CERTIFICATE OF LIABILITY INSURANCE (10) DATE(MM/DD/YYYY)
A�" CERTIFICATE OF LIABILITY INSURANCE
02/03/2022
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 Melony Perez
StateFarm Dick Martin Insurance Agency Inc A/CNNo Ext: 727-785-4995 a/c No: 727-785-0499
30826 US Hwy 19 N ADDRESS: Melony.Perez.SNQX@statefarm.com
Palm Harbor, FL 34684 INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: State Farm Florida Insurance Company 10739
INSURED INSURER B: State Farm Mutual Automobile Insurance Company 25178
Edward N Bates INSURERC: State Farm Fire and Casualty Company 25143
Kinneys Kitchen LLC INSURER D:
1540 Club Dr INSURER E:
Tarpon Springs FL 34689 INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS
LTR INSD WVD POLICY NUMBER MM/DD/YYYY MM/DD/YYYY
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTE
CLAIMS-MADE � OCCUR PREMISES
(E.occur.ence) $ 1,000,000
MED EXP(Any one person) $ 10,000
A Y N 98-CM-S680-4 02/01/2022 02/01/2023 PERSONAL&ADV INJURY $
GEN'LAGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,000
X
POLICY PRO-
LOC PRODUCTS-COMP/OPAGG $ 2,000,000
OTHER:
Employee Dishonesty $ 50,000
AUTOMOBILE LIABILITY Y N E92 4310-D20-59A 10/20/2021 04/20/2022 COEaMBINED accident SINGLE LIMIT $
ANY AUTO BODILY INJURY(Per person) $ 1,000,000
B OWNED SCHEDULED BODILY INJURY(Per accident) $ 1,000,000
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $ 1,000,000
AUTOS ONLY AUTOS ONLY Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE AGGREGATE $
DED RETENTION$ $
WORKERS COMPENSATION X PER OTH-
AND EMPLOYERS'LIABILITY /�Y/N STATUTE ER
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000
C OFFICER/MEMBER EXCLUDED? Y N/A 98-CB-X027-1 10/30/2021 10/30/2022
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
If yes,describe under 500,000
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)
Concession Stand(Restaurant:Fast Food)2998 Drew St.Clearwater, FL 33759
2008 Dodge Ram 1500 VIN 1 D7HA18288S608303
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Clearwater
PO Box 4748 AUTHORIZED REPRESENTATIVE
Clearwater, FL 33758-4748
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD
1001486 132849.13 04-22-2020