CERTIFICATE OF LIABILITY INSURANCE (22) AC 1 CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY)
04/02/2019
THIS CERTIFICKATE WISSUED AS A PUTTER F RMPMATI514 6INLY XN15 CONFERS NO RIGHTS UPON THE CERTIFICATE OLDER. TWI
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.
IM : If the certificate holder is an ADDITIONAL INSURED,the policy(les)must have 70511MNAL INSORED 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: Mass Merchandising Underwriting
K&K Insurance Group, Inc. 1-840-328.2317
AIC No Ext): AlCNo 1-26(x-459-5542
.
1712 Magnavox Way
Fort Wayne IN 46804 ADDRESS: entertainers@kandkinsurance.com
CUSTOMER Io:
INSURERS)AFFORDING COVERAGE NAIL#
INSURED INSURER A: Nationwide Mutual Insurance Company 23787
Howard A Frostm'an INSURER B:
DBA:Tony the Balloon Guy INSURER C:
21230 Moore Road
Brooksville FL 34604 INSURER D:
A Member of the Sports, Leisure&Entertainment RPG INSURER E:
INSURER F:.
COVERAGES CERTIFICATE NUMBER: W01412859 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-
LTR TYPE INSURANCE INSD wVD POLICY NUMBER FAMIDDiYYYS' MM QDfYYYY LIMITS
A X COMMERCIAL GENERAL LIABILITY K 6BRPGO000007005600 0412612019 04126/2020 EACH OCCURRENCE $1,000,000
CLAIMS- 12:01 AM EDT 12:01 AM r
MADE X I OCCUR PREMISES Ea Occurrence $1,000,000
MED EXP(Any one Person) $5.000
PERSONAL&ADV INJURY
GENERAL AGGREGATE $5,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $1,000,000
POLICY [:]!PRO- �
JECT I.00 PROFES6IONAL LIABILITY
OTHER: LEGAL LIAR TO PARTICIPANTS $1,000.000
AUTOMOBILE.LIABILITY i w L IIv41
E770
a racciden Ii
ANY AUTO BODILY INJURY(Per person)
MA IED AUTOS ®'SCHEDULED
ONLY I,AU rOS BODILY INJURY(P4 occioanl)
HIRED NON 6WNED PdIOPERTY DAMA E
.... AU 1 OS ONLY J AUTOS ONLY � Zr auc�rz�rl,
NOT'PREPVIr.)EI:I VA-ILE IN HAWA'l
- UMBRELLA L1Aa f}tiJi:LJF"w EACH OCCURRENCE
, _ u ........_
P1 EXCESS LIAR CLAIMS-MADE AGGREGATE
DED RETENTION
WORKERS COMPENSATION AND N/A PER OTHER
EMPLOYERS'LIABILITY STATUTE
ANY PROPRIETOR PARTNERI YIN E,L EACH ACCIDENT
EXECUTIVE OFFICERIMEMBER i DISEASE-EA EMPLOYEE
t
EXCLUDED?(Mandatory in NH) i_J _..
IF yes,descrte under DESCRIPTION E.L.DISEASE-POLICY L AMT
OF OPERATIONS belc+.v _
A MEDICAL PAYMENTS FOR PARTICIPANTS 613RPG0000007005600 04/26)2019 04/26/20217 PRIMARY MEDICAL $5.0001
12.01 AM EDT 12:01 AM EXCESS MEDICAL
DESCRIPTION OF OPERATIONS'LOCATIONS t VEHICLES(ACORD 101,.Additional Remarks Schedule,may be attached It more space is required)
Performing as Balloon artist Face painter(use of non toxic and FDA Compliant Ingredients only) Juggler,Magician,Musician/singer/vocalist,Storyteller
The certificate holder Is added as an additional Insured, but only for liability caused,in whole or In part, by the acts or omissions of the named insured.
CERTIFICATE HOLDER CANCELLATION
City Of ClearwaterTHE ULEXPIRATILON THE
DATE THEREOF,BENOTICE IES
WILL BE DELIVERED BEFORE
IN
PGI BOX 4745
Clearwater,FL 33758 ACCORDANCE WITH THE POLICY PROVISIONS,
(Owner/Lessor of Premises) AUTHORIZED REPRESENTATIVE
Coverage Is only extended to U.S.events and activities.
* NOTICE TO TEXAS INSUREDS:The Insurer for the purchasing group may not be subject to all the insurance laws and regulations of the State of Texas
ACORD 25(2016103). C 1988-2016 ACORD CORPORATION. All rights reserved,
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