Loading...
CERTIFICATE OF LIABILITY INSURANCE c ca CERTIFICATE OF LIABILITY INSURANCE P' -THIS CF1171rICA. TS ISSUED?,AS A Ii.ATTF.1$-OFR1GI aNFONLYd:°IdtAilTti]N LY diNO CC?NFERS Hi3 TS lfPf YCERT1FaG1TE MCiEDER.TRPS:GERTI FiCATE B9Es Pit7T AFFIR1Yi gTtVELY AfI. H ATM-LYA'AEND,EXTEND OR AL-MR THE 60 ERAC�E AF ©itDED BY THE POLICIES,SELOW.7tirS C PTIF.t.7biE CATE OF f NWRANCE t7OE NOT L�e7PsSTf111TE.A CONTRACT BETWEEN THE ISSUING MURER(S AU1'H8i�1ZEf1 REPR�r-St-NTATNEORPF ODVCFP,ANN THE,CIo1'TIFIIbAT H MR 'IM3' TMT;:If Ihsqs anASJMKWAL.INSMrDE -Wk-064ey(i")treat be ondr mdd.If SUSROGAITON IS WAIYEI:d,iju*x:oatrn 16.m and condiikins 6f thapolocoda£po$cins may:qjpqw nandwsdnwLAsteMir iWINs e (y raterlonotmogi :9otheeer"ahaldei6ri�rafswh&w'4rww*nljs$ . .. witorstOrrlt CONTACT NAh Z: . S Ba3113.nefer -Inc. P'HdkdiNC FAKIAIG, 154 JFK Parkway No Ext] 00"126-1379 878 IQT 07078,-5'000 EMAIL AOD KESS: 1*lawxs: 804-A45-5311 -E"- 973-521-8236 INSI.IRERB WORdiNG COVERAGE NAIL# ? IteURER 0. ,Markel,lnsu arxcff cowpany W77 EISA SailMha1:1 azd Members of the JCd FL — Flor da jHStOEa�R:B= Irdividual Reglstrat=on Program 'Carlto7�$8J3t9i] INSURER C-� 1843 BO-dIverelFlSlifT Rt] 1.ske,31=d7 ft 3381£3 INSUROE_ COVERAGES CERTIFICATE-NUMBER,, REVISION MBER: 'UM IS T0,CERTkFY T"T TIRZ POLICIES OF 3HSU WCE LiSTCD BELOW HAVr;BEEN ISSUED 10 TIRE IRSUREWWAREt3�ABONIEL FOR THE P{OLICY'PEWOD:wgiq TED:.KO,rfflTHsrANORNo;ANY _QSIaFE'k1EH1;,TERIH SSR;C�hp3718N¢F ANY c6lfT'RACT?f3l'3IIHEiS9OG.Uk1EHT��MVITH RES f'EG7;7'O MtNIGH YHi$C IfiICRTE1i1e4Y BE 4"aS'13k37.k1FG Y 4'�F.ieTJ4fHr 1'tliE..NV5UR"CE,AFFr4¢!C',W-BY- .11HE PCC1CtE3 DES ® HLSR '11 St3BJir P Cil ALIa* T sS,rxoLUsf6Na Aux:coNdnmus r SUCK FouciES.uw" Si own-'HAY RAVE'BfEN,RFTItf6EpB'I`S!A1U CLAWS: NSRTYAi°BYF.iN$UtrANGE n PoucyNcin� € POM..€FF PDUCrEXP umus, Eye- 30=230069- zt36.112Aff'230069- -08101/18 a91.0-i°1o. nH!OCCLIFIRWCK faDts444 O 6wmE C-IAL GENERAL LLtWLtrlr ,• �-^� DAaMAG�E TQ RENTER usn I 1. e NeAdH orcurx y PREr»asES.[Ea wxI ca] X1,490,4574 El 'Nan-;PaetEr ,rnL,.an}y MED fAnY':orae Fre+'>ton) 14,C1E1IS • . karttliatst1,iahiiity PERSON,4L4AOV.kIIitRY $2r440,pt74 Segu>dF3ts06-b1lestdEidn$. tiperoeasrctc�:.:$9.L'k7C,6SQ .. r>eaa'.Auessuac&Aji'LuoiriAppufs PEn- Se ua6 Alves i S AWeslagcn Aggretjsta lia.szboo:goo, G_ENEWU AG°GREGATS. qS A:000..OqQ ❑POLICY mtojct v C t4 . ❑ EPRcse+vCass-ctaoa; 8z.4acr,o€aQ AUTOMQORE L ANOTY COPFL7�,1EASINGLEi�'ATIT �. ANY ALTir (E`s.acehiaT]- JALLOMEBA4lI>SS BO®aL'Y iNtUR* S _ �9Gt19,»EIVL�AUTY3S. (B'esPa�n^;] NMI),AtnO5 00MLYPN uPy 5. �rEl NON-OWNED AUTOS jPETlGtidR9F!} ",��-�-"i PRC/PIRM DAMAGE S L_E (oor mu ldent)� FACH OCCURRENCE: ❑. L.- CtcCUR L" ,AGGR£CaATie., ❑LIAR ❑CS..AMRS MADE . _ EBS D HET€?ROC3k S' 5 WORKWS CSNNPE99ATiON AND Qvrc STA"O"00TIMk EIIFPLCY£R'S LLAISHXN' YRd 1...-.i u1e11S F.,.� V7MZfVJX4I Di"+1rCXCt 1€r CUTTw'L. GF'�t,�OTi.EOIGLUITEE77 F._.,! E.i..E14C",RCC3DEHT IS S _ .;w f 'PRJ"d,afty1LNf. F EELt..Di7rSS3�I=a --EPNA11-EaMCYLLO1fkAlTit S lye!,j=,:ad:MSFnoNC s. OT'HE'R, oucmprwN OF OPPIATl4 S I LOCATIONS I VELNCLES Wimb A0ARH'�'F.,�4tdlYW WFLemw s Sch*Adr..d marc space Lt ugviead) COV HRIA PNDXR THIS PCILItY SBIiLL APPLY TO -t.Tn TITTY OF TAR INSURED ttS NG OUT Or TRE APTON:ESTRATIQN,. T?Lh-' COR '3tYLCTICE ()f? AhSATECIR=Si] I _ , -BUT._OHLY..- .3NCI12IINTS INVOLVING.BobILY I3i;7TFRY.QR,PRbPERTY DAMAGE, M..TISC TY 1 ODERIS KAHZD AS I 3U%I, 11150M. THIS'' RTIFICATS IS`.TSSWRD ON BE ._gT.* C1®arwitrur T.44y Bombers 1 F14 Cao1¢ CERTIFICATE HOLDER CANCELLATION City at' Cleazwate'r- SHOULD.ANY OF TETE ABOVE-DESCFJBED POLICIES BE. CANCELLED SE.FOiIETHE-E3CPIRA TION 6A'E THEREt1F,NCiTICEMI.L Eat 6EI.,1'4IERELI.I ACC RRDANCI WIT H"1'HEPQLJ YPROVISIONS. 3854 Drew St. AUTHORMED REPRESEJLTAME 01eax.ratP-r n6rida a375g ACORD 25(2014145) 61068-2018 ACORD Ct1RFIORATION-Affrights reserved. The ACORD-natateand I©gcr are registered marks-of ACORD _._....- Clearwater Lady Bombers EXEMPTION FOR REQUIRED INSURANCES: (check if applicable) Automobile Liability Insurance On behalf of the W3 &mxr- I submit our organization dues 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. Workers Compensation/Employers Liability Insurance On behalf of the t-41 91LWs 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 W-1 bov-�46 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: �,I�� �� � ����] 6#"►er5 Title: Name of Representative; .tr Signature: Bate: ' - `1