CERTIFICATE OF LIABILITY INSURANCE
Date: 9/13/2002 02:51 PM
Sender's Fax ID: 727-449-1267
Page 2 of 2
ACORD.
CERTIFICATE OF LIABILITY INSURANCE
OP ID DT
BLACK-2 09/13/02
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.
DATE (MMlDDlYV)
PRODUCER
Bouchard-Starcrest
101 Starcrest Drive
POBox 6090
Clearwater FL 33758-6090
Phone: 727-447-6481 Fax: 727-449-1267
INSURERS AFFORDING COVERAGE
INSURER B:
AMERICAN STATES INSURANCE CO
AUTO OWNERS INSURANCE CO
INSURED
INSURER A
Black Tie Janitorial Services
Neil Brickfield
PO Box 13
Safety Harbor FL 34695
!NSURER C:
INSURER 0
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 MAY BE ISSUED OR
MAY PERT AN 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 ~~fkcJ.,~~~J~VE P8i~~v ::O~~~N LIMITS
LTR
GENERAL LIAEJILlTY EACH OCCLRREt"CE $ 1000000
~
A ~ COMMERClAL GEr,JERA.L liABILfrf 01CG1498221 03/02/02 03/02/03 FIRE DAMAGE (Any one nre) $ 200000
- ~ CLAJM5 MADE [i] OCCUR MED EXP (AIl)' one person) $ 10000
PERSON,..!.. .!.!-I:N iNJURY $ 1000000
~
GENEP.Al. AGGREGATE $ 2000000
-
GENI_ AGGREGATE LlMlT APPUES PER PRODUCTS. COMPIOP AGG $ 2000000
n nPRO nlOC
POLICY JECT
AUTOMOB"-E LIABILlTV COMBINED SINGLE LJMIT
~ $1000000
B --!- "NY AUTO 4379519400 03/02/02 03/02/03 (Ea accident)
.ALL OWNED AUTOS SODlLy' J"JJURY
f--- $
SCHEDULED AUTOS (rer pcr.:;on)
-
HIRED AUTOS BOOlLY lNJL!RY
~ $
NON.OWNED AUTOS (per acciaent)
-
- PROPERTYQAJAAGE $
(per accident)
GARAGE LIABILITY AUTO ONLY. EA ACC10ENT $
q "NY AUTO OTHER THAN EAACC $
AUTO m.JLY AGG $
Excess LIABILITY EACH OCCLRPE:NCE $
=:J OCCUR o CLAIMS M-\DE AGGREGATE $
$
==1 ~EDUCTJBLE $
RETENTION $ $
WORKERS COMPENSATION AND I ~~R~TG~~s [ [OTH-
ER
EMPLOYERS' LIABILITY
EL EACH ACCIDE~JT $
EL DISEASE - EA EMPLOYEE $
EL DISEASE - POLICY UMIT $
OTHER
DESCRlPTIOI'IOF OPERATIONSA.OCAlJONSNEHICl.ESlEXCLUSIONS ADOED BV ENOORSEMENTISPECIAL PROVISIONS
JANITORIAL SERVICES
CERTIFICATE HOLDER I N \ AOOITIONAlINSURED: INSURER LETTER: CANCELLATION
CITOCLE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPJRA7JON
DATE iHEREOF, THE lSSUU\IG lNSURER WILL ENDEAVOR. TO MAIL 3L DAYS WRITTE"
CITY OF CLEARWATER NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
ATTN: TED STRAND
1900 GRAND AVE IMPOSE NO OBLiGA.TION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
CLEARWATER FL 33765 REPRESENTNIVES.
AUTHOR\!jt:T~
I ,,. "'-"
ACORD 25-8 (7/97)
@ACORD CORPORATION 1988