CERTIFICATE OF INSURANCE (253)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE T DATE (MM/DDIYVYY)
R182-01W 12/29/2004
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Risk Transfer Holdings ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
301 E, Pine Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
Suite 350 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Orlando, FL 32801
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: First Commercial Insurance Company
Afford-A-Staff, Inc,
1554 South Fort Harrison INSURER 8:
Clearwater, FL 33756 INSURER C:
: INSURER D:
I
. INSURER E:
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,
l~sR ~~~~ POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
TR 0
~NERAL LIABILITY I EACH OCCURRENCE $
I
f--- 3MMERCIAL GENERAL LIABILITY ~~~~~~~9E~~~~~nce\ $
f--- CLAIMS MADE D OCCUR MED EXP (Anyone person) $
PERSONAL & ADV INJURY $
GENERAL AGGREGATE $
~'L AGGREGATE LIMIT APnS PER: PRODUCTS - COMP/OP AGG $
rc-l- PRO-
POLICY JECT LOC
~TOMOBILE LIABILITY COMBINED SINGLE LIMIT $
(Ea accident)
- ANY AUTO
'-- ALL OWNED AUTOS BODILY INJURY
(Per person) $
- SCHEDULED AUTOS
- HIRED AUTOS BODILY INJURY
(Per accident) $
- NON-OWNED AUTOS
- I PROPERTY DAMAGE $
(Per accident)
RRAGE LIABILITY AUTO ONLY. EA ACCIDENT $
ANY AUTO I OTHER THAN EA ACC $
I AUTO ONLY: AGG $
DEsS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR D CLAIMS MADE AGGREGATE $
$
q DEDUCTIBLE $
RETENTION $ i $
A WORKERS COMPENSATION AND I 15396-3 , 01/01/2005 01/01/2006 X I TVj,'i,~;~I,~;" I 1OJbl-
EMPLOYERS' LIABILITY $ 1,000,000
E,L, EACH ACCIDENT
ANY PROPRIETOR/PARTNER/EXECUTIVE
--- _OFF!Qg~MS.M!l_EB~)<CLUDED? ,___ -----~..~-, -,-_.~ ____..____m.._._ "---- '.. E.L. DISEA,SE - lOA E.MPLOYE,E $ 1,000,000
If yes, describe under E,L, DISEASE - POLICY LIMIT $ 1,000,000
SPECIAL PROVISIONS below
OTHER :
I I i
I
DESCRIPTION OF OPERATIONS I LOCATIONS /VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
Coverage is extended to the leased employees of alternate employer (Florida Operations Only) :
688 Skate Park, Inc. - # 01-01-122 - Effective - 01/18/04
DISCLAIMER: This Certificate of Insurance 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,
This certificate only applies to Skating Rink,
CERTIFICATE HOLDER
CANCELLATION
City of Clearwater
City Clerk
P,O, Box 4748
Clearwater FL 33758
ACORD 25 (2001/08)
JAN 03 2005
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ 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
~
RECEIVED
@ ACORD CORPORATION 1988