CERTIFICATE OF LIABILITY INSURANCE " OAT'E(MMMDfYYYY)
A ")?L ►� CERTIFICATE OF LIABILITY INSURANCE 06/08/2018
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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 he 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 1-813-229-8021 CONTACT
NAME. Amber Richards
M. E. Wilson Company, LLC PHONE FAS,
(AtC,No,Fxt� 813,-349-2220IAIC,No): 813-,229-2795
E-MAIL arichardsOmewilson.com — —
300 W. Platt St. ....ADDRESS;.... ...__.._ __.. _... ........
Ste 200 .__ INSURER(S),AFFORDING COVERAGE ... ...... MAIC#
Tampa, FL 33606 INSURERA: NATIONAL CAS CO !11991
...INSURED _ ..INSURERB: Nationwide 1 11 . Life Ins Co 111991
Florida Youth Soccer Assn Inc. _...._..._
INSURER C:
C
- f
2828 Lake Myrtle Park RoadINSURER D:
-- .........---._ ...__ ....__.... .._......---
INSURER E
Auburndale, FL 33823 INSURERF:
COVERAGES CERTIFICATE NUMBER:53019130 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 CONDITION'S OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
RNSR�....__........ ........_ - rRDOIn'SUBR. ..__.. .....— ._.. POLICY EFF. POLICY EXP _.
LTR TYPE OF INSURANCE POLICY NUMBER MWDD1YYYYd.. MMIDDrYYYY LIMITS
A i X I COMMERCIIALGENERAL W X ' ILKRS0000007389700 06/01/15 1 06/01/19 EACH OCCURRENCE $ 1,000,000
1 I_ ( CUR DAMAGE TO RENTED
PREMISES(Ea occurrer10,1 $ 300,000
i X Participant Legal Liab MED EXP(Any one person) $ 5,000
fX Sexual Abuse...& Moles. i PERSONALS ADV INJURY ($ 1,000.000
a _ , _II$ 2,000,000
I
GENL AGGREGATE LIMIT APPLIES PER
GENERAL AGGREGATE
j POLICY i._ EGF X LOC PRODUCTS-COMPIOP ACO 1$ 2,000,000
IOTHER: ',
• AUTOMOBILE LIABILITY 6LKKOOOO0007389900 06/01/18 06/01/19 COMBINED SINGLE LIMIT $ 11000,000
ANY AUTO i BODILY INJURY(Per person) S .
.......i OWNED ( SCHEDULED BODILY INJURY(Per ac.cidzint) S _
AUTOS ONLY _�AUTOS ._.
i -- HIRER NON-OWNED PROPERTY DAMAGE
"...... AUTOS ONLY X i AUTOS ONLY ;(Per aceldent)..... .. $ .. ._.
S
A f UMBRELLALIAB X •OCCUR �.. 11LXX5U00000'7389500..._ 06/01/18 06/01/19 `EACHOCCURRENCE S 1,000,000
X. EXCESS LIAe ...1.. AGGREGATE
..._ $ 1,.000,00 0
ttt _ .....
..._.❑ D _.. RETENTION _. .... $
E
WORKERS COMPENSATION ...1 PERSTATL[TL_ OTH
AND EMPLOYERS'LIABILITY YIN £13.,
ANYPROPRIETOWPARTNERIEXE.CUTIVEI E.L.EACH ACCIDENT $
OFFICER)MEMBE REXCLUDEDn LINIAi .— .— -. - - -
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $
if yyes,describe Linder
DESCRIPTION OF OPERATIONS Wlaw I E.L.DISEASE-POLICY LIMIT $
B Participant Accident 16ASPX0000028860500 106/01/18 06/01/19 (Medical Exp Limit 50,000
Medical Expense Limit Ded Per Claim ( 2,000
i
DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached it more space Is reciulred)
All operations of the Florida Youth Soccer Assn, its to-ams, leagues & clubs.. Coverage applies only to official,
sanctioned and supervised activities of FYSA. CERTIFICATE HOLDER IS NAMED AS ADDITIONA-L INSURED if required by
direct written contract_ This certificate is issued on behalf of: CHARGERS SOCCER CLUB (CLUB CODE: CN-CSC)
EDDIE C. MOORE COMPLEX - 3050 DRESS ST, CLEARWATER FL 33759, COUNTRYSIDE SPORTS PLEB - 3060 MCMULLEN BOOTH RD. CLEARWATER
FL 33761, JOE DIMAGGIO FIELDS - 2450 DREW ST. CLEARWATER FL 33765, GLEN OAKS PARK/DAVID MARTIN FIELDS - 1345 COURT ST,
CLEARWATER FL 33756 / -*SUPERCEDES ALL PRIOR CERTIFICATES ISSUED.°*-
*Sexual Abuse & Molestation is included under the Ren Liab Policy with a separate limit of $2M AGG/$1M OCC.
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
Athletics Office ACCORDANCE WITH THE POLICY PROVISIONS.
706 N. Missouri Avenue AUTHORIZED REPRESENTATIVE. ..
Clearwater, FL 33755
USA
1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD
AR002
53019130
Chargers Soccer club
3060 Drew St.
Clearwater, Fla. 33759
Exemption for Required Insurances:
(Check if Applicable)
X Automobile Liability Insurance
On behalf of the Chargers Soccer club, Inc I submit our organization does not own
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 expemption from
providing auto liability insurance per the Co-Sponsored agreement.
X Workers Compensation /Employers Liability Insurance
On behalf of the Chargers Soccer Club, Inc I submit our organization does not
Have paid employees/volunteers attend any practices, games, or organization
Sponsored activities. Our workers compensation coverage does not provide
Coverage for volunteers.
X Property Insurance
On behalf of the Chargers Soccer Club, 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: Chargers Soccer Club, Inc.
Title: President
Name of Representative: Steve KimWell
Signature:
Date: