CERTIFICATE OF LIABILITY INSURANCE (21) DATE(MM/DD/YYYY)
AC"R" CERTIFICATE OF LIABILITY INSURANCE
02/03/2021
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 Keith Thompson
NAME:
Brown&Brown of Florida,Inc. a/CNr o Ext): (727)461-6044 a/c,No): (727)442-4695
Pinellas Division E-MAIL kthompson@bbpinellas.com
ADDRESS:
83 Park Place Blvd,Suite 101 INSURER(S)AFFORDING COVERAGE NAIC#
Clearwater FL 33759 INSURERA: Philadelphia Indemnity Insurance Company 18058
INSURED INSURER B: RetailFirst Insurance Company 10700
Chi Chi Rodriguez Youth Foundation,Inc. INSURER C:
3030 McMullen Booth Rd. INSURER D:
INSURER E:
Clearwater FL 33761 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL212322418 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 MM/DD/YYYY MM/DD/YYYY LIMITS
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
CLAIMS-MADE FX OCCUR PREM SDAMAGES Ea oNcurDrence $ 100,000
MED EXP(Any one person) $ 5,000
A PHPK2231277 02/01/2021 02/01/2022 PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000
X POLICY ❑ PRO ❑ LOC PRODUCTS-COMP/OP AGG $ 3'000'000
JECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
X ANYAUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED PHPK2231277 02/01/2021 02/01/2022 BODILY INJURY(Pe r accide nt) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
PIP-Basic $ 10,000
X UMBRELLA LIAB OCCUR EACH OCCURRENCE $ 4,000,000
A EXCESS LAB HCLAIMS-MADE PHUB754532 02/01/2021 02/01/2022 AGGREGATE $ 4'000'000
DED I X1 RETENTION $ 10,000 $
WORKERS COMPENSATION ER/� STATUTE EORH
AND EMPLOYERS'LIABILITY Y/N 1'000'000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
B OFFICER/MEMBER EXCLUDED? N/A 0520-60017 02/01/2021 02/01/2022
(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 $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Certificate holder is an Additional Insured with respect to General Liability if required by written contract.
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 ACCORDANCE WITH THE POLICY PROVISIONS.
P.O.Box 4748
AUTHORIZED REPRESENTATIVE
Clearwater FL 33756-5520
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