CERTIFICATE OF LIABILITY INSURANCE (23) DATE(MM/DD/YYYY)
A�" CERTIFICATE OF LIABILITY INSURANCE
01/31/2023
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 Keith Thompson
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 Keith.Thompson@bbrown.com
ADDRESS:
INSURER(S)AFFORDING COVERAGE NAIC#
Clearwater FL 33759 INSURERA: Church Mutual Insurance Company,S.I. 18767
INSURED INSURER B: FFVA Mutual Insurance Co. 10385
Chi Chi Rodriguez Youth Foundation,Inc. INSURER C:
3030 McMullen Booth Rd. INSURER D:
INSURER E:
Clearwater FL 33761 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL2313121781 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 $ 1,000,000
MED EXP(Any one person) $ 5,000
A Y 0336874-02-520262 02/01/2023 02/01/2024 PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3'000'000
X POLICY ❑ PRO ❑ LOC PRODUCTS-COMP/OPAGG $ 1,000,000
PJECT
OTHER: Emp Ben(Claim/Agg) $ IM/3M
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
X ANYAUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED 0336874-09-520320 02/01/2023 02/01/2024 BODILY INJURY(Pe r accide nt) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
X PIP 10,000 $
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4'000'000
A EXCESS LAB CLAIMS-MADE 0336874-81-520263 02/01/2023 02/01/2024 AGGREGATE $ 4'000'000
DED I X1 RETENTION $ 10'000 �/ $
WORKERS COMPENSATION /� STATUTE EORH
AND EMPLOYERS'LIABI LI TY Y/N 1,000,000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
B OFFICER/MEMBER EXCLUDED? N/A WC840-0798393-2023A 02/01/2023 02/01/2024
(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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