CERTIFICATE OF LIABILITY INSURANCE
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1: ACORD.. CERTIFICATE OF LIABILITY INSURANCE OP ID JDI DATEIMMlOD/YY)
BOYSA-1 02/21/03
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
A.J. Gallagher & Co.-Tampa Bay HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
2600 McCor.mdck Drive, Ste 300 AL TER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Clearwater FL 33759
Phone: 727-797-4190 Fax: 727-791-1613 INSURERS AFFORDING COVERAGE
INSURED INSURER A First National Insurance Co.
INSURER 8: General Star Indemnity COIIIPanv
Boys and Girls Clubs of the INSURER c: Bridgefield Employers Ins. Co.
Suncoast Inc.
5111 66th street North Ste 200 INSURER 0:
St Petersburg FL 33709
I INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
~ 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.
INSR TYPE OF INSURANCE POLICY NUMBER ~~~c;:,,~~~:'E P~~j~:~'::~~IN LIMITS
LTR
GENERAL LIABILITY EACH OCCURRENCE $ 1, 000, 000
I--
A X COMMERCIAl. GENERAL LIABILITY CP7781991 10/18/02 10/18/03 FIRE DAMAGE (Any one "reI $200,000
I CLAIMS MADE [j] OCCUR MED EXP (Any one person) $ 10,000
PERSONAL & N)V II>UURY $1,000,000
GENERAL AGGREGATE $ 3,000,000
GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/OP AGG $ 3,000,000
I n PRO. nLOC IEIIIP Ben. 1,000,000
POLICY JECT
AUTOMOBILE UABILITY COM81NED SINGLE LIMIT
- $ 1,000,000
A ~ ANY AUTO BA7781991 10/18/02 10/18/03 (Ea accident)
ALL OWNED AUTOS 80DILY INJURY
- $
SCHEDULED AUTOS (Per person)
I--
HIRED AUTOS BODILY INJURY
I-- $
NON-OWNED AUTOS (Per accident)
I--
I-- PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS LIABILITY EACH OCCURRENCE $ 2,000,000
B t!"J OCCUR D CLAIMS MADE IUG379046A 10/16/02 10/16/03 AGGREGATE $ 2,000,000
$
~ DEDUCTI8LE $
X RETENTION $ 10 r 000 $
I WC STATU. I 10TH-
WORKERS COMPENSATION AND TORY LIMITS ER
C EMPLOYERS' LIABILITY 0830147990000 04/01/02 04/01/03 $ 500000
EL EACH ACCIDENT
EL DISEASE. EA EMPLOYEE $ 500000
EL DISEASE. POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER I Y I ADDITIONAL INSURED; INSURER LETTER: CANCELLATION
CITCLEA SHOULIl ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ...:J.JL-. DAYS WRITTEN
City of Clearwater NOTICE TO THE CERTIFICATE HOLOER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
Debbie - 562-4825
100 S. Myrtle Avenue IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
Clearwater FL 33756 REPRESENTATIVES.
I Aun;~REPRJsENT~l ~,/.
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ACORD 25 S (7/97)
@ACORD CORPORATION 1988
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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 Dr negatively amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25-S (7/97)