CERTIFICATE OF LIABILITY INSURANCE (8) fir, QDATE QMIMfDD7YYYY)
p9s CERTIFICATE LIABILITY INSURANCE r 08/12/2020
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 ri hts to the certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT Wend Wilson
NAME,, y
'ftl', a oif"Ill Dick Markin Insurance Agency Inc. PHONE 727-785 4995 Nol. 727-785-0499
Il�r 30826 US Hwy 19 N EDoal : WendyWilson.MC3QJ'at��.statefarrn.com
itf" Palm Harbor,FL 34684
__INSURERS AFFOROING COVERAGE INAIiC#
INSURER A! State Farm Mutual Automobile Insurance Company 25178
INSURED INSURER B: -
BATES,EDWARD N INSURER C:
DBA KINNEYS KITCHEN INSURER D
1540 CLUB DR INSURER F,
TARPON SPGS FL 34689-7027 INSURER F'
COVERAGES CERTIFICATE NUMBER, REVISION NUMBER:
THIS 13 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 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS..
INSR ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR TYPE OF INSURANCE POLICY NUMBER MM MM! DIYYYY
COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $
CLAJMS-MADE l OCCUR @ DAMAGETORENTED
L
p PREMISES_ jEa occurrence $
MED EXP(Any one person)
PERSONAL&ADV INJURY S
GEN'LAGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $
POLICY[ ]JEOTPRO- L] LOC PRODUCTS-COMP)OPAGG S
OTHER- $
AUTOMOBILE LIABILITY Y E92 431 O-D20-59A 04/20/2020 10120/2020 COMBINED SINGLE LIMIT
Ea.accident
ANY AUTO BODILY INJURY(Per person) $ 1,000,000
A OWNED SCHEDULED BOMLYINJURY(Per accident) $ 1,000,000
AUTOS ONLYH
AUTOSHIRED NON-OWNED PROPERTY DAMAGE $ lappppp
AUTOS ONLYAUTOS ONLY Per accident _
$
UMBRELLA LIAR OCCUR EACH OCCURRENCE $
EXCESS LIAR CLAIMS-MADE AGGREGATE $
DED RETENTIONS $
WORKERS COMPENSATION PER
ERS
EMPLOYERS'LIABILITY YIN N STATUTE ER
ANY PROPMETORPARTNERIEXECUTIVE E.L.EACH ACCIDENT $
OFFICERIPAEMBER EXCLUDED? N P A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYE $
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additionat Remarks Schedule„may be attached'.if more space is required)
2008 DODGE RAM 1600 PICKUP VIN: 1 D7HA1828BS608303
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DES ElD POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE T EOF NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE P CY PROVISIONS.
City of Clearwater
PO 130X 474$ AUTHORIZED REPRESENTATIV
Clearwater,FI_33758-4748
Q 198 015 ACORD'CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
1001485 132849.13 64-22.2620