CERTIFICATE OF LIABILITY INSURANCE CERTIFICATE OF LIABILITY INSURANCE F DATE(MMiDDIYYYY)
01/3112019
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 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 rights to the certificate holder in lieu of such endorsement(s).
PRODUCERCONTACT NAIVE. ,lack Miller
Coleman Insurance Agency,Inc P NQ.N Ext), (727)441 9911 N®, (727)441-9586
4831 Ruen Dr E-MAIL
ADDRESS: Jack@ColemanAgencyFL.com w
Suite 200 INSIURER($)AFFORDING COVERAGE � NAIC#
Palm Harbor FL 34685 INSURER A: PHILADELPHIA INDEMNITY INS 18058
INSURED INSURER 8
The Kimberly Home,Inc. INSURER C:
1189 N.E.Cleveland Street INSURER D:
INSURER E
Clearwater FL 33755 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
[EXCLUSIONS
HIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
DICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
ERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
. TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP POLICYNUMBER MMIDD YYY (MMMDrfYYY) LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
PREMISES ERENTEDu ncep...®,..
CLAIMS-MADE OCCUR $ 100,000
MED EXP(Any one person) $ 5,000
A PHPK1772529 0210112019 02101/2020 PERSONAL s ADV INJURY $ 1,000 000
GEN L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000
PR
X POLICY F JECCT- 1:1 LOC PRODUCTS-COMPIOP AGG $ 2,00'0,000
OTHER; $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
ANY AUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED PHPK1772529 02/01/2019 02/0112020 BODILY INJURY Par accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED OROPER-ZrAGE
AUTOS ONLY AUTOS ONLY Per accidont
LX $
UMBRELLA LIAR OCCUR EACH OCCURRENCE
]EXCESS LIAR CLAIMS-MADE AGGREGAT€..... $
DED F RETENTION$ $
WORKERS COMPENSATION I AER I O1TH-
AND EMPLOYERS'LIAfIILITYTAT TE ER ��
Y7N
ANY PROPRIETC RIPARTNERdEXEGUTIVE: L""j I E.Ly EACH ACCIDENT _ $_.--
lof f1IC 1JMJzM8LR EXCLUDED? i_..__I N J A
(Mandatory In NN) E.L.DISEASE-FA EMPLOYE $
If yea,describe under - - -
DESCRIPTION OF OPERATIONS below �� E.L.DISEASE-POLICY LIMIT $
Directors&Officers Professional Each Claim 1,(100,000
A Liability Retroactive 011011241 1 PHSD1407171 01/0112019 01/01/2020 Aggregate 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Additional Remarks Schedule,may he attached If more space is required)
Locations:114 North Missouri Avenue Clearwater FL,1181-1183 Browns Court Clearwater and 1192 Browns Court Clearwater
RECEIVED
CERTIFICATE HOLDER I CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Clearwater GAS ADMIN ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
400 N.Myrtle Avenue
Clearwater FL 33755 � �"' �--- �`•-r-� �—�`� -
a 1988-2015 ACORD CORPORATION. All rights reserved.
CORD 25(2016103) The ACORD name and logo are registered marks of ACORD