CERTIFICATE OF INSURANCE
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.PR'oiiiicliif'......,..............,....,........ .,....,........, 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.
RBH of Tampa
4511 North Himes
Su i te 265
Tampa, FL 33614
813-876-2633
Ave.
COMPANIES AFFORDING COVERAGE
COMPANY A
LETTER
ST. PAUL FIRE & MARINE
INSURED
COMPANY B
LETTER
EMPLOYERS SELF INSURANCE FUND
Boys & Girls Clubs of the
Suncoast, I nc
5111 66th Street N.
Su i te 200
St. Petersburg
FL 33709
h::CEIV
SEP 2 2 199
C
D
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICA TED, 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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LTR
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRATION
DATE (MM/DD/YY) DATE (MM/DD/YY)
LIMITS
GENERAL. L.IABIL.ITY GENERAL AGGREGATE $ 1000000
A COMMERCIAL GENERAL LIABILITY CK00903330 9/18/95 9/18/96 PRODUCTS-COMP lOP AGG. $ 1000000
CLAIMS MADE ~ OCCUR. PERSONAL & ADV, INJURY $ 1000000
OWNER'S & CONTRACTOR'S PROTo EACH OCCURRENCE $ 1000000
FIRE DAMAGE (Anyone fire) $ 100000
MED. EXPENSE (An one arson $ 5000
AUTOMOBIL.E L.IABIL.ITY COMBINED SINGLE
$
A X ANY AUTO CK00903330 9/18/95 9/18/96 LIMIT 1000000
ALL OWNED AUTOS BODILY INJURY $
SCHEDULED AUTOS (Per person)
A X HIRED AUTOS BODILY INJURY
A X NON-OWNED AUTOS CK00903330 9/18/95 9/18/96 (Per accident)
PROPERTY DAMAGE $
A X Ph CK00903330 9/18/95 9/18/96
EACH OCCURRENCE
A UMBRELLA FORM CK00903330 9/18/95 9/18/96
OTHER THAN UMBRELLA FORM
-. ---------Y1np.KEP2s.--COMPENSA"r!C'N ______ _____ __________ __n
B 0830-14799-0000 4/01/95 4/01/96 EACH ACCIDENT $ 100000
AND
DISEASE-POLICY LIMIT $ 500000
EMPL.OYERS'L.IABIL.ITY $
DISEASE-EACH EMPLOYEE 100000
OTHER
A Physical Damage CK00903330 9/18/95 9/18/96 $500 Comprehensive
Deductibles: $500 Coil ision
DESCRIPTION OF OPERATIONSILOCATI
o 1~/~ILrfjS\Yl ~
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..........................................................................................................................
ECONOMIC DEVELOPMENT\
CITY OF CLFARWATER '::'
SH ULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EX RATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO
MAli.. ~ DA YS WRITTEN NOTICE TO THE CERTIFICA TE HOLDER NAMED TO THE
LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR
L1ABILI OF ANY KIND UPON THE COMP ANY,ITS AGENTS OR REPRESENT A TIVES.
City of Clearwater
Economic Development Dept.
P.O.Box 4748
Clearwater, FL 34618
Attn: Pat Fernandez
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707980000
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