CERTIFICATE OF LIABILITY INSURANCE (2)
CERTIFICATE OF LIABILITY INSURANCE
ACORD,.
DATE (MM/DDNYYY)
BOYSA-1 12 30 03
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
A.J. Gallagher & Co.-Tampa Bay
2600 McCormick Drive, Ste 300
Clearwater FL 33759
Phone: 727-797-4190 Fax:727-791-1613
INSURED
INSURERS AFFORDING COVERAGE
Boys and Girls Clubs of the
Suncoast Inc.
5111 66th Street North Ste 200
St Petersburg FL 33709
INSURER A:
INSURER B:
INSURER C:
INSURER 0:
INSURER E:
Markel Insurance Company
Bridgefield Employers Ins.
NAIC#
38970
o.
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.
LTR NSR[ TYPE OF INSURANCE POLICY NUMBER PD9..If~~&~JtftWiE P8ktCl(~*XmfJ!..~N LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
-
A X X COMMERCIAL GENERAL LIABILITY 8502CY2581860 10/16/03 10/16/04 ~RE~~ES (E~7,'~~u~~nce) $100,000
I CLAIMS MADE [!] OCCUR MED EXP (Anyone person) $10,000
PERSONAL & ADV INJURY $1,000,000
-
GENERAL AGGREGATE $3,000,000
f--
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS. COMP/OP AGG $3,000,000
n n PRO. nLOC Emp Ben. 1,000,000
POLICY JECT
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
I-- $1,000,000
A ~ ANY AUTO 8502CY2581860 10/16/03 10/16/04 (Ea accident)
ALL OWNED AUTOS BODILY INJURY
- $
SCHEDULED AUTOS (Per person)
-
X HIRED AUTOS BODILY INJURY
- $
X NON-OWNED AUTOS (Per accident)
-
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY - EA ACCIDENT $
=1 ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $2,000,000
A ~ OCCUR D CLAIMS MADE 4602CY258189 10/16/03 10/16/04 AGGREGATE $2,000,000
$
~ DEDUCTIBLE $
X RETENTION $10,000 $
WORKERS COMPENSATION AND X I TORY LIMITS I IOJ~-
B EMPLOYERS' LIABILITY 0830147990000 04/01/03 04/01/04
ANY PROPRIETOR!PARTNER!EXECUTIVE E.L. EACH ACCIDENT $ 500000
OFFICER!MEMBER EXCLUDED? E.L. DISEASE. EA EMPLOYEE $ 500000
If yes, describe under $ 500000
SPECIAL PROVISIONS below E.L. DISEASE. POLICY LIMIT
OTHER
DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES / EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
The Certificate Holder is added as an additional insured with respect to the
General Liability. Fax #562-4825
CERTIFICATE HOLDER
CANCELLATION
CITY OF CLEARWATER
PARK & RECREATION DEPT
ATTN REID
POBOX 4748
CLEARWATER FL 33758
CLEARWA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 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.
AUTHOR 0 REPRES
@ACORD CORPORATION 1988
ACORD 25 (2001/08)
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
holderin 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)