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CERTIFICATE OF LIABILITY INSURANCE (12) Aco® CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) L..---- - 09/26/2021 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 Maribeth Patino NAME: Stahl&Associates Insurance Inc. Vac.N ). (813)818-5300 FAX No): (813)818-5396 3939 Tampa Road E-MAIL maribeth.patino@stahlinsurance.com ADDRESS: INSURER(S)AFFORDING COVERAGE NAIC# Oldsmar FL 34677INSURERA: FCCI Insurance Company 10178 INSURED TechnologyInsurance Co 42376 INSURER B: Clearwater Golf Club LLC INSURER C: 525 N Betty Lane INSURER D: INSURER E: Clearwater FL 33755 INSURER F: COVERAGES CERTIFICATE NUMBER: 21-22 Liability 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 •.. SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE ,INSD WVD POLICY NUMBER (MM/DD/YYYY) (MM/DD/YYYY) LIMITS X COMMERCIAL GENERAL LIABILITYEACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED 100,000 CLAIMS-MADE X OCCUR PREMISES lEa occurrence) , $ MED EXP(Any one person) $ 10,000 A Y CPP10003036004 10/01/2021 10/01/2022 PERSONAL BADVINJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000 POLICY XI jE OT- 1-1 LOC PRODUCTS-COMP/OP AGG $ 2,000,000 xlOTHER: Liquor Liability Liquor Liability $ 1,000,000 AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO BODILY INJURY(Per person) $ A OWNED SCHEDULED Y CA0017060 10/01/2021 10/01/2022 BODILY INJURY(Per accident) $ AUTOS ONLY AUTOS X HIRED X NON-OWNED PROPERTY DAMAGE $ - AUTOS ONLY _ AUTOS ONLY (Per accident) — XUMBRELLALIAB OCCUR EACH OCCURRENCE $ 1,000,000 A EXCESS LIAB CLAIMS-MADE UMB10001709805 10/01/2021 10/01/2022 AGGREGATE $ 1,000,000 DED X RETENTION$ 0 $ +WORKERS COMPENSATION PER OTH- AND EMPLOYERS'LIABILITY Y/N STATUTE ER B ANY PROPRIETOR/PARTNER/EXECUTIVE N OFFICER/MEMBER EXCLUDED N/A TWC4017522 10/01/2021 10/01/2022 E.L.EACH ACCIDENT 500 000 $ , (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ Scheduled Equipment $480,430 Inland Marine A CM10003036204 10/01/2021 10/01/2022 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached if more space is required) City of Clearwater is listed as additional insured with respect to general liability per form CG2011(attached)subject to the terms,conditions and exclusions of the policy. City of Clearwater is listed as additional insured with respect to auto liability per form CA0001(attached),subject to policy terms,conditions, and exclusions. 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&Recreation Dept. ACCORDANCE WITH THE POLICY PROVISIONS. 100 So Myrtle Ave AUTHORIZED REPRESENTATIVE Clearwater FL 33756 --'1:4:%4,,•,e, '" O I ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD