PRACTICE THIRD PARTY CERTIFICATE OF INSURANCE AMATEUR ATHLETIC UNION OF THE US INC (2) PRACTICE THIRD PAKUYCERTIFICATE OF INSURANCL
AMAITUR ATFILETIC UNION OF THE U.S.,INC
CERTIFICATE HOLDER City ofcar%vater Parks and Recreation COVERAGE,BATES:
800 Phiffies Drive
Clearwater,1-1, 33755 t2/28/20 19-Skll/2019
-1-his certificate is issued is a matter ofinforrmation only and confers no rights upon the certificate holder,Thipee'ruticatq, c4"notalm-nativelyor
ricgatively arnend,extend or alter the coverage afforded by the policies below. 'Mis certificate of instnaivee'do'e§B6 C,imlt.nure a contract between the
issuing insurer(s),autbori7ed reprM�nrativc or producer,grid the certificate holder-
PRODUCER INSURED m R'N'lu UR &�Tl F[CATE ID. 9KF 1,84T3
CLUBCODE: WY8TFW
Foy Insurance Amatc ur Athletic Dation of the U.S Inc, 4�, N
64 Portsmouth Ave Wait Disricy World Resort F�I .in fiAte i-a4'r6A,
110 Box,22409157 it et
110 Box 1030 , 1�111
7
Lake Buena Vis[aji- 32830-100
Exeter,NH 03933-1030 e
(407)934-7200
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Company A United State File Insurance CornpattyN 116, i %
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Company B Everest National Insurance Compact R,Lj mens tCompany A ut B
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COVERAGES- 111is is to cwify'"t,4#6jpo 'Ajeg-of onsfit;ai I I a Ill pc fo tilt jnsk'ed named above for the policy period indicated-
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Notwithstanding any requirement'jerm0, C 0 , c Inch this certificate may be issued or rnay pertain,the insurance]a 1 re
a I I t as 01 icy(i es),linnets shown may have been reduced by paid cl In Ili s.
afforded by the policy(ies'��
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F COVERA�'Ks�,� LIMITS
INSR TYPE [%
I,TR IN SURANV1 N U'Mkw DATE(MM QAi F. /Do� yV�
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A Participant 34,;, 2 1 M� `401,'20,19J ..'i' 1,"A14. Adci,' I call 100,000
c�i n Amernberment 20,OH
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12:01 Y'lit"'Ofe"O Piar Club 9,000,000
B Excess E 1 1201 1,20
Liability P, ic�,A gaic Per Club 9,000,000
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B si*ty V176�jgj % 'WU'no 1`4 11,61 AR wo,1 qC119 d el l rach Occurrence Limit 1,000,000
Liability N, General.A4, rcgateUtnit Per Club 3,000,000
ficipant Leg I M0,000
Pat
at Liability
N�
yr Personal and Advertising Injury Linut 1,000,000
rod ticts-Completed Operations Aggregate 3,000,000
% --i re Damage 10 pi ein I ses Rented to Y on
(Any One Premises) 1,000,000
Medical Expenses Limit(Any One person) 5,000
Sexual Abuse Liability 1,000,000
Sexual Abuse Aggregate 2,000,000
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ADDITIONAL INFORMATION AE - '4
�TIPN 1SMfJA,L4'il-ENIS
I'4T1 Practice,Blazin Ravenz Track Club front
Coverage avolies to Blazin u n,
12128,-'2018tliTotit,hOg13112101 fibk,i 3e o 'nb'Iilggtic' =tn Loor liabilities cif the AAU Club(s)of registered members.
For said club to have coverage,all1kren 1111) ire ents in the AAU must be met-
Primary non=contributory applies as oe\ che I on oror
,- cut EC(3 24 520(74 02
'File Certificate holder shall be an Additional Insured,but only with respect to the operations ofthe Named Insured,subject to the provisions and limitations of
the .olio°ies).attached CG 20 26 0413 applies.
CANCELLATION-Sbould arty ofthe above described policies be cancelled before the expiration date thereof notice wilt be delivered in accordance with
the policy provisions. But,future to mail such notices shall impose no obligation for liability of airy kind upon the insurer,its agents or representatives.
REVOCATIONOF MEMBE"'HIP-will result in cancellation ofcoverage.
FACILITY OWNER SHOtILD VERIFY TIIIS CERTIFICATE.
Go to www,eatisl)orts.org,Membership,Insurance,Issued Third Party Certificates, Insert member club code
Certificate No.20197126
Authorized Representative
11OLICY NUMBER:S I 8MLOO 176-181 COMMERCIM.,GENERAL LIABILITY
THIS ENDORSENIFNIf CHANGES THE POLICY.PLEASE READ IT[CAREFULLY'
ADDITIONAL INSURED-DESIGNATED PERSON OR ORGANIZATION
This endorsement modifies insurance provided under the fiollowing:
COMMERCIAL GENERAL LIABILITY COVERAGE lk I
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SCHEDULE',,,
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Name of Person or Organization: City ol'Clearwafe"I", 4'iq 1
800 Phiq v,
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Cleanvatcr,Fj, ,5 1,j'
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Event: Practice,Mazin Raven zl'nack Club has
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Date: 12128/20 18 through 08/31120L \
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THE ABOVE,PERSON VK OR(jAN,VA-T4O -D BY WRITTEN CONTRACT.
Nl"U F,47D AS REQUIRE
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N, endorsement 4 20197126
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(If no entry,appears, to(30mptele this cA§ M b S i cl r,ti 11s,ag"applicable to
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A. Section ll-Wh6is4 lnNlirq&('
s enQ adil
lit 11, K, i tions(s)shown in the
pe r§9
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N,Injam, Tf6prty dvertising injury caused,in
am�Vor*N�o al
Schedule,but only with�qpecth�' % N
whole or in part,by seobting
your ae4orom4skgiIis�p o
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1. In the performance
2. In connection with your pr I L v 'ned
�,rehllcd 10'Y"o
However:
"a I, t t permitted by 1-mv;and
I. The lnsuranqt,offpi��
to such Witipa4i
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2. lfcovei-dgep' ,v146dto,b&,,oddition�trr,�ttted IN t or agreement,the insurance afforded to such
additional insured witi,niat 0&,W40er thin (Xvhibh' pua1r v
y the contract or agreement to ide for such pro
additional insured. l,_,,,1,ll,,, N "0
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B. With Respect to the insur, ttrclulldianal insureds,the following is added to Section III-Limits Of
Insurance:
It,
If Coverage pn ro-vide'd to the cldztrlandl°'
is required by a contract or agreement,the most we will pay on behalf of the
additional insured is tti"c;�anlou i h ttZAnce:
I. Required by the contra I r agkte'went;or
1. 1
1 A vai tab I e under the applihigble Limits of Insurance shown in the Declarations,whichever is less.
'This Endorsement shall not increase the applicable Limits of Insurance shown in the Declarations.
CG 20 26 0413 Copyright,Insurance Services Office,Inc.,1984 Page I of 1
1301KY N U1 MBER:Sl 8M1,00 176-181 CONIMFRCIAL GENERAL LIABILITY
ECG 24 520 04 02
THIS ENI ORSENIENTCHANGES T111,POLICY.PLEASE RFAD IT CARFFULLY.
ADDITIONAL-OTHER INSURANCE
(PRIMARY NONCONTRIBUTORY)""""...,
This endorsement Hindi lies insurance provided under the hollowing:
COMMERCIA1,GF"NEIRA1.1JAB11,1TY COVE'RAGE'PARI
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A.Paragraph a.Primary Insurnee of 4. Other In-surancep, CT Q
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COMMERCIAL GENEI;UXL LIABILITY CONDITIONS �aQed
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4,6110wing:
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a. Primary Insurance
This insurance is primary exqr� t
insurance is primary, ourW*Ipns altNO t c I c
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other insurance is a1s6 pri" ar Nvb6o.
qu'
insurance by at
y
seek contri bu�o tr6 ix aespgrc in
written c4trq&ot� lb4zhtthat,fthi�,irw�hAiqc, yYfll b6,prmf ry an
noncontrib606- if fbe,#1riJ`, ajpontradt 6, agaementa "P ()r,io
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the subject"oNqurrenc, pr
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ECG 24 520 04 02 Includes copyrighted material of Insurance Services Office,Inc., Page I of I
with its permission
ORGANIZATIONAL LETTERHEAD
EXEMPTION FOR REQUIRED INSURANCES:
(check if applicable}
LAutomohile Liability Insurance
On behalf of the 1 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.
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Workers Compensation/Employe rs Liability Insurance
On behalf of the T� 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--21-7-c —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: O-f'Z,1Y e r- f4 C (VI
Title: -4�V
Name of Representative:
Signature:
Date: Z I f
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