CERTIFICATE OF LIABILITY INSURANCE (20) DATE(MM/DD/YYYY)
AC"R" CERTIFICATE OF LIABILITY INSURANCE
06/22/2022
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 Jessica Komons
NAME:
Brown&Brown of Florida,Inc. a/CNr o Ext): (727)461-6044 a/c,No): (727)442-7695
83 Park Place Blvd,Suite 101 E-MAIL Jessica.Komons@bbrown.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Clearwater FL 33759 INSURERA: Southern-Owners Insurance Company 10190
INSURED INSURER B: FFVA Mutual Insurance Co. 10385
Clearwater Golf Associates Inc INSURER C:
1875 Airport Dr INSURER D:
INSURER E:
Clearwater FL 33765-2002 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL2262286879 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 $ 300,000
MED EXP(Any one person) $ 10,000
A Y 20115551 06/17/2022 06/17/2023 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
PJECT
OTHER: $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANYAUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED 20115551 06/17/2022 06/17/2023 BODILY INJURY(Per accide nt) $
AUTOS ONLY AUTOS
X HIRED �/ NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY X AUTOS ONLY Per accident
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DED I I RETENTION $ $
WORKERS COMPENSATIONX1 STER ATUTE EORH
AND EMPLOYERS'LIABILITY Y/N 1 OO,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
B OFFICER/MEMBER EXCLUDED? N/A WC840-0016106-2022A 03/17/2022 03/17/2023
(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 $
Liquor Liability Aggregate 1,000,000
A 20115551 06/17/2022 06/17/2023 Each Common Cause 1,000,000
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
Excluded Officers:Jerry Huston,Julie Huston,John Huston,Suzanne Huston
City of Clearwater is Additional Insured with regspect 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 ATTN:Michael Lavery ACCORDANCE WITH THE POLICY PROVISIONS.
P.O.Box 4748
AUTHORIZED REPRESENTATIVE
Clearwater FL 33758f
:. a
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD