CERTIFICATE OF LIABILITY INSURANCE (19) 72/1/2019
E(MM/DDYYY)
A�" CERTIFICATE OF LIABILITY INSURANCE /Y
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).
PRODUCER CONTACT
NAME: Keith Thompson
Brown &Brown Insurance-Clearwater PHONE FAX
83 Park Place Blvd., Suite 101 A/C No Ext): 727 461-6044 A/c,Noy 727-442-7695
E-MClearwater FL 33759-3925 ADDRESS: kthompson@bbpinellas.com
INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: National Casualty Company 11991
INSURED CHICHIR-01 INSURERS:Zenith Insurance Company 13269
Chi Chi Rodriguez Youth Foundation, Inc.
3030 McMullen Booth Rd. INsuRERc:
Clearwater FL 33761 INSURER D7
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:233568118 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MM/DD MM/DD
A X COMMERCIAL GENERAL LIABILITY KK00000007253300 2/1/2019 2/1/2020 EACH OCCURRENCE $1,000,000
�
OCCUR DAMAGE TO
CLAIMS-MADE
PREMISES(E.
occurrence)
ccurrence) $300,000
MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $None
POLICY❑ PRO-
[:]JECT LOC PRODUCTS-COMP/OP AGG $10,000,000
OTHER: $
A AUTOMOBILE LIABILITY KK00000007253300 2/1/2019 2/1/2020 COMBINED SINGLE LIMIT $1,000,000
Ea accident
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
X PIP$10,000 $
A X UMBRELLA LAB X OCCUR XK00000007253400 2/1/2019 2/1/2020 EACH OCCURRENCE $1,000,000
EXCESS LAB CLAIMS-MADE AGGREGATE $1,000,000
DED X RETENTION$n $
B WORKERS COMPENSATION Z836521219 2/1/2019 2/1/2020 X PER OTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $1,000,000
OFFICE R/M EMBER EXCLUDED? FN] N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
A Liquor Liability KK00000007253300 2/1/2019 2/1/2020 Per Occurrence 1,000,000
Aggregate 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Certificate holder is an Additional Insured with respect to General Liability if required by written contract.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater
P. O. Box 4748 AUTHORIZED REPRESENTATIVE
Clearwater FL 33756-5520
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