CERTIFICATE OF LIABILITY INSURANCE (13)
F"om: SANDRA VOSS At: BOUCHARD INSURANCE, INC FaxlD: To: Attn Earl Barrett
Date: 2/1112008 03:21 PM Page: 2 of 3
ACORD. CERTIFICA TE OF LIABILITY INSURANCE OP 10 S, DATE (MM/DDIYYYY)
SILVEOl 02/11/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Bouchard-Clearwater ONL Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
101 Starcrest Drive HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
POBox 6090 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Clearwater FL 33758-6090
Phone: 727-447-6481 Fax;727-449-1267 INSURERS AFFORDING COVERAGE NAIC#
INSURED It~SURER A 1898S
Auto-OWner" Insurance Company
INSURER B Foremost Insurance Company 11185
Silver Dollar Trap- Club Inc I INSURER C
16316 Patterson Ra I'NS~I~~R D -- ---------------- --" ---------------- ----.-- ------------
Odessa FL 33556
INSURER E
COVERAGES
THE POLICIES OF II<SURAIJCE liSTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POliCY PERIOD INDICATED. NOTVVIT,"STAt~DING
ANY REQUIREMEI'H, IEI'lM OR e,)ND, IIUN Of ANY CONTRAcr OR 01 HER DOCUMENf WiTH RESPECT ro WHICHIHIS CtRI'rICAlt MAY e~ ISSUW 011
MAY PERgIN, THE INSURNJCE ,AFFORDED BY THE POliCIES DESCRIBED HEREIN IS SUBJECT TO AlL THE TERMS, E>.CLUSIOIJS AND C')NDITIONS )F SUCH
POLlCIFS AGGReGATE LI~.1ITS cd)WN MAY I-LAVE REEN REDUCED BY PAID CLAIMS
'~~~ ~S~[ TYPE OF INSURANCE POLICY NUMBER DATE (MM/DDIYY) I' DATE (MMlDD/YYI LIMITS
GENERAL LIABILITY 01/29/osl EACH OCCURRENCE $ 1000000
f--- >
A X COMMER':IAL GENERAL L1ABUT', 20693662 01/29/09 ~~_~~I__~~~_ W~__0_~~~.~!2~_~1_____ $ 300000
1-----. U eL.i\IMS MADt W UCCJP I -- -------- --- .- "--- ----
! MELI EXP (Anyone person) $ 10000
f--
f- I PERS )IIAl & ADV INJURY $ 1000000
X Hired/nonowned au I GENERAL AGGREGATE $ 3000000
f--
GEN'L AGGREGATE LIMIT APPLIES "ER PROCJCTS - COMP/OP AGG $ 3000000
!xl n PRO- nL(lC
X PI)LICY JECT
AUTOMOBILE LIABILITY CO~IEINED SINGLE LIMIT
f--- $ 1000000
A AI\IY AUT!) 4703500300 11/19/07 11/19/0S (F <l <l( ci dent)
I.. -------- . ------- - - ---------- ----- ----.. -------
ALL OWNED AUTOS 80Dll'lIIlJURY
f--- $
X SCHEDULE[I AUTOS (Per ~ ~rs(Jn)
1_____ ----- -- ---- ---- ----------- -- --------- ....
HIRFD AUTOS BODIL Y INJURY
1--- $
I'ICJ~IOWI"ED AUTO 3 (Per c.ccluenl)
f---
1-- PROPERTY DAMAGE $
(Per c.ccident)
GARAGE LIABILITY AUTO OIlL Y - EA ACCIDENT $
'~ NI'I AUTO --- ___n_"_ ------ ----- 1-------------- ----
OTHER ~AN EA ACe "
AUTO ONLY AGG $
EXCESS/UMBRELLA LIABILITY EACI.IOCCURRENCE "
~ OCCUR D CLAIMS MADE AGGREGATE $
"
=ll.lElJUCTI8Le $
RETENTIO~I " $
WORKERS COMPENSATION AND I Wc;~IAILJ- I IllER-
DRY LIMITS
EMPLOYERS' LIABILITY I
ANY PROPRIETOR:/PARTNERIE:'ECUTIVE EL EACH ACCIDENT $
---" ........... ____un_un
OFFICER/MElvlflER F;CrlUDFn' E L CISEASE - FA EMPI.OYEF :,
If yes, :1
SF-Eel.IlL below EL C'ISEASE POLICY LIMIT
OTHER
B Antique Auto ACS925S215 04/10/07 04/10/0S CSL 1,000,000
DESCRIPTION OF OPERATIONS' LOCATIONS / VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
re: vacant land - part of the Southeast 1/4 of Section 19, Township 27
south, Range 17 East Hillsborough County, FL.
Cert Holder is an additional insured with respect to General Liability
subject to the terms, conditions, and exclusions of the policy.
Fax: 727-562-4755
CERTIFICATE HOLDER
CANCELLATION
CITYCLW
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Clearwater
Attn Earl Barrett
Engineering Department
PO Box 4748
Clearwater FL 3375S-4748
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10
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
ACORD 25 (2001/08)
@ACORDCORPORATION 1988
F-om: SANDRA VOSS At: BOUCHARD INSURANCE, INC FaxID: To: Attn Earl Barrett
Date: 2/1112008 03:21 PM Page: 3 of 3
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 (2001/08)