CERTIFICATE OF LIABILITY INSURANCE (2)
ACORDTM CERTIFICATE OF LIABILITY INSURANCE I DATE (MM/ODIYYYY)
03/05/2005
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
USI of Southern California ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Llc# 0351162 *** 818-251-3000 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
POBox 4367
Woodland Hills, CA 91367 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A: Zurich/American Ins. Grp 99999
Church of Scientology INSURER B: American Guarantee & Liability
Flag Service Organization INSURER C:
503 Cleveland St. INSURER 0:
Clearwater, FL 33755 INSURER E:
Cllent#: 53126
CHURCOF
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 PJ>A~1::J8,w,e Pg~'fl,~~~N LIMITS
A GENERAL LIABILITY GL0929735706 08/15/04 08/15/05 EACH OCCURRENCE $1 000000
..... - --.....-. ".--'------- - ---. ~!;.~!a R"'NT!'n
. XCOMMERCiAl..GENERAL CiABlLIl'Y" .-.-- . -~---- ---"-----_.,- 00-.000
= =:J CLAIMS MADE ~ OCCUR MED EXP (Anyone pelSon) $10,000
- PERSONAL & ADV INJURY $1 000.000
- GENERAL AGGREGATE $10.000000
~'L AGGREAE LIMIT APnS PER: PRODUCTS-COM~OPAGG $1 000.000
POLICY ~~T LOC
A ~TOMOBILE LIABILITY BAP929735606 08/15/04 08/15/05 COMBINED SINGLE LIMIT
X ANY AUTO (Ea accident) $1,000,000
-
ALL OWNED AUTOS BODILY INJURY
r- (Pel person) $
SCHEDULED AUTOS
r-
f HIRED AUTOS BODILY INJURY
(Per accident) $
NON.OWNED AUTOS
rx Physical Damage Comp $2,000 Ded PROPERTY DAMAGE
Coli $2,000 Ded (Per accident) $
GARAGE LIABILITY AUTO ONLY. EA ACCIDENT $
R ANY AUTO OTHER THAN EA ACe $
AUTO ONLY: AGG $
B OESS/UMBRELLA LIABILITY AUC508691300 08/15/04 08/15/05 EACH OCCURRENCE $25 000.000
OCCUR D CLAIMS MADE AGGREGATE $25.000.000
$
R DEDUCTIBLE $
RETENTION $ ~ $
,^, ~~OMPli/ol5ATjOH-AND- -~ '-'.'-.~ ~.'-'-' c ...... IOJ~'
EMPLOYERS' LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L. EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED? E.L. DISEASE - EA EMPLOYEE $
If yes, describe under E.L. DISEASE. POLICY LIMIT $
SPECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDEO BY ENDORSEMENT I SPECIAL PROVISIONS
*Except 10 Days Cancellation Notice for Non Payment of Premium.
Coachman Park and the City of Clearwater are included as Additional
Insured as respects to the operations of the named insured.
RE: Annual Easter Egg Hunt 8am to 6 pm on Sunday March 27, 2005
CERTIFICATE HOLDER
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Clearwater DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL ~ DAYS WRITTEN
112 S. Osceola NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
Clearwater, FL 33756 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR
REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
~ /(. ~
ACORD 25 (2001/08) 1 of 2
#S275842/M266669
DCT JA
@ ACORD CORPORATION 1988
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