CERTIFICATE OF LIABILITY INSURANCE (14) DATE(MWDD/YYYY)
AC"R" CERTIFICATE OF LIABILITY INSURANCE
09/28/2023
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 Madison Oxiner
NAME:
Stahl&Associates Insurance Inc. a/CNr o Ext): (813)818-5300 a/c,No): (813)818-5396
3939 Tampa Road E-MAIL madison.oxiner@stahlinsurance.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Oldsmar FL 34677 INSURERA: GreatAmerican Insurance Co 16691
INSURED INSURER B: FCCI Insurance Company 10178
Clearwater Golf Club LLC INSURER C: Technology Insurance Co 42376
525 N Betty Lane INSURER D:
INSURER E:
Clearwater FL 33755 INSURER F:
COVERAGES CERTIFICATE NUMBER: 23-24 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 $ 500,000
MED EXP(Any one person) $ 20,000
A Y MAC490769000 10/01/2023 10/01/2024 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
JECT
X1 OTHER: Liquor Liability Liquor Liability $ 1,000,000
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANYAUTO BODILY INJURY(Per person) $
B OWNED SCHEDULED Y CA10000518408 10/01/2023 10/01/2024 BODILY INJURY(Pe r accide nt) $
AUTOS ONLY AUTOS
X HIRED �/ NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY /� AUTOS ONLY Per accident
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 1'000'000
A EXCESS LAB CLAIMS-MADE UMB490769100 10/01/2023 10/01/2024 AGGREGATE $ 1'000'000
DED I X1 RETENTION $ 10'000 $
WORKERS COMPENSATIONX1 STER ATUTE EORH
AND EMPLOYERS'LIABILITY Y/N SOO,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
C OFFICER/MEMBER EXCLUDED? N/A TWC4312181 10/01/2023 10/01/2024
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000
If yes,describe under 500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
Inland Marine Scheduled Equipment $480,430
B CM 10003036206 10/01/2023 10/01/2024
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 � r
j141 el
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