CERTIFICATE OF LIABILITY INSURANCE (11) A ® DATE(MMlDDlYYYY)
C"R" CERTIFICATE OF LIABILITY INSURANCE 06/09/2020
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
Marsh USA,Inc. NAME'
PHONE FAX
3031 N.Rocky Point Drive West,Suite 700 A/C No Ext): A/C NO)7
Tampa,FL 33607 E-MAIL
ADDRESS:
INSURER(S)AFFORDING COVERAGE MAIC#
116677224-CCBF-GAWUC-20-21 INSURER A:Safety National Casualty Corp. 15105
INSURED INSURER B:XL Specialty Insurance Company 37885
Coca-Cola Beverages Florida,LLC
10117 Princess Palm Avenue,Suite 100 INSURER C:Indian Harbor Insurance Co. 36940
Tampa,FL 33610
INSURER D
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: ATL-005042113-03 REVISION NUMBER: 0
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 INSR WVD POLICYNUMBER MMlDDlYYYY MMlDDlYYYY
A COMMERCIAL GENERAL LIABILITY GL-4062918 04/01/2020 04/01/2021 EACH OCCURRENCE $ 1,500,000
CLAIMS-MADE 1XI OCCUR SIR per policy terms and conditions DAMAGE TO PREM SES Ea occurrRENTEence) $ 500,000
MED EXP(Any one person) $ 5,000
PERSONAL&ADV INJURY $ 1,500,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 3,500,000
X POLICY❑ PRO JECT ❑ LOC PRODUCTS-COMP/OP AGG $ 3,500,000
OTHER: $
A AUTOMOBILE LIABILITY CA-6675562 04/01/2020 04/01/2021 COMBINEDINGLELIMIT
EaaccidentS $ 5,000,000
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 UMBRELLA LIAB X OCCUR US-00071476LI-20A 04/01/2020 04/01/2021 EACH OCCURRENCE $ 1,000,000
EXCESS LIAB CLAIMS-MADE AGGREGATE $ 1,000,000
DED X RETENTION$10,000 $
A WORKERS COMPENSATION LDS4062915 04/01/2020 04/01/2021 X PER OTH-
AND EMPLOYERS'LIABILITYY/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000
OFFICER/MEMBER EXCLUDED? ❑N NIA
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 1,000,000
If yes,describe under 1,000,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
C Cyber MTP-903697902 05/29/2020 05/29/2021 Aggregate 5,000,000
SIR:$100,000 SIR per policy terms and conditions See Acord 101
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
City of Clearwater is included as Additional Insured where required by written contract with respect to the General Liability and Automobile Liability policies.
CERTIFICATE HOLDER CANCELLATION
City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
100 South Myrtle Avenue THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Clearwater,FL 33756-5520 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTATIVE
of Marsh USA Inc.
Suzanne ShannonEc
O 1988-2016 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
AGENCY CUSTOMER ID: 116677224
LOC#: Tampa
ACS" ADDITIONAL REMARKS SCHEDULE Page 2 of 2
AGENCY NAMED INSURED
Marsh USA,Inc. Coca-Cola Beverages Florida,LLC
10117 Princess Palm Avenue,Suite 100
POLICY NUMBER Tampa,FL 33610
CARRIER MAIC CODE
EFFECTIVE DATE:
ADDITIONAL REMARKS
THIS ADDITIONAL REMARKS FORM IS A SCHEDULE TO ACORD FORM,
FORM NUMBER: 25 FORM TITLE: Certificate of Liability Insurance
Cyber Liability:
Combined Policy Aggregate Limit-$5,000,000
Media$5,000,000/Retention$100,000
Privacy and Cyber Secu*$5,000,000/Retention$100,000
Claims Made Policy
Retro Date-Full Prior Acts
ACORD 101 (2008/01) (D 2008 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD