CERTIFICATE OF LIABILITY INSURANCE (54)
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ACORDTM CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DDIYYVY)
12/28/07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Wachovia Insurance Services ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
4600 W. Cypress St, Suite 200 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 25277 (Zip 33622)
Tampa, FL 33607 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: The Charter Oak Fire Insurance Compa 25615
OSI Restaurant Partners, LLC, etal INSURER B: Travelers Property Casualty Co of Am 25674
Attn: Joe Hartnett INSURER C:
2202 N. Westshore Blvd INSURER 0:
Tampa, FL 33607 INSURER E:
Client#. 116902
OSIREST
COVERAGES
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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
II'ISR ~~~~ TYPE OF INSURANCE POLICY NUMBER PJ>l-~~iri~~~8~,E P~~.fl,~~~~N LIMITS
LTR
~NERAL LIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $
I- CLAIMS MADE D OCCUR MED EXP (Anyone person) $
PERSONAL & ADV INJURY $
f--
I-- GENERAL AGGREGATE $
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS - COMP/OP AGG $
II nPRO- n
POLICY JECT LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $
ANY AUTO (Ea accident)
-
- ALL OWNED AUTOS BODILY INJURY
$
SCHEDULED AUTOS RECEI'J (Per person)
- ED
- HIRED AUTOS BODILY INJURY
$
NON-OWNED I\UTOS (Per accident)
-
JAN 15 21 08 ---
- PROPERTY DAMAGE
- $
(Per accident)
~RAGE LIABILITY OF r" :--IAL RECOR bs A '\'D AUTO ONLY - EA ACCIDENT $
ANY AUTO LE r.;ISLATIVE SRV( S DEPT OTHER THAN EA ACC $
AUTO ONLY: AGG $
:::=JESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR D CLAIMS MADE AGGREGATE $
$
R DEDUCTIBLE $
RETENTION $ $
A WORKERS COMPENSATION AND TC20UB395J499508 01/01/08 01/01/09 X I T~~i;r~ws I IOJ~'
B EMPLOYERS' LIABILITY LR.J 1)13.395-J_49~~()1L__ Qj/011OB 011(l1/09 $1.JlQ!l,.00O-_~'H
AN-~'l'ORtPARiN€Ri,")(€eUTjV1:- -" -._~ -.- ------ -llJ;ACH.ACCillENT__ '-.
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $1,000,000
If yes, describe under $1,000,000
SPECIAL PROVISIONS below E.L. DISEASE - POLICY LIMIT
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
CERTIFICATE HOLDER
CANCELLATION
ACORD 25 (2001/08) 1 of 2
#M1297159
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ---3.0... DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
~ t\,). ~.
MSM04
@ ACORD CORPORATION 1988
City of Clearwater Beach
483 Mandalay Ave.
Clearwater, FL 33767
,"
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement
on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
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).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between
the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it
affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-5 (2001/08) 2 of 2
#M1297159