearwater, Florida 33766
Telephone: (727)754-4005
EXEMPTION FOR REQUIRED INSURANCES:
(check if applicable)
–X–Automobile Liability Insurance
On behalf of the Countryside Junior_Cougars Inc, I submit our
organization does not own any vehicles nor does the organization provide or arrange for
any transportation/carpooling for any members, participants, employees, or volunteers
of the organization to any practices, games, or organization sponsored activities. Thus,
our organization is requesting exemption from providing auto liability insurance per the
Co-Sponsorship agreement,
–X—Workers Compensation/Employers Liability Insurance
On behalf of the Countryside Junior Cougars, Inc. I submit our organization does not
have paid employees/volunteers attend any practices, games, or organization
sponsored activities.
_x® Property Insurance
On behalf of the Countryside Junior Cougars, Inc. I submit Our organization is exempt
from providing property insurance due to the value of the property. Unless it's damaged
as a result of City negligence while in our care, custody and control, our organization
will be responsible for covering any losses.
Name of Organization: Countryside Junior Cougars, Inc.
Title- President
Name of Representative: Richard C. Millian
Signature:
Date: 4 V