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CERTIFICATE OF LIABILITY INSURANCE (4) 06 [TATE(MMIDDfYYYY) .A+ew`€ I?r-> CERTIFICATE OF LIABILITY INSURANCE 44/13/2418 ift� 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEN. 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 1-602-840-3234 CONTACT -_NAME: ... Risk Management Services, Inc. PHONE ';FAX $AdG tVG.Exti. (642) 840-3234 (AIC,No): DDR AE-MAILinfo@therisk eo le,cam ......_.. P.O. Box 327126OResS;_ .P P INSURER(S)AFFORDING COVERAGE ...- .._._,. NAIC# Phoenix, A2 85064.-2712 INSURER A. NATIONAL CAS CO j11991 ENSURED INSURER 8: Nationwide Life insurance Company 66869 CLEARV`+ATER. AQUATIC TEAM '.BNSIIRER C LISA Swimming, Inc dba USA Swimming __.. _._.....—. _._....._ 1501 N BELCHER ROAD, SUITE 229' INSURER D: --._- INSURER E CLEARWATER., FL 33765-1339 INSURER F: COVERAGES CERTIFICATE NUMBER:52581249 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. A4DL-ISUFtT ...... .._ 7 POLICY EFF POLICY E7tP LIMITS LTR TYPE OF INSURANCE i POLICY NUMBER MM7DD MMYDbfYYYY A ! X (:COMMERCIAL GENERAL LIABILITY j 75 ( X --IKK.ODO00007136900 01/01/1.8 01/01/19 EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED — p ....-i CLAIMS-MADE �. 7' J OCCUR PRE MISE$(Ela uccurrence� $ 1.000.400 X Participant Legal MED EXP(Any onepersony $ 5,440 X ! Liability Included . .-- j PERSONAL&ADV INJURY $ 1,000,000 GFN L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ UNLIMITED -_.._..._I POLICY.... I PRO. ._.I LOG PRODUCTS COMPtOPAGG $ PRO. x 2,4x4,444 _ OTHER: Abuse/Molestation $ 1,000,004 AUTOMOBILE LIABILITYCOMBINED SINGLE LIMIT $ _ Ea_accasCenl}._.. ANY AUTOBODILY INJURY(Per person) $ .. ALL OWNEDSCHEDULED BODILY INJURY(Peraoxideni) $ --. -. AUTOS .. - AUTOS. ' I ......i NON OWNED PROPERTY DAMAGE $ .I MIRED AUTOS J_---i AUTOS.. (Per accident}__ I ! I I $ A UMBRELLA LEAD _ x OCCUR x x XK00000007137000 01/01/18. 01/41/19 EACH OCCURRENCE ...-_ �s 5,440,404 R EXCESS LEAS CLAIMS-MADE. AGGREGATE ----. {$ 5,_040,404 —-- DFD I RETENTION$ Is 1 WORKERS COMPENSATION PER OTH AND EMPLOYERS'LIABILITY Y i N ,.i STATUTE .ER ANY PRO PRI ETOWPARTNERIEXECUTIVE E L.EACH ACCIDENT OFFBCERIMEMSER EXCLUDED? N 7 A ..- .... .. _.. _. .. (Mandatary In NH) E.L.DISEASE-EA EMPLOYEE $ If yes describe under ....-... _.. IDESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT. s B EXS Accident-Medical I SPX0000028503500 41/01/18 41/01/19 jMaximum, Limit 25,000 j I j I I DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If mare space is required) Verification of General Liability, Excess Liability & Abuge/Molestation coverage for COVERED ACTIVITIES (See Attachement) Abuse/Molestation Aggregate on the General Liability Policy is $5,000,000 Abuse/Molestation is excluded on the Excess Liability Policy. Excess Medical/Dental Accident coverage Provided for members only. 30 Day Notice of Cancellation Per Policy Provisions_ Certificate Bolder is included as Additional Insured per attached ADDITIONAL INSURED ENDORSEMENT EFFECTIVE CERTIFICATE ISSUE DATE. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Clearwater THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN C/O Athletics Office ACCORDANCE WITH THE.POLICY PROVISIONS. Gary Brokaw 706 N' Missouri Ave. AUTHORIZED REPRESENTATIVE Clearwater, FL 33755-4321 ass s +it r USA [ 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 2014101) The ACORD name and logo are registered marks of ACORD FL-CAT 52581209 Na DATE IMMIDDIYYYYI CERTIFICATE OF LIABILITY INSURANCE 05/14/2018 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER, IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the pollcy(ies)must have ADDITIONAL INSURED Provisions or 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:: Debra Williams _ Disk Management Services, Inc. PHONE FAX P.O. BOX 32712 1 No_xt): 4 46021 840-3234 .._ iC-N�};46Si�} 279138 EMAIL _ADDRESS;... dwilliame�theriskpeople.cam Phoenix AZ 85064-2712 INSURER(S).AFFORDING.COV€MAGI; .INSURER A National Casualty ...... ... ( 11991 INSURED .._. (727) 791-9542 INSURER B; Clearwater Aquatic Team, Inc. —._..--- —_..._....._ INSU RERC. ( __ I 1501 N. Belcher Rd., #229 INSURERO Clearwater FL 33765 INSURER€ 3 — _ INSURER F': I COVERAGES CERTIFICATE NUMBER:Cert IIs 20740 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. .._... .. _.__ ..------ ..---._ ""InDDEe SUBFa - 111 POLICY EF�_..I POLICY EXP-� lLTR TYPE OF rNSURA NCE POLICY NUMBER MMIDDAYYYY ! MMIDDIYYYY:I LIMITS LTR COMMERCIAL GENERAL LIABILITY ! (EACH OCCURRENCE $ .__._.. _.__......._...._.._.. .. DAMAGE TO RENTED I CLAIMS-MADE [. OCCUR PREMISES CEa accurrencea £$ MED EXP(Any one pars nn) _..- -_ PERSONAL&.ADV INJURY I$ GENLAGGR.EGATELIMIT APPLIESPER:; GENERAL AGGREGATE-,,,,,,---,o {$ _._..'POLICY I... ,E .._._� LOC PRODUCTS COMPIOP AGG $ ..... `., OTHER: $ -- �AUTOMOBILE LIABILITY _ COM BINEDt$1ROLELIMIT $ _._. 11000,000 ._.._..... Y Y 6L-KKO-00000074229_0 05/14/2018 051141297.9 BODILY INJURY(Per person) $ ,q I ANY AUTO _ I _.. OWNED _...._.-I SCHEDULED I BODILY INJURY(Per accident)I S _ .. AUTOS ONLY —_.. AUTOS HIRED NON-OMED PhOPERTY DAMAGE ._)AUTOS ONLY .-_....._q AUTOS ONLY [Per acdout_ $ X _ ( I UMBRELLA LIAR . I,OCCUR EACH OCCURRENCE _. S _ —.....-1 EXCESS LIAB I I...CLAIMS-MADEI AGGREGATE:... S OED -..I RETEN'r10N S $ YWORKERSCOMPENSATION ( I PER OTH- AND EMPLOYERS'LIABILITY YIN I. ._..,L.STATUTE, s E 2 __ ....... ANYPROPRIETORfPARTNERIEXErUTIVE ] N f A r E.L-EACH ACCIDENT S OFFICERrMEMBEREXCLUDED7 (Mandatary in NH) E.L.DISEASE-EA EMPLOYEE S__ — If yes,describe under — ..... ....._ .. ... DESCRIPTION OF OPERATION'S below E.L.DISEASE-POLICY LIMIT S I1 $ DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES IACORD 101,Additional Remarks Schedute,may be attached If more apace Is required) Verification of Hired & Non-Owned Auto Coverage.. 30 day cancellation per policy provisions. The Certificate Holder is included as Additional Insured on Auto Liability, but only as respects to the Named Insured's operations CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Clearwater c/o Athletics Office AUTHORIZED REPRESENTATIVE _. 706 N. Missouri Ave. Clearwater FL 33755-4321 01988-2415 ACORD CORPORATION. All rights reserved,. ACORD 25(2415103) The ACORD names and logo are registered marks of ACORD Page 1 of 1 AGENCY CUSTOMER ID: LOC ACORDTM ADDITIONAL REMARKS SCHEDULE Page 1 of 1 AGENCY NAMED INSURED K&K Insurance Group, Inc. POLICY NUMBER MEMBER NO: KKO-71369-00 USA SWIMMING,INC. DBA USA Swimm i ng Eta I CARRIER MAIC CODE SEE ACORD 25 l EFFECTIVE DATE; SEE ACORD 25 ADDITIONAL REMARKS THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM, FORM NUMBER: ACORD2 FORM TITLE, CERTIFICATE OF LIABILITY INSRUANCE "COVERED ACTIVITIES" With respect to USA Swimming member clubs,group members, member coaches,volunteers and additional insured owners/lessors of premises,sponsors and co-promoters, "Covered Activities" are defined as: 1) Swimming meets that have been issued a written sanction or approval. Approval means a permit issued by one of the USA Swimming, Inc. Local Swimming Committees for swimming meets conducted in conformance with USA Swimming, Inc,technical rules in which members and non-members may compete. USA Swimming, Inc. member clubs that either host or participate in a swimming meet that has been issued an approval will be considered an insured provided that all of its athletes or participants and coaches are members of USA Swimming, Inc. 2) Swimming practices,dry land training activities,camps and learn to swim programs where all swimmers or participants are members of USA Swimming, Inc. or United States Masters Swimming and are conducted under direct and active supervision of a member coach. Dry land training activities means weight training, running, calisthenics,exercise machine training,and any other activity for which an insured has received approval from USA Swimming,Inc. or its authorized representative. 3) USA Swimming, Inc. Swim-A-Thons,Fund raising activity which clubs can purchase for lap-athons 4) Approved social events and approved fund raising activities that are social events and activities for which an insured has received approval from USA Swimming,Inc.or its authorized representative. 5) Swimming tryouts. Swimming Tryouts means swimming practices where a swimmer(s)who is not and who has never been a member of USA Swimming,Inc. participates with a USA Swimming, Inc. club for a period not to exceed thirty consecutive days in a twelve month period to determine the swimmers interest in becoming a member of USA Swimming, Inc. 6) Office premises liability for Member Clubs and LSCS 7) STSG, CPR, and Lifeguard Certifications of USA Swimming member coaches done by USA Swimming member coaches that are member representatives of one of the approved agencies listed on the USA Swimming STSC In-Water Skills Checklist. 8) "Organized practices"that have been reported and a premium has been paid for. Organized practices are defined as recreation league meets hosted by USA Swim Teams with community teams that are not USA Swimming member teams. ACORD 101(2008101) X2008 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORN ENDORSEMENT National Casualty Company NO. ATTACHED TO AND ENDORSEMENT EFFECTIVE DATE FORMING A PART OF (12:0`1 A.M.STANDARD TIME) NAMED INSURED AGENT NO. POLICY NUMBER KKO-71369-00 0110112018 USA SWIMMING,INC,DBA: USA Swimming Etat THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSUREDS OWNERS ANWOR LESSORS OF PREMISES, SPONSORS OR CO-PROMOTERS This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART The policy is amended to include as an additional Insured c, This insurance does not apply to liability of any person or organization of the types indicated by an"X" the owners and/or lessors for"bodily injury" or in any boxes shown below, but only with respect to liability property damage" arising out of any design arising out of your operations: defect or structural maintenance of the prem- ises or loss caused by a premises defect. Owners and/or lessors of the premises leased, With respect to any additional insured included rented, or loaned to you, subject to the following under this policy, this insurance does not apply to additional exclusions: any negligence of such additional insured. a. This -insurance applies only to an 'occur- Sponsors rence" which takes place while you are a ten- ant in the premises; FX-] Co-Promoters b. This insurance does not apply to "bodily [I Any individual person(s) or organization(s) listed injury" or "property damage" resulting from below: structural alterations, new construction or demolition operations performed by or on behalf of the owner and/or lessor of the premises; Aw Z AUTHORIZED REPRESENTATIVE DATE KR-GL-56(4-07) Page 1 of 1 ORGANIZATIONAL LETTERHEAD LKLM PI tO KI POP,R FQ.UHRFD INSURANCES (che,rk it ippticablel, Automobile Uability Insurance On behalf of The I s.brrot ow organization dares not own aT)y vc-hDclm nor does the organization pfovide or ari-aoge fog,any tr ansportation/ca rpooling foo any tnem bir i,partid pants, employees,or volunteers of the organization to any practices,gatren.or organization sponsored activities. Thu-s'our organization is requesting exemption from prov0ding,auto liability insurance pee the aura-Sponsurship agreCMent. Wo kers Compe;rsatiow/E'mploy'er, 6a'bilAy in'W'Ince On behalf of the I subn-tit our orgaoualbun does not have paid i,,nnpioyecsfvolLjnLeers attend any practices,games,or organization spor,,Gred activities- Our workcrs vampensat on covefage als d o doe,not prov�- e average for volunteers- V Propenyinsuf-ance Can behalf o f tine r' i I submit our orpani7ation rs exempt from ptoviding property msurance due to the value -,of the property.Unless it's damaged as a ri-sult of City negligence wh4e err out care, cun.Ludy and control,our orf anization will be responsbfe far covering any lea¢Ses. Name of Orgartkuation fiVe.. N4mc of Rep restntative- Signature-. Date. I I.----I IWimmlv&yyvYj ,�Ac-".Ra CERTIFICATE .OF LIABILITY IN THIS GERTIFICAlE IS ISSUF,D A-5 A MATTER OF[INFORMATION coNFcR---,uo miGHTs ur-oN THE CERTIFICATI=mnOER,THIS CERTIFICATE DOE's Nar AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND,OR ALTER THE COVERAGE ArrOIROEO AV THE POLICIES 8-FLOW,YMS CF-,,RRFhDATE OF INSURANCE DOES N07 COINSTITUTE A CONTRACT BFI-WIFIEN THE ISSURIG 2N'SURtRjS),AUTHORIZED H*P HESIEN TATIV E OR PRODUCEA.AND THE cEnnncATE H mDm IM PIORTA NT' If ttw.c�,,00kr,,i to"kW is aft ADDITIONAL tusAinED,the puNcKm�,)racist twive ADD 171014 AL INSURED pr visiqmu of w endorsed. if SMIRMATION IS WAIVED,subjecl to die tenum and corWhigms of ileo polky;certain Wlcie�may requim an cndorscmimt,A staler"ent on this tertiricate dots not confer rightN to the ria tificnlv holorf In Ileo of s PRDOLKER P"omt rx3, M ol III,Gr�affqa-"m Yaa Pulm bmtcl, L Y�4 Iq AM "Aor 0 th'SOFWA AV04xx,lowlwre(,&Arksly cat-Am-WIP'll r.n Unne F:"y 4r1 IWA r 7,426 P Alril twWwft D I IRFR F CERTIFDCATE NUUnERijFmT.,r-7x REVISION NUMBER: THIS IS TO CrRTIFY THAT lHL ClfIN'�1.10RAIWC lj:�,TT:P F.T-1(,iw KA%,c rCCI4 WrU[D ro Tw:misu,"L-Ei NAmm Artowr rop Ti,jE poLycy Rcmic NDICATED- NOTWITIiSrAIRDMG M4Y REOLMHEMUNI-7 FRIA M, Ft}40ITION Or ANY C1,41ATAAET OH Ul M-k LYX;kJW,.%IT WITH TIF—IPECT TO VO,iiCii I His C F-F1,11ftC ATr MAY K I&SUC 0 Oil MAY PERT.41M TP IL Al"FORD 1-1)BY THF F-D-JC IES 9tS,Cnj&tD I ICAE ift IS SU IM T,C.;'r TO Al,,C,THE 7[n M IJSICpis5 Ar4t)C(WrJI710t-'�CAT-SfJCH POLJClr&LIKLIS S-4f()IVN MAY HAVE MLL,%RFDJIjC,F n 13V FAID CLAM-4S —Abok-kitip Poo') i inml ICY wownt'R i I —----------- LOMW(ccvu- .44F NRA' 51 M,I Owe WI.!.,I"is is ASW.40 97,7ATF IMFAI�I 1 11,,f, A. 04 CIA I I' PfpAJRA:M'. J� AUrol,004ULE UA&MMY 7)4iFi-J�Tklt D xQrcs dLc s „momNIT 01""Op&ir imu"N' 161! ulE l hd a'�i44- A i MOKEfl$1'010I*M-"IOK I7Jn I r2 f") AM UNKCYLEW MMUT" x YT"TEtER.AcLK� "WmFL6 Lfi" TAGRIXXXI v�L,ls"'w,ma I In a-Iq 1 1 S IP7 UA- E L(IlSrA8:-r Pl-20Y lAftl I$ Or OPERATrMS {ACUID M, ls— . b. Owm-wpc iu aamrdtal to 6kd s ffq*iyoo,1-4 f.0 CLCARvllATCAkbLkmc MAW,WC. ClEATIFICATE HOLDER CANCE.LLATIQN SHOULD ANY QFTHF AIWVE(WSOLAItIfia POLIC;IES BE CANCZLLED QRF THE EXPIRATION DATE THFIFIFID17, NOTICL WILL UE DELIVERED IN ACCO. -EWITH THE POLICY (,4y 4)1Y40114ZM REPREGENTAIWL ok-ww�jwi,rL!C755 0 t.-. 205 ACORD CORPORATION.All dghts to,,wrvod, ACORD 2S(201"3) The ACORD name and i0oo ate re�WaU-m-d rnmrk%of ACORD