CERTIFICATE OF LIABILITY INSURANCE (3)
A'cORD~ CERTIFICATE OF LIABILITY INSURANCE OP 10 S~ DATE (MM/DDIYYYY)
BOYSA-1 11/05/04
'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 McCormick Dr. , Suite 300 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Clearwater FL 33759
Phone: 727-797-4190 Fax:727-791-1613 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Markel Insurance Company 38970
INSURER B: Bridqefield Employers Ins. Co.
Boys and Girls Clubs of the INSURER C:
Suncoast Inc.
5111 66th Street North Ste 200 INSURER 0:
St PetersburgFL 33709
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 MAYBE 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.
NSR[ POLICY NUMBER PD~1'~T~EFF~~~E pgk~~rl~~mw!,.~N LIMITS
LTR TYPE OF INSURANCE DATE MMIDD
GENERAL LIABILITY EACH OCCURRENCE $1,000,000
-
A X X COMMERCIAL GENERAL LIABILITY 8502CY2581860 10/16/04 10/16/05 PREMffi'Es (E~~~~~nce) $200,000
I CLAIMS MADE ~ OCCUR MED EX? (Anyone palSon) $ 10,000
PERSONAL & ADV INJURY $1,000,000
-
GENERAL AGGREGATE $3,000,000
-
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 X ANY AUTO 8502CY2581860 10/16/04 10/16/05 (Ea accident)
I--
ALL OWNED AUTOS BODILY INJURY
I-- (Per person) $
SCHEDULED AUTOS
I--
X HIRED AUTOS BODILY INJURY
I-- (Per accident) $
X NON-OWNED AUTOS
I--
I-- 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 10/16/04 10/16/05 AGGREGATE $2,000,000
$
~ DEDUCTIBLE $
X RETENTION $10,000 $
WORKERS COMPENSAll0N AND X IT~~/(I~WS I IUJ~-
B EMPLOYERS' LIABILITY 83014799 04/01/04 04/01/05 $ 500000
ANY PROPRIETOR/PARTNER/EXECUTIVE E.l. EACH ACCIDENT
OFFICERlMEMBER EXCLUDED? E.l. DISEASE - EA EMPLOYEE $ 500000
If yes, describe under E.l. DISEASE - POLICY LIMIT $ 500000
SPECIAL PROVISIONS below
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
CITY OF CLEARWATER
PARK & .RECREATION DEPT
ATTN: REID
POBOX 4748
CLEARWATERFL 33758
CANCELLA TION
CLEARWA 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
ACORD 25 (2001/08)
@ACORDCORPORATION 1988
~
IMPORTANT
Ifthe 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)