CERTIFICATE OF LIABILITY INSURANCE (5) ,�+► i i� CERTIFICATE OF LIABILITY INSURANCE DATEIMM,DI�IYM
- 1012312018
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 INSPIRED 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 rip his to the certificate holder in lieu of such endorsementjs).
PRODUCER CONTACT TERRI MONDEALI
NAME,m ���
ate DICK.MARTIN INSURANCE AGENCY INC PHONE 727-785,4995 f IAArC,Nal. 727-785 4499
30826 US HIGHWAY 19 N EDDRESMAIL S, terd.monderau.hznc@statefarm.Co
PALM HARBOR,FL 34684 _
INsuRERIS)nrraRraNG caovERAGE NAIc r
INSURER A.-State Farm Mutual Automobile insurance Company 25178
INSURED �,..._..,..,
INSURER B
EDWARD N BATES DBA KINNEYS KITCHEN INSURER C.
1540 CLUB DR INSURER D:
TARPON SPRINGS,FL 34689 INSURER E
INSURER.F: -.
COVERAGES CERTIFICATE NUMBER 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 SLleR � .®...�.'.
LTR TYPE OF INSURANCE POLICY NUMBER 9A IMM NCY YYYIMWI)DffYYYI
Y£91P LIMITS
COMMERCIAL GENERAL LIABILITY --FEACH OCCURRENCE S
CLAIMS-MADE OCCUR DAMAGE TO KL N I LU
PREI�IS Ea occurrence)
MEDEMP,,,,.(lSr rxee rson:
-- I PERSONAL S ADV INJURY $
GENT AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE S
POLICY I-- I JEODT F1 LOC PRODUCTS-COMPIOP AGO s
OTHER: $
AUTOMOR"LIABILITY Y E92 4314-D20-59A 1OJ20/2018 0412412419 COM9INED sINCL E uiwtT
E'a acdelae __
ANY ALTO BODILY INJURY{Per persons) $ 1.444,444
A OWNED SCHEDULED BODILY INJURY Pe
AUTOS ONLY AUTOS (Per nt) $ 1,444,440
HIRED NON-4VVNED PfTC7PERTY DAMAGE S 1,000,1744
AUTOS ONLY AUTOS ONLY Pdr s dent
S
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
EXCESS LJAB CLAIMShtADE AGGREGATE $..-.
DED RETENTION$ $
WORKERS COMPENSATION 1€'ER H
AND EMPLOYERS!LIABILITY YIN ATUTE ER
ANY PROPRIETORIPARTNERZ31ECUTIVE E.L.EACH ACCIDENT $ _
OFFICEPUMEMBER EXCLUDE N/A
NIA .
(Mandatory In NH) E.L.DISEASE-EA EMPLOYE
II y�s%descfto under
DESCRIPTION OF OPERATIONS belrna E.L.DISEASE-POLICY LIMIT S
DESCRIPTION OF OPERATIONS 1 LOCATIONS 1 YENCLES(ACORD 101,Additional Remarks Schedule,any be attadwd II'rsAssra space is required)
DESCRIPTION OF VEHICLE:2648 DODGE RAM 1500 P-UP VIN ID7HA18288S608303
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY O E ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE E%PI CON DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF CLEARWATER ACCO r D CE THE POLICY PRCOVISIONS.
PO BOX 4748
AUTii __XESENTAIT
VE
CLEARWATER,FL 33759-474.8
1988-2415 ACORD,CORPORATION. All rights reserved.
ACORD 25(2016103) The ACORD name and logo aregistered marks of ACORD
1001486 132845,12 03-16-201.6