CERTIFICATE OF LIABILITY INSURANCE (4) ,�+► i i� CERTIFICATE OF LIABILITY INSURANCE DAI 'Mw off �Y)
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THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMIATION ONLY AND CONIFERS 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 INSPIRED 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 rip hts to the certificate holder in lieu of such endorsement(s).
PRODUCER NAMEACT TERRI MONDEAU
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StateFatlll DICK.MARTIN INSURANCE AGENCY INC PHONE 727-785-4985 FFFax 727-785-0499
E d�IRl4 f EAIC.Nal: a
30826 US HIGHWAY 19 N DDRE SI terd. ondeau.hznc@statefarm.Com
PALM HARBOR,FL 34684 _
INSURER( )nrFaRssrvG COVERAGE NArc r
INSURER A. State Farm Mutual Automobile insurance Company 25178
INSURED �..._..,..._
INSURER g
EDWARD N BATES DBA KINNEYS KITCHEN INSURER C
1540 CLUB DR INSURER D:
TARPON SPRINGS,FL 34589 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.
INSRAL1DL SLlaR � .®...�.'.
LTR TYPE OF INSURANCE POLICY NUMBER 9A POLICY
NYYY)jMwopffyYY1
Y£91P LIMITS
-. COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE �.
CLAIMS MADE OCCUR -PREMISES Me occurrence)
E MED EXP(Arra oae rson
I
PERSONAL S ADV INJURY $
GENT AGGREGATE:LIMIT APPLIES PER:PO. F1 IGENERAL AGGREGATE S
POLICY JET LOC PRODUCTS-COMPIOP AGO S
OTHER: $
AUTOMOBILE LIABILITY Y E92 431 0-D20-59A 1OJ20/2018 U4J2MO19 CDM9INED sINGL E uMIT $
E�ecdc�±nr ANY AUTO BODILY INJURY{Per person) $ 1,000,000
AUTOS ONLY _-_.. A[C!TOSULED BODILY INJURY(Par et7d'sonq $ 1,000,W0
HIRED NON-4VVNED F fR—PERTY DAMAGE S 1,D ,i
AUTOS ONLY AUTOS ONLY P&r s idem
00
S
UMBRELLA LIAB LJ OCCUR EACH OCCURRENCE -_ S
EXCESSLJAH I I CLAIMS-MADE AGGREGATE S
DEC, RETENTION$ $
WORKERS COMPENSATION PER
AND EMPLOYERS'LIABILITY YIN STATUTE ER
ANY PROPRIETORIPARTNERfEXECUTIVEE.L.EACH ACCIDENTS _
OFFICEPUMEMBER EXCLUDED? N 1 A �.
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE
UnII ea,describe under
RIPTIOIN OF OPERATIONS Wow E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 VEHICLES(ACORD 101,Additional Remarks Schadule,may 5e aLtadwd If space is required) -
DESCRIPTION OF VEHICLE:2648 DODGE RAM 1500 P-UP VIN ID7HA18288S608303
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY O E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE E%PI CRN DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF CLEARWATER ACCO THE POLICY PROVISIONS.
PO BOX 4748
All; ZESENTAIT
VE
CLEARWATER,FL 33759-474.8
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1001486 132844,12 03-15-201.6