CERTIFICATE OF LIABILITY INSURANCE [" 7—
ACORD- CERTIFICATE OF LIABILITY INSURANCE 71112712018E'MM/DD/YYYY)
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 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 fights to the
certificate holder in lieu of such endorsement(s).
PRODUCER
CONTACT
Chappell Insurance Agency NAME: richard@chappollinsurance.com
25807-A Cox Rd PHONE 804-733-2020 FAX804-733-2968
(
Petersburg,VA,23803 (Arc,No.Ext): 'J',No):
E-MAIL suppcil@chappellinsurance.com
ADDRESS:
INSURED R INSUR 0
�L_J�j AFFORDING COVERAGE NAIL
U.S.Amateur Basketball,LLC INSURER A: Nationwide Mutual Insurance Company 23787
P.O.Box 2929 INSURER B: Nationwide Life insurance Company 66869
Suwartee,GA 30024 INSURER C:
(6)Teams in Clearwater Basketball Club group INSURER D:
INSURER R.
INSURER F.
COVERAGES CERTIFICATE NUMBER: USAB-BK-6-000156 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
INSR ADDL IIB POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER (MMIDDffYY-Y) (MWD YY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACHOCCLIRRENCE 2.000000
7 CLAWS-MADE OCCUR DAMAGE To RENTED
X Abu ittioi millipri PREMISES(Ea occurrence) 300,000
A X PLL-$2,000,000 7� MED EXP(Any one Wson)
X RPG301061-00 0810112018 0810112019 PERSONAL&ADV INJURY 2,000,000
HGEN'L AGGREGATE LIMIT APPLIES PER: 12,01 AM 12 01 AM GENERAL AGGREGATE 51000,000
POLICY [:] PROJECT 7 LOC PRODUCT&COMPIOPAGG 2,000,000
X OTHER PARTC-IPANT LEGAL LIABILITY 2,000,000
UMBRELLALIAB OCCUR EACHOCCURRENCE
EXCESS LIAR _. GLAIMS•MADE AGGREGATE
DED I I RETENTION
EXCESS MEDICAL
PARTICIPANT ACCIDENT 1201 AM 12,01 AM
DEDUCTIBLE
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addlitonal Rernarks Schedule,may be attached it mare space is required)
Coverage includes amateur play and practice in the insured sport for Clearwater Basketball Club USAB-BK-5-000156.The certificate holder
is named as an additional insured but only with respect to the operations of the named insured.
Coverage Effective From 11126/2018 TO 08/01/2019
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED
City of Clearwater BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED
1501 IN BELCHER ROAD IN ACCORDANCE WITH THE POLICY PROVISIONS.
CLEARWATER,FL 33765 AUTHORIZED REPRESENTATIVE
Certificate Number: USAB-BK-5-000156
ACORD 25 (2014/01) @1998-2014 ACORD CORPORATION. All rights reserved.
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 C-�)C- _- 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.
zworkers Compensation/Employers Liability Insurance
On behalf of the C bic— I submit our organization does not have paid employees/volunteers
attend any practices,games,or organization sponsored activitles. Our workers compensation coverage
also does not provide coverage for volunteers.
Zproperty Insurance
On behalf of the C 6L 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.
C)
Name of Organization:
Title: —LIA 06,U
Name of Representative LW
Signature:
Date: