CERTIFICATE OF LIABILITY INSURANCE (24) DATE(MM/DD/YYYY)
A�" CERTIFICATE OF LIABILITY INSURANCE
01/24/2024
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.
PHONE
Ext): (727)461-6044 ac No: (727)442-7695
140 Fountain Parkway N E-MAIL Keith.Thompson@bbrown.com
ADDRESS:
Suite 600 INSURER(S)AFFORDING COVERAGE NAIC#
St.Petersburg FL 33716 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: CL2412466505 REVISION NUMBER:
THIS IS TO CERTIFYTHAT 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 INSURANCE ADSL UBR POLICY NUMBER MM/DD YYYYMLICY EFF O DD YYYY LIMITS
ICY EXP
LTR INSD WVD
X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE_7CLAIMS-MADE �OCCUR PPENTE
REM SESOEa occur«Dance $ 1,000,000
MED EXP(Any one person) $ 5,000
A Y 0336874-02-714387 02/01/2024 02/01/2025 PERSONAL&ADV INJURY $ 1,000,000
GEN'LAGGREGATE LIMITAPPLIES PER: GENERAL AGGREGATE $ 3,000,000
X POLICY PRO 1,000,000
JECT LOC PRODUCTS $
OTHER: Emp Ben(Claim/Agg) $ 1M/3M
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,000
Ea accident
ANYAUTO BODILY INJURY(Per person) $
A OWNED SCHEDULED 0336874-09-715005 02/01/2024 02/01/2025 BODILY INJURY(Per accident) $
AUTOS ONLY AUTOS
X HIRED �/ NON-OWNED PROPERTY DAMAGE $
AUTOS ONLY /� AUTOS ONLY 1 Per.accident
PIP$10,000 $
X UMBRELLA LIAB X OCCUR EACH OCCURRENCE $ 4,000,000
A EXCESS LIAB CLAIMS-MADE 0336874-81-714388 02/01/2024 02/01/2025 AGGREGATE $ 4,000,000
DED I X1 RETENTION$ 10,000 $
WORKERS COMPENSATION X STATUTE ER
AND EMPLOYERS'LIABILITY YIN 1'oQo'000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $
B OFFICER/MEMBER EXCLUDED? NIA WC840-0798393-2024A 02/01/2024 02/01/2025
(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
....F" ®.,�.�..
Clearwater FL 33756-5520 ✓" --""��
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