CERTIFICATE OF LIABILITY INSURANCE
A CORDTM
CERTIFICATE OF LIABILITY INSURANCE
DATE IMMlDDIYYYY)
10/11/2004
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE .COVERAGE AFFORDED BY THE POLICIES BELOW.
PRODUCER (727) 789-1488
Lonq &. Company Inc
29190 U S 8wy 19 N
POBox 1495.8
Clearwater
INSURED
FL
33766-4958
INSURERS AFFORDING COVERAGE
INSURER A: TRAVELERS INSURANCE CO
NAIC#
AFRICAN AMERICAN LEADERSHIP COUNCIL
INSURER B:
INSURER C:
INSURER D:
INSURER E:
1201 Douglas Avenue
Clearwat.er FL 33755-
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FO~ THE POLICY PERIOD INDICATED. NOTWITHSTAt.lDING ANY
REQUIREMENT; TERM OR CDNDITION 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 lERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE UMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD"L POUCY~ POUCY E~~
LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE-1M"" DATE (MMI LIMITS
A X GENERAL LIABILITY I-660-~OBXS326-TCT-04 02/14/2004 02/14/2005 EACH OCCURRENCE $ 500,000
-
X COMMERCIAL GENERAL llABlLJn' ~~~~I~H?E~7,Ncc~~ncel $ 100,000
I ClAIMS MADE ~ OCCUR / / I I MEDEXPrA~one~r~1 $ 5,000
PERSONAL & ADV INJURY $ 500.,000
/ / / I GENERAL AGGREGATE $; 500,000
GEN'LAGGREGATE LIMIT APPL1E S PER, PRODUCTS. COMP'OP AGG $ 500,000
I nPRO- n / / / /
POLICY JECT LOC
AUTOM.OBILE LIABIUTY I / / I COMBINED SINGL.E LIMIT
- '(Ea accident) $
- ANY AUTO
AL L. OWNED AUTOS I / / / BODIL.Y INJURY
- IP....pe'son) $
- SCHED U LED AUTOS
- HIRED AUTOS I / / / BODIL YINJURY
(p.,. accident) $
NON-OWNED AUTOS
- I / / /
PROPERTY DAMAGE
IPer accident) $
GARAGE L.IABILlTY AUTO ONL. y. Ell ACCIDENT $
~ ANY AUTO I / I / OTHER THAN EAACC $
AUTOONL.Y: AGG $
EXCESSlUMBRELLA LIABI UTY / / I / EACH OCCURRENCE $
~ OCCUR o CI.AI\1S MAOE AGGREGATE $
$
~ DEDUCTIBLE / / I I $
RETENTION $ $
WORKERSCOMPENSAnONAND / / I / I T~~I\UI"I-s I IOJ~-
EMPLOYERS' LIABILITY E,L. EACH ACCIDENT $
ANY PROPRIETDRlPARTNERlEXECUTIVE
OFFICERlMEMBER EXCLUDED? / / I / E. L., DISEASE - EA EMPLOYEE $
If yes, !lescrib& In:l&r E.L.. DISEASE - POLICY LIMIT $
SPECIAL PROVISIONS below
OTHER I / I I
I I I I
/ I I I
DESCRIPTION OF OPERAnONSILOCATIONSIVEHICLESlEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
1201 Douglas Avenue, Clearwater, FL - Clearwater I?arks & Recreation Department Included as ~tiocal Lnsured - Lessor
Risk Only
CERTIFICATE HOLDER
( )
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TliE
EXPIRATION DATe THEREOF, THE ISSUING INSURER IML.L Er-IDEAVOR TO MAil
10 DAYS WRITTEr-I NOTICE TO THE CERllACATE HOLDER NAMED TO THE LEFT. BUT
FMLURE TO DO SO SHALL IMPOSE NO 0 GATION OR UABILlTY OF ANY KIND UPON THE
INSURER, ITS A NTS R ES T
AUTHORIZED P S' T
v'
@ACORDCORPORATION 19a5
Page 1 of2
Clearwater Parks & Recreation
At.tn: Art Kadir
Transmitted by fax:
727-562-4825
ACORD 25 t2001/08)
i2I. _ INS025 (0108),05
lifT"
ElECTRO~IC LASER FORMS, INC. . lBOO)327.QS4S
I . d
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WdIO:~ ~002 II +~O