CERTIFICATE OF LIABILITY INSURANCE (20) 711/21/2023
E(MM/DD/YYYY)
ACOR" CERTIFICATE OF LIABILITY INSURANCE
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
NAME: Jacquie Monroe
Arthur J. Gallagher Risk Management Services, LLC PHONE FAX
4350 W Cypress Street A/C No Ext): 727 796-6250 .J C,No):
E-MSuite 300 ADDRESS: CertRequests@ajg.com
Tampa FL 33607 INSURER(S)AFFORDING COVERAGE NAIC#
INSURERA: Philadelphia Indemnity Insurance Company 18058
INSURED BOYS&GI-05 INSURER B: United States Liability Insurance Company 25895
Boys&Girls Clubs of the Suncoast, Inc
4625 East Bay Drive INsuRERc: MEMIC Indemnity Company 11030
Suite 103 INSURER D7
Clearwater FL 33764 INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER:195357322 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 MM/DD
A X COMMERCIAL GENERAL LIABILITY PHPK2627135 12/1/2023 12/1/2024 EACH OCCURRENCE $1,000,000
�
OCCUR DAMAGE TO
CLAIMS-MADE
PREMISES(E.
occurrence)
ccurrence) $100,000
MED EXP(Any one person) $5,000
PERSONAL&ADV INJURY $1,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $2,000,000
POLICY❑ PRO [:]JECT LOC PRODUCTS-COMP/OP AGG $2,000,000
X
OTHER: $
A AUTOMOBILE LIABILITY PHPK2627135 12/1/2023 12/1/2024 COMBINED SINGLE LIMIT $1,000,000
Ea accident
X ANY AUTO BODILY INJURY(Per person) $
OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
HIRED NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY AUTOS ONLY Per accident
A X UMBRELLA LAB X OCCUR PHUB890219 12/1/2023 12/1/2024 EACH OCCURRENCE $5,000,000
EXCESS LAB CLAIMS-MADE AGGREGATE $5,000,000
DED X RETENTION$1 n nnn $
G WORKERS COMPENSATION 3102809278 12/19/2023 12/19/2024 X PEROTH-
AND EMPLOYERS'LIABILITY Y/N STATUTE ER
ANYPROPRIETOR/PARTNER/EXECUTIVEE.L.EACH ACCIDENT $1,000,000
OFFICE R/M EMBER EXCLUDED? FN] N/A
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $1,000,000
If yes,describe under
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $1,000,000
A Prof.Liability/Abuse Molestation PHPK2627135 12/1/2023 12/1/2024 Limit $1,000,000
B Employment Practice Liability& NPP157304OG 12/1/2023 12/1/2024 Limit $1,000,000
Directors&Officers
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached if more space is required)
'Prof. Liability$2,000,000 Aggregate,Abuse Molestation$3,000,000 Aggregate
Cyber-Policy#: AB664175202 12/1/2023 to 12/1/2024,Trisura Specialty Insurance Company,$1,000,000 per Claim/Aggregate
City of Clearwater Parks and Recreation Department is included as an additional insured under the terms and conditions of the attached forms and the General
Liability and Automobile Liability Policies,when additional insured status is required by written contract. Excess Liability Policy extends over the underlying
General Liability and Automobile Liability Policies.
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 Parks and Recreation Department
100 S. Myrtle Avenue AUTHORIZED REPRESENTATIVE
Clearwater FL 33756
@ 1988-2015 ACORD CORPORATION. All rights reserved.
ACORD 25(2016/03) The ACORD name and logo are registered marks of ACORD