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CERTIFICATE OF LIABILITY INSURANCE (5) 1 r 13ATE.(MM+l]D�h'YYY) ' ' �' CERTIFICATE OF LIABILITY INSURANCE 912112018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE GOES 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 lied of such endorsement(s). PRODUCER _. CONTACT NAM . RPS Bollinger-Sports&Leisure 1A PHONE Ext800-"6-5311 Fac Nc. 973-921-8474 150 JFK Parkway E-MAIL PO Box 390 Short Hills,NJ 07078-5000 PRODUCERCUSTOMER ID a INSURER S..AFrORDING COVERAGE NAiC# INSURED INSURER A: Markel Insurance Company 38970 US Lacrosse,Inc. INSURER B: 2 Loveton Circle INSURER C: Sparks,MD 21152 INSURER O: Re: Clearwater Youth Lacrosse INSURER E: INSURER F': 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 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. - INS.R A0f3L SUe- POLICY EFF POLICY EXP TYPE OF INSURANCE POLICY NUMBER LIMITS LTR —M2 (IJI&DVIYYYY�GENERAL LIABILITY --.. EACH OCCURRENCE $1,000,000 A X COMMERCIAL GENERAL.LIABILITY X $5t}2AH2213fi9 01101118 01101119 DAM 6l �f„ .SCSED 1 000000 CLAIMS MADEOCCUR, sexual Abuse and Molestation co rage Is afforded—,3` Limits of Llabifityof$1,000,0001oc iurrenceand$2,0)0,000 aggregate. MED EXP(Any ono person) 10000 X Inc],Participants PERSONAL&ADJ INJURY $1,000mo '....GENERAL AGGREGATE $6,000,000. GENL,AGGREGATE LIMIT APPLIES PER. PRODUCTS COMPtOPAOG L2,000&00 POLICY PROJECT -- LOC AUTOMOBILE LIABILITY COMBINED]SINGLE LIMIT (Ea accident) ANY AUTO BODILY INJURY(Per_person) __ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) HIRED AUTOS KION OWNED PROPERTY DAMAGE AUTOS (Per accident) A UMBRELLA LIAR X OCCUR EACH OCCURRENCE $2,000,000 EXCESS LIAR CLAIMS MADE X. 46t72AH221370 0110111$ 01101119 AGGR'.EGATE $2 000000 DED RETENTION. $.. WORKER'S COMPENSATION we s7Au-T. 0THEI3. AND EMP..LOYERS'LIABILITY YIN ANY PROPRIETORRARTNERiEXECUTIVE NIA E L EACH ACCIDENT OFFICERIMEMBER EXCLUDED? !Mandatory in NH) E L DIS€,ASE-EA EMPLOYEE ff yes,describer under E.L DISEASE•POLICY LIMIT DESCRIPTION OF OPERATIONS bolow A Accident Medical 4102AH025220 01101118 01101/19 Acc Limit $100,000 A Catastrophic Acc 41€12AH305882 01101118 01101119 Cat,Acc. $1,000000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,AdditionalRemarks Schedule,If mere space is required) Coverage applies only to teams/leagues comprised of 100%US Lacrosse member participants during scheduled&supervised lacrosse activit es.Certificate Halder is named as an Additional Ensured. Certificate is issued on behalf of Clearwater Youth Lacrosse. CERTIFICATE HOLDER CANCELLATION - City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1501 N. Belcher Road EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH Clearwater, FL 33756 THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 26(2010105) The ACORD name and logo are registered marks of ACORD OP ID:5_v CRATE(MMIDDffYYY) CERTIFICATE OF PROPERTY INSURANCE 09/2112018 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. If this certificate is being prepared for a party who has an insurable interest in the property,do not use this.farm. Use ACORD 27 or ACORD 28. NT PRODUCER NAOMEACT Abigail Panciello _. RPS Bollinger Sports 8,Leisure PHONE I30f1 446-5311 FAx ��+-aaa PO Bax 390 i�a�aaNc., sal; - 4A c._Nol; Short Hills,NJ 07078 ADOREss; Abigail PancielloCLEAR-7 PRODUCER _CUSTOMER Io. IN SURERIS,).AFFORDINo COVERAGE + NAIL Ii INSURED Clearwater Youth Lacrosse INSURER A°'Markel Insurance Company 38970 Dan Wood INSURE RB; — - ---.__ 2663 Megan Court INSURER c-; Palm Harbor,FL 34684 INSURER D: -... INSURER E- ..INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: LOCATION OF PREMISES 1 DESCRIPTION OF PROPERTY(Attach ACORD 147,Additional Remarks Schedule,It more space is required) 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. tNSR� POLICY EFFECTIVE T POLICY EXPIRATION' ... .-.. i LTR TYPE OF INSURANCE POLICY NUMBER DATE(MM IDDtYYYY) DATE(MMtDDtYYYY); COVERED PROPERTY LIMITS PROPERTY E { BUILDIN53 s CAUSES OF LOSS DEDUCTIBLES I ( -. PERSONAL PROPERTY ...__._�-UA.$IC ._ -.... _ ` ... BUSINESS INCOME L+� BUIi.L71NG -1 ' BROAD i _ ._ -El EXTRA EXPENSEIs - -- Caritents l -.. SPECIAL iRENTALVAL.UE ACS I r ERTHQUAKE I .... _.. _.-� I, I .... BLANKET F$ ..... ......_ t WINO l BLANKET PERS PROP s FLOOD j ( BLANKET BLDG&PP is I f $ s A INLAND MARINE TYPE OF POLICY On File wtCo. s 2,40 CAUSES OF LOSS - r NAMED PERILS POLICY NUMBER 0912112018 1 0912112419 $ 7002AH010610 CRIME _.. 'TYPE OF POLICY _ I$ - - I BOILER&.MACHINERY I I is I -._....EQUIPMENT BREAKDOWN P --... .. ...___. -- I I is i �. -$ $ .. SPECIAL.CONDITIONS I OTHER COVERAGES(Attach ACORD 141,Additional Remarks Schedule,If more space is required) Coverage is for specific items on file with the company.Location of equipment at 1345 Court Road,Clearwater,FL 33756. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Proof of Insurace ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1995-2009 ACORD CORPORATION. All rights reserved. ACORD 24(2009109) The ACORD name and logo are registered marks of ACORD ORGANIZATIONAL LETTERHEAD EXEMPTION FOR REQUIRED INSURANCES: (check if applicable) Automobile Liability Insurance On behalf of the OW b4f 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. Workers Compensation/Employers Liability Insurance on behalf of the A1V—tA5,—e I submit our organization does not have paid employees/volunteers attend any practices,games, or organization sponsored activities. Our workers compensation coverage ,also does not provide coverage for volunteers. —Property Insurance On behalf of the 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: A Title: Name of Representative: Signature: Date: