Certificates of InsuranceCOMMERCIAL LIABILITY
DECLARATIONS
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A� SCOTTSDALE INSURANCE COMPANY'
U533ub 8877 North Gainey Center Drive, Scottsdale, Arizona 85258
:n�wau oraac,�ntrec 1-800-423-7675 or in AZ 1-800-225-9458 Policy Number
?i E . P01.ICi' A STOCK COMPANY
CLS- 099017,�,
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Item 1. Named Insured and Mailing Address:
REEF RELIEF
P.O. 30.E 430
KEY UF,ST , MONROh _, 33040
Agent Name and Address:
YA:OZV SO'dTri 7NC.
W 4346 East Ti-adewirtdrs Aver:u:-
Ft. L=;uderd F � 33308 Agent No: 'n`; 14
Item 2. Policy Period a:,, From: 4 5 (3 To: n
12:01 A.M. Standard Time at the address of the Named Insured as stated herein.
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Item 3. Retroactive Date: :'A.
Item 4. Business Description: R PAI1
Item 5. In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the
insurance as stated in this policy.
t ' This policy consists of the following coverage parts for which a premium is indicated. Where no premium is shown, there is no
coverage. This premium may be subject to adjustment.
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Coverage Part(s)
Form No. and Edition Date
Premium
Commercial General Liability Coverage Part
G 0001 11— 'b
$ -7 90
Professional Liability Coverage Part
$
ADDITIONAL INSURED
CG 2026 11-85
$
$
$
$
$
Total
$ ;y,,•,,,,
-32-
I?iS� FEE:$ 3!'
Item 6. Forms and endorsements applicable to all Coverage Parts: Ci `;—.f
SHOW NUMBERS
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' Countersigned a i' i 4 / �; '; ., +_: ! By
DATE AUTHORIZED REPRESENTATIVE
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a., c4 THIS COMMERCIAL LIABILITY DECLARATIONS AND THE SUPPLEMENTAL DECLARATIONS. TOGETHER WITH THE COMMON POLICY CONDITIONS.
0 COVERAGE FORM(S) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBERED POLICY.
CLS-0-1 (10-92) T
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POLICY NUMBER: CLS 099017 COMMERCIA''G
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
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ADDITIONAL INSURED -DESIGNATED PERSON OR
ORGANIZATION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART. PREMIUM: $50. (FLAT)
SCHEDULE
Name of Person or Organization: MONROE COUNTY
BOARD OF COUNTY COMMISSIONERS
5100 COLLEGE ROAD
KEY WEST,$ FL 33040
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations
as applicable to this endorsement.)
WHO IS AN INSURED (Section 11) is amended to include as an insured the person or organization shown in the
Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or
rented to you.
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CG 20 26 1185 Copyright, Insurance Services Office, Inc., 1984 0
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SUPPLEMENTAL DECLARATIONS
These Supplemental Declarations form a part of policy number CLS 099017
LIMITS OF INSURANCE
General Aggregate Limit (other than Products/Completed Operations) $ 300, 000.
Products/Completed Operations Aggregate Limit $ 0
Personal and Advertising Injury Limit $ 300,000.
Each Occurrence Limit $ 300, 000
Fire Damage Limit $ 50,000. any one fire
Medical Expense Limit $ EXCLUDED any one person
BUSINESS DESCRIPTION AND LOCATION OF PREMISES
Form of business:
❑ Individual ❑ Joint Venture ❑ Partnership ® Organization (other than Partnership or Joint Venture)
NON—PROFIT
Business description:
REPAIR OF BUOYS IN %dATER OFF KEY WEST, FLORIDA
Location of all premises you own, rent or occupy:
SAME AS MAILING ADDRESS
PREMIUM
Rate Advance Premium
Classification Code No. "Premium Basis PR/Co All Other' Pr/Co All Other
REPAIR OF BUOYS IN WATER OFF 11111 IF ANY FLAT $ $700.
KEY WEST, FL
INCL. COMP. OPS. /PRODS.
.. _ ,... «�# , a fa;��;;,�ct:wt�sy, ts�•d�i t3aG?t��e8 t)�C��
E1 s"y" S.JSia ned by 4rt
of'property"damagi
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FORMS AND ENDORSEMENTS other than applicable forms and endorsements shown elsewhere in thepolicy)
Forms and endorsements applying to this Coverage Part and made part of this policy at time of issue:
'(a) Area, (c) Total Cost, (m) Admission, (p) Payroll, (s) Gross Sales, (u) Units, (o) Other
THIS SUPPLEMENTAL DECLARATIONS AND THE COMMERCIAL LIABILITY DECLARATIONS, TOGETHER WITH THE COMMON
POLICY CONDITIONS, COVERAGE FORM(S) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBERED POLICY.
CLS-SD-1 (2-92)
THIS IS TO CERTIFY THAT 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I CO LTR I TYPE OF INSURANCE I POLICY NUMBER I DATE
POLICY(MM/DD/YY) EFFECTIVE I DAITE (MM D T/YY) I LIMITS10
I
A
GENERAL
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LIABILITY I
COMMERCIAL GENERAL LIABILITY
CLAIMS MADE Xa OCCUR
OWNER'S & CONTRACTOR'S PROT
I
1MP30085733703
05/10/97
05/10/98
GEfiERAL AGGREGATE 1
$300, 000
PRODUCTS - COMP/OP AGG
$ 300,000
PERSONAL k ADV INJURY
$
EACH OCCURRENCE
S 100,000
FIRE DAMAGE (Any one fire)
S
MED EXP (Any one person)
f
AUTOMOBILE
LIABILITY
ANY AUTO
ALL OWNED AUTOS
SCHEDULED AUTOS
HIRED AUTOS
NON -OWNED AUTOS
GEM
` `
BY -
DATE
NT
COMBINED SINGLE LIMIT
$
BODILY INJURY
(Per person)
$
BODILY
(Per accident)URY
S
PROPERTY DAMAGE
$
GARAGE LIABILITY
ANY AUTO
4rJA I F R:
AUTO ONLY - EA ACCIDENT
$
OTHER THAN AUTO ONLY:
EACH ACCIDENT
$
AGGREGATE
$
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
EACH OCCURRENCE
$
AGGREGATE
$
$
WORKERS COMPENSATION AND
EMPLOYERS' LIABILITY
THE PROPRIETOR/ INCL
PARTNERS/EXECUTIVE
OFFICERS ARE: FIEXCL
STATUTORY LIMITS
. FsCH ArCmgnrr
o
DISEASE - POLICY LIMIT
$
DISEASE - EACH EMPLOYEE
1 $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS
NON-PROFIT ORGANIZATION
"CERTIFICATE HOLDER IS ALSO ADDITIONAL INSURED"
MONRO-6
Monroe County Board of County
Commissioners -
5100 College Roadt
Key West FL 33040
NCELLATiOPI
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL
10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
BUT FAIL 0 MAIL SUCH NOTICE SHALL NO OBLIGATION OR LIABILITY
OF ANY IQND U OON THE COAtP',9&_._h AGENWS REPRESENTATIVES.