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CERTIFICATE OF LIABILITY INSURANCE (19) DATE(MMIDD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 06/01/2020 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 Peggy Amos NAME: Lassiter-Ware Insurance of Tampa Bay HCNN. Ext): (800)845-8437 a/c,No): (888)883-8680 1300 N.Westshore Blvd E-MAIL Pe A lassiterware.com ADDRESS: g Suite 110 INSURER(S)AFFORDING COVERAGE NAIC# Tampa FL 33607 INSURERA: United States Fire Insurance Company 21113 INSURED INSURER B: The North River Insurance Company 21105 Boys&Girls Clubs of the Suncoast,Inc INSURER C: 4625 East Bay Drive INSURER D: Suite 103 INSURER E: Clearwater FL 33764 INSURER F: COVERAGES CERTIFICATE NUMBER: 20-21 Pkg/Excess Rewrite 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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 INSURANCEAUULbUBK POLICY EFF POLICY EXP LTR INSD WVD POLICY NUMBER MMIDD/YYYY MMIDD/YYYY LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1'000'000 CLAIMS-MADE FX OCCUR PREM SDAMAGES Ea oNcurDreme $ 100,000 MED EXP(Any one person) $ 5,000 A Y 506-899195-2 06/01/2020 06/01/2021 PERSONAL&ADV INJURY $ 1'000'000 GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 2'000'000 X POLICY ❑ PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 2,000,000 JECT X1 OTHER: Professional Liability $1,000,000 Occurrence $ 2,000I00OAgg AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 Ea accident X ANYAUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED Y 506-899195-2 06/01/2020 06/01/2021 BODI LY I NJ U RY(Pe r accide nt) $ AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTY DAMAGE $ AUTOS ONLY AUTOS ONLY Per accident PIP-Basic $ 10,000 UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4'000'000 B X EXCESS LAB CLAIMS-MADE 582-114275-1 06/01/2020 06/01/2021 AGGREGATE $ 4'000'000 DED I X1 RETENTION $ 0 $ WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANY PROPRIETOR/PARTNER/EXECUTIVEElN/A E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Abuse&Molestation A 506-899195-2 06/01/2020 06/01/2021 $1,000,000 Occurrence $3,000,000Agg DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Employment Practices Liability Policy#NPP1573040C 10/28/2019-12/1/2020$1,000,000 Per Occurrence w/$1,000 per claim deductible. Directors&Officers Liability Policy#NPP1573040C 10/28/2019-12/1/2020$1,000,000 Per Occurrence w/$1,000 per claim deductible. City of Clearwater Parks and Recreation Department is included as an additional insured under the terms and conditions of the attached forms and the General Liability and Automobile Liability Policies,when additional insured status is required by written contract.Excess Liability Policy extends over the underlying General Liability and Automobile Liability Policies. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN City of Clearwater Parks and Recreation Department ACCORDANCE WITH THE POLICY PROVISIONS. 100 S.Myrtle Avenue AUTHORIZED REPRESENTATIVE Clearwater FL 33756 ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD DATE(MMIDD/YYYY) � CERTIFICATE OF LIABILITY INSURANCE 06l041202Q 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: Doug Jones PHONE FAX c/o Artex Risk Solutions, Inc. Arc No E.11: (480)951-4177 n c No; (480)951-4266 E-MAIL SDL.BSD.Certificates@artexrisk.com 8840 E.Chaparral Rd.;Suite 275 ADDRESS: Scottsdale,AZ 85250 INSURER(S)AFFORDING COVERAGE NAIC# INSURER A: American Zurich Insurance Company 40142 INSURED INSURER B: Oasis,a Paychex Company Aft.Emp:Boys&Girls Clubs of Suncoast Inc 8215 Forest Point Blvd Suite 150 INSURER C: Charlotte,NC 28273 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER:20FL281991574 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 ADDLTYPE OF INSURANCE INSD WVD SUER POLICY NUMBER POLICY EFF MM/DD/YYYY LIMITS LTR COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS-MADE El OCCUR PREM SESOEa occurrDence $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: - GENERAL AGGREGATE $ POLICY❑ PECT RO [:] LOC PRODUCTS-COMP/OP AGG $ J OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident) ANY AUTO BODILY INJURY(Per person) $ OWNED SCHEDULED BODILY INJURY(Per accident) It AUTOS ONLY AUTOS HIRED NON-OWNED PROPERTYDAMAGE $ AUTOS ONLY P AUTOS ONLY Per accident UMBRELLA LIAB OCCUR EACH OCCURRENCE $ _ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATIONX PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER ANYPROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1,000,000 A OFFICER/MEM BER EXCLUDED? NIA WIC 67-35-454-01 06/0112020 06101/2021 -- (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 Location Coverage Period: 0610112020 0610112021 Client# 40881-FL DESCRIPTION OF OPERATIONS 1 LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required) Coverage is provided for Boys&Girls Clubs of Suncoast Inc only those co-employees 4625 E Bay Drive#103 Service Center of,but not subcontractors Clearwater,FL 33764 to: CERTIFICATE HOLDER CANCELLATION City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO Box 4748 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Clearwater,FL 33758 ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE �r��r rIAYIA�� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and loco are registered marks of ACORD