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HomeMy WebLinkAboutCertificate of Insurance.6C CERTIFICATE OF LIABILITY INSURANCE `� OATE(M 07277201712017 Y) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement Astatement on this certificate does not confer rights to the certificate holder In lieu of such endomement(s). PRODUCER KE Insurance Agency 990 Us Highway 1 Suite A Sebastian, FL 32958 Phone (772) 589-1800 Fax (772) 388.2067 NONEACT Jodi Delaporte PHONE(772) 589-1600 FAC( No): (772) 388-2067 -MaL andr @keagency.com INSURER(S) AFFORDING COVERAGE NAIC9 INSURER A: Covington Specialty Insurance Company INSURED CRAB E BILL'S, Inc 1540 Indian River Or Sebastian FL 32958 INSURER B: INSURER C: INSUREC: INSURERR E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 CONTRACTOR 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. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. l�TR TYPE OF INSURANCE ACDUa POLICY NUMBER POLICY EFF IMMIDOvYYYYI POUCYEXP (MNUDDIYYYY)LIMITS A Q COMMERCIAL GENERAL LIABILITY ❑ CLAPAS-MADE © OCCUR ❑ Y VBA556854-00 07/252017 EACH OCCURRENCE $ 1000000 AGE TO RENTED PREM SES(Ea ocomence It 100000 MED EXP (Any we Person) $ 5000 ❑ 07/25/2018 PERSONAL aAUVINJURY $ 1000000 GEN'L AGGREGATE LIMITAPPLES PER: ❑ POLICY ❑ JRO- ET ❑ LOC ❑ OTHER GENERAL AGGREGATE $ 2000000 PRODUCTS-COMP/OP AGO $ 1000000 $ AUTOMOBILE LIABILITY ❑ ANYAUTO ❑ AUTOS ONLY WNED❑ AUTTOS AUTOS HIRED ❑ NON -OWNED ❑ AUTOS ONLY AUTOS ONLY ❑ ❑ CEaacciE�tSINGLE LIMIT $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PpOPERTYDAMAGE $ fger acciderd $ ❑ UMBRELLA UAB ❑ OCCUR ❑ EXCESS UAB ❑ CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ ❑ DED ❑ RETENTIONS $ WORKERS COMPENSATION ANDEMPLOYERS' UABIUTY YIN ANY PROPRIETOR/PARTNERIEXECUTN OFFICERIMEMBER EXCLUDED? (Mandatory In NH) M yes, descnbe under DESCRIPTION OF OPERATIONS below N/A ❑ PER OTH- BIlOT_ EJE E.L. EACH ACCIDENT $ E.L. DISEASE -EA EMPLOYE $ E.L. DISEASE -POLICY LIMB $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, If more apace Is required) CERTIFICATE HOLDER CANCELLATION City of Sebastian 1225 Main Street Sebastian, FL 32958 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORCED REPR ENTA71VE ©1 8-2015 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) OF The ACORD name and logo are registered marks of ACORD A`o�Ro� CERTIFICATE OF LIABILITY INSURANCE 11/2 rzo17 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the pollcy(les) must have ADDITIONAL INSURED provisions or be Endorsed 0 SUBROGATION IS WAIVED, subject to the terns and conditions of the policy, Certain policies may require an endorsement A statement on Ude codificate does not confer rights to the certificate holder in Uou of such endoreament(s). PRODUCER CONTACT Jodi Delaporte KE Insurance Agency PHONE 2) 589.1800 1 FWD (772) 388.2067 'MAIL andrew®keagencycom 990 Us Highway 1 Suite A INSURERS AFFORDING COVERAGE NIUCa Sebastian, FL 32958 INSURER A: Covington Specialty Insurance Company Phone 2 589.1800 Fax 2 388-2067 INSURED INSURER 8: INSURERC: CRAB E BILL'S, Inc INSURER D: 1540 Indian River Dr S Sebastian FL 32958 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW RAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERMOR 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. NSR TYPE OF INSURANCE Met UB PODCY NUMBER YWDPOLI� EFF NMN EXP DYiTB A COMMERCIAL GENERAL LIABILITY ❑ CLANS -MADE 0 OCCUR ❑ Y VBA474807.00 07252015 EACHOCCURRENGE S 1000000 p� a GE TO RENTED S 100000 MEDEXP ma aeon S 5000 ❑ 072512017 PERSONAL& ACV INJURY s 1000000 GEML AGGREGATE LMIT APPLES PER ❑ POLICY ❑ JET ❑LOC ❑ OTHER GENERAL AGGREGATE S 2000000 PRODUCTS -COMPIOPAGG S 1000000 S AUTOMOBILE LIABILITY ❑ ANY AUTO SCHEDULED ❑ UUTTOS ONLY ❑ AUTOS" C] AUTOS ONLY HIRED❑ AUTOS ONLY ❑ CO gB�N BD SINGLE LIMIT $ ESE; pawn) S BpODILY PUURY(Porrs MmI S Frge� FRm S S ❑ UMBRELLA LIAR ❑ OCCUR EXCESS DAB CLAM54AADE EACH OCCURRENCE $ AGGREGATE $ DECEl El RETENTION s S WORKERS COMPENSATION ANDEMPLOYERS' LIABILITY YIN ANY PROPRIENR/PARTNERIEXEC OFFICERMEMBER EXCLUDED? u Wandetoryin NN) aye.. do..Ibe we DESCRIPTION OF OPERATIONS below NIA EPTERTITE OTI- E.L. EACH ACCIDENT S E.L. DISEASE - EA EMPLOYE S E.L DISEASE. POLICYLMIT S DESCTEPTIONOFOPERATIONS1 LOCATIONS /VEHICLES (Af ehACORDID1,Addifknel Remark,Schedulo,Ifmora,patolamqubad) CERTIFICATE HOLDER CANCELLATION ®1988-9615 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) OF The ACORD name and logo are registered marks of ACORD SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Sebastian THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 1225 Main Street ACCORDANCE WITH THE POLICY PROVISIONS. Sebastian, FL 32958 AUTHORUMO REPRESENTATIVE ®1988-9615 ACORD CORPORATION. All rights reserved. ACORD 25 (2016103) OF The ACORD name and logo are registered marks of ACORD Named Insured: Policy Number: Policy Period: State of Florida Policy Cover Page Crab E Bill's, Inc. VBA474807-00 Surplus Lines Agent's Name: Surplus Lines Agent's Address: Surplus Lines Agent's License: Producing Agent's Name: Producing Agent's Address Effective From: 7/25/2016 To: 7/25/2017 Edward P. Jackson 6951 W. Sunrise Blvd. Plantation, FL 33313 A128903 Andrew Rich 990 US Hwy 1 Ste A Sebastian FL 32958 "THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS LINES LAW. PERSONS INSURED BY SURPLUS LINES CARRIERS DO NOT HAVE THE PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT TO THE EXTENT OF ANY RIGHT OF RECOVERY FOR THE OBLIGATION OF AN INSOLVENT INSURER." SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT APPROVED BY ANY FLORIDA REGULATORY AGENCY. Total Premium: Fees: Surplus Lines Tax: Service Office Fee: FEMA Surcharge: FHCF CPIE: Total: Surplus Lines Agent's Countersignature: $9,110.00 Insp Fee $150.00 Policy Fee $35.00 $464.75 $13.94 $4.00 $9,777.69 FLORIDA COMMON POLICY DECLARATIONS THIS POLICY IS ISSUED BY THE COMPANY NAMED BELOW COMPANY NAME: Covington Specialty Insurance Company (A New Hampshire Stock Company) BRANCH ADDRESS: 945 East Paces Ferry Road Suite 1800 Atlanta GA 30326-1160 POLICY NO.: VBA474807 00 NAMED INSURED: Crab E Bill's, Inc. MAILING ADDRESS: 1540 Indian River Drive SEBASTIAN, FL 32958 PRIOR POLICY: VBA394798 00 POLICY PERIOD: From 7/25/2016 to 7/25/2017 12:01 A.M. Standard Time at your Mailing Address above. 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. THIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS LINES LAW. PERSONS INSURED BY SURPLUS LINES CARRIERS DO NOT HAVE THE M PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT TO THE EXTENT OF ANY RIGHT OF RECOVERY FOR THE OBLIGATION OF AN INSOLVENT UNLICENSED INSURER. © SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT APPROVED BY ANY FLORIDA REGULATORY AGENCY. THIS POLICY CONTAINS A SEPARATE DEDUCTIBLE FOR ❑ HURRICANE OR WIND LOSSES, WHICH MAY RESULT IN HIGH OUT- OF-POCKET EXPENSES TO YOU. THIS POLICY CONTAINS A CO -PAY PROVISION THAT MAY RESULT IN HIGH OUT-OF-POCKET EXPENSES TO YOU. GBA 900016 1012 Page 1 of 2 THIS POLICY IS ISSUED BY THE COMPANY NAMED BELOW FLORIDA COMMON POLICY DECLARATIONS COMPANY NAME: Covington Specialty Insurance Company (A New Hampshire Stock Company) BRANCH ADDRESS: 945 East Paces Ferry Road, Suite 1800, Atlanta GA 30326-1160 POLICY NO.: VBA474807 NAMED INSURED: Crab E Bill's, Inc. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. COVERAGE PARTS PREMIUM Commercial Property $ 1,962.00 Commercial General Liability $ 6,398.00 Liquor Liability $ 750.00 Commercial Inland Marine $ Not Covered Commercial Professional Liability $ Not Covered Annual Minimum and Deposit Premium $ 9,110.00 Audit Period: Annual unless otherwise stated: SL taxes and fees Policy Fee 35.00 Inspection Fee 150.00 Terrorism Premium $ --Excluded— Surplus Lines Tax 464.75 FEMA 4.00 Service Office Fee 13.94 Other Other charges (SL taxes, fees) $ 667.69 TOTAL POLICY PREMIUM 1 $ 9,777.69 FORMS AND ENDORSEMENTS APPLICABLE TO ALL COVERAGE PARTS: SEE SCHEDULE OF FORMS AND ENDORSEMENTS — GBA900002 BUSINESS DESCRIPTION: Seafood Market & eatery THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE FORM(S) AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE CONTRACT OF INSURANCE. AGENCY NAME / ADDRESS: Bass Underwriters Inc Bass Underwriters - Altamonte Springs, FL 225 South Westmonte Drive, Suite 3320 Altamonte Springs, FL 32714 Countersigned: 7/25/2016 By: Date Aut116n Zed resentnt(ve hndudes copyrighWd nnatnial of Insurance Services Offico. Inc., with IV perp ssim. CMIn Ighl. Insurance Services. Inc., 1984. GBA 900016 1012 Page 2 of 2 POLICY NO.: VBA474807 00 NAMED INSURED: Crab E Bill's, Inc. COMMERCIAL LINES SUPPLEMENTAL DECLARATIONS EFFECTIVE DATE: 7/25/2016 SCHEDULE OF ENDORSEMENTS FORM NUMBER TITLE GBA 901001 1112 Insurance Policy Jacket Forms Applicable to All Coverage Parts GBA 900016 1012 Florida Common Policy Declarations GBA 909008 0407 Florida Important Notice to Policyholders GBA 909009 0407 Florida Coinsurance Contract Important Notice GBA 909022 0415 State Fraud Statement RSG 99018 1211 Notice - Rejection of Terrorism Coverage GBA 904010 1007 Minimum Earned Premium Retained GBA 906005 0115 Exclusion Of Terrorism GBA 906011 0414 Exclusion of Other Nuclear, Biological, Chemical or Radiological Acts of Terrorism GBA 909001 0407 Service of Suit IL 0003 0802 Calculation of Premium IL 0017 1198 Common Policy Conditions IL 0021 0504 Nuclear Exclusion Forms Applicable to Coverage Part - GENERAL LIABILITY GBA 100001 0813 Commercial General Liability Coverage Part Declarations CG 0001 0413 Commercial General Liability Coverage Form CG 2011 0413 Additional Insured - Managers or Lessors of Premises CG 2144 0798 Limitation of Coverage to Designated Premises or Project CG 2407 0196 Products - Completed Operations Hazard Redefined GBA 104014 0106 Basis of Premium GBA 106032 0614 Exclusion - Liquor - Absolute GBA 106059 0113 Exclusions and Limitations Amendatory GBA 106084 0212 Exclusion - Athletic or Sports Participants GBA 106109 0115 Exclusion - Access or Disclosure of Confidential or Personal Information and Data - Related Forms Applicable to Coverage Part - LIQUOR LIABILITY 900002 1105 POLICY NO.: VBA474807 00 NAMED INSURED: Crab E Bill's, Inc. COMMERCIAL LINES SUPPLEMENTAL DECLARATIONS EFFECTIVE DATE: 7/25/2016 SCHEDULE OF ENDORSEMENTS FORM NUMBER TITLE LLG 30013 0414 Liquor Liability Coverage Part Declarations LLG 30108 0208 Liquor Liability Coverage Part Forms Applicable to Coverage Part - PROPERTY GBA 400001 0516 Commercial Property Coverage Part Declarations CP 0010 1012 Building and Personal Property Coverage Form CP 0030 1012 Business Income (And Extra Expense) Coverage Farm CP 0090 0788 Commercial Property Conditions CP 1030 1012 Causes of Loss - Special Form CP 1033 0695 Theft Exclusion GBA 404002 0813 Actual Cash Value Defined GBA 4040050416 Coverage Enhancement Endorsement GBA 404012 1208 Total or Constructive Loss Clause GBA 404028 0615 Spoilage Coverage GBA 404030 0116 Construction Type Definitions GBA 406010 0413 Windstorm or Hail Exclusion GBA 406014 0114 Exclusion of Pathogenic or Poisonous Biological or Chemical Material IL 0415 0498 Protective Safeguards Forms Applicable to STATE FORMS and ENDORSEMENTS CP 0125 0212 Florida Changes GBA 402002 0514 Florida - Sinkhole Loss Coverage GBA 903001 0914 Florida Changes - Cancellation and Nonrenewal 900002 1105 Cotft ❑'X' IF SUPPLEMENTAL DECLARATIONS ATTACHED 1. POLICY NO.: VBA474807 00 Crab E Bill's, Inc. 2. NAMED INSURED: COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS EFFECTIVE DATE: 7/25/2016 3. LIMITS OF INSURANCE PREM General Aggregate Limit (Other Than Products - Completed Operations) $ 2,000,000 Products -Completed Operations Aggregate Limit $ 1,000,000 Personal and Advertising Injury Limit $ 1,000,000 Each Occurrence Limit $ 1,000,000 Damage To Premises Rented To You Limit $ 100,000 Any ono Promise Medical Expense Limit $ 5,000 Any one Person Coverage A of this Insurance does not apply to injury caused by a wrongful act which was committed before the Retroactive Date, if any shown here: Retroactive Date: None (Enter Date or •Nono It no Retroactive Dare) LOCATIONS INCLUDING ZIP CODE OF ALL PREMISES YOU OWN, RENT OR OCCUPY (Enter same gsame location as your maxing adrkess): 1. 1540 INDIAN RIVER DRIVE, SEBASTIAN, FL 32958 CODE PREM PREMIUM EXPOSURE I RATE ADVANCE PREMIUM NO. NO. CLASSIFICATION BASIS AMOUNT PRao ALLOTHER PRICO ALL OTHER 15224 1 Meat, Fish, Poultry or Gross 1,077,480 0.787 2.517 $848.00 $2,712.00 Seafood Stores Sales 16916 1 Restaurants - with alcohol Gross 386,891 0.994 6.341 $385.00 $2,453.00 30% tofincl. 75% of annual Sales receipts - without dance floor TOTAL ADVANCE PREMIUM FOR THIS PAGE $1.233.00 $ 5,165.00 TOTALADVANCE PREMIUM rOR THIS $ 6,398.00 COVERAGEPART 4. t•ORMS AND ENDOR5EMENTS APPLICABLE (other than applicable Forms and Endorsements shown elsewhere In this policy) 'Fors and Endorsements applying to this Coverage Part and made a part of this policy at time of issue: SEE SCHEDULE OF FORMS AND ENDORSEMENTS — GBA900002 'Entry optIonal If shown on Common Policv Declarations 5. FORM OF BUSINESS: _❑ Individual ❑ Joint Venture ❑ Partnership ❑ Limited Liability Company M Corporation ❑ Other THESE DECLARATIONS, WHEN COMBINED WITH THE COMMON POLICY DECLARATIONS, THE COMMON POLICY CONDITIONS, COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE CONTRACT OF INSURANCE. Indudes ooprOWd maWft of Nwranco SOMoee Once. tn,, with Ib NaoY ar. CapyNOt. InoerenW 50niWz, Inc., 1886. GBA 100001 0813 Page 1 POLICY NUMBER: VBA474807 00 COMMERCIAL GENERAL LIABILITY CG 20 11 04 13 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - MANAGERS OR LESSORS OF PREMISES This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Designation Of Premises (Part Leased To You): 1-11540 Indian River Drive; Sebastian, FL 32958 Name Of Person(s) Or Organization(s) (Additional Insured): City of Sebastian 1225 Main St, Sebastian, FL 32958 Additional Premium: $ INCLUDED Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II — Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability arising out of the ownership, maintenance or use of that part of the premises leased to you and shown in the Schedule and subject to the following additional exclusions: This insurance does not apply to: 1. Any 'occurrence" which takes place after you cease to be a tenant in that premises. 2. Structural alterations, new construction or demolition operations performed by or on behalf of the person(s) or organization(s) shown in the Schedule. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the Insurance afforded to these additional insureds, the following is added to Section III — Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. CG 20 11 04 13 © Insurance Services Office, Inc., 2012 Page 1 of 1