CERTIFICATE OF INSURANCE (3)
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SHAFER-BROWN INS INC
POBOX 1328
CLEARWATER FL 33517
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CINCINNATI INS CO
CLEARWATER HIGH SCHOOL
BAND BOOSTERS
1779 DREW ST
CLEARWATER FL 33515
AGL2961498
10/30/82
300
300
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50
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March 1, 1982 F
CITY OF CLEARWATER
CLEARWATER FL33515
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SHAFER-BROWN INS INC
POBOX 1328
CLEARWATER FL
33517
CLEARWATER HIGH SCHOOL
BAND BOOSTERS
1779 DREW ST
CLEARWATER FL 33515
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AGL2961498
X
X
RECEIVED
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SEP 119m
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ADDITIONAL INSURED CITY OF CLEARWATER
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CITY OF CLEARWATER
CLEARWATER FL33S16
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CINCINNATI INS CO
10/30/82
300
50
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300
26, 1981 F
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Name of PolicyhoWer C~: -;-/.1/1t,'//J777;. ;-lie",! <;..- ;.p..".'~hl )~~'7?:.7:..S. T....J '.
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Permanent Mailing Address Ie; J~ 17. i'> -...i' . U'! 111<..-:- L c..L710'A rz-~' f'Z-.
(NUMBERl (STREET)" (CITY) (STATE)
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APPLI~ATION TO NATIONAL CASUAL ~Y 'MPANY
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for a
SPECIFIED HAZARD INSURANCE POLICY
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(ZIP)
2.
Policy Term: The Policy Term begins on
which shall be the Effective Date and ends on
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which shall be the First Renewal Date
3. Schedule of Insurance: The benefits included are only those opposite which in the Schedule below a specific amount is set forth. The
word "None" set forth opposite any such benefit listed indicates that the benefit is not included.
Maximum Amount
Description of Benefits
Class 1 Class 2 Class 3
Accidental Death and Dismemberment
Accidental Death. $1,000.00 $2,500.00 $ 5,000.00
Accidental Dismemberment (Principal Sum) . 5,000.00 5,000.00 5,000.00
Aggregate Maximum Limit of Liability for
Any One Accident S ___2~~9QO~OQ__
Weekly Accident Indemnity for ... _.__._________.____weeks None None None
Medical Expense
Accident
Deductible Amount. None None None
----
Dental Maximum. 500.00 500.00 500.00
Overall Maximum. 5,000.00 5,000.00 ) 0,000.00
Sickness (Overall Maximum) None None None
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4. Eli ibility and Premiums (Check Coverage for which application is bein made)
Class
Description of Eligible Classes
Individual Annual Premium with the Policy Term
Premium subject to a minimum of $25.00
'fgJ Full Coverage 0 Excess Coverage
Members or Members and Counselors of the Youth Group
which is sponsored and/or endorsed by the Policyholder
and is composed of (check only one box):
1
2
3
Boys only, all of whom are under age 12; boys and girls;
or girls only
~ Class 1 Benefits
o Class 2 Benefits
o Class 3 Benefits
2
3
Boys only, including boys age 12 and over
o Class 2 Benefits
o Class 3 Benefits .
$1.00 $0.70
1.20 0.90
1.60 1.30
1.50 1.15
2.00 1.60
5_ Description of Hazards to be Insured Aaainst
In attendance at or part;cipation in any regularly approved and supervised Activity which is sponsored and/or endorsed by
the Policyholder and while traveling directly Detween the Insureci's home premises (building and grounds where he resides)
and the meeting place to participate in or attend any such activity.
6.
The Policy is to cover all Eligible Persons which includes:
D Members Only
.IX:; Members and Counselors
7. It is understood and agreed that; (a) The Company reserves the right to audit the Policyholder's records if deemed necessary
~tion with the insurance. (b) The premium for the Polic.y' .....iil bE: r:-.::id in the foliawing manner: Ann;;ally ln adva:-ice
, and (c) if "Excess Cover<.tge" is elected above, the premium will be paid by the Policyholder with all Eligibl
~ ~rf'(fS being Insured and that n.o benefits will be payable for hospital or surgical charges to the extent that benefits are payable theref
xnld'er any Olher policy or pre-payment plan (including a plan under federal, state or other governmental law, unless it is a requireme
,,?O~ such law that insura'lce benefits be paid first.)
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IPREVIOU POLICY NUMBER)
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(DATE) .\.. . . j r Wi'lINTED NAME OF APPLICANT)
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IAGC~'S r,;A~J\EY' '(. '7 -j i. . - (ADDiifS~ OF AI~f'LICANT)
FormSHBA1500 1./C/:Jc---r I'U-:; "J - C .{Q{(/I..,' Cl <~,I. rL-. 3'2 -//
NOT~: SPECIFIED HAZARD PLAN NOT AVAILAgLE IN MARYt"ArlD /NEW YORK, AND
PEf\Jr:SYL VANIA. EXCESS CO VERAGE NOT A VAl LABLE IN ALABAMA, CALIFORNIA,
CCW"r,Ci!CUT. ILLlI'W!S, KANSAS, ~:EW HAMPSHIRE OR TO SCHOOLS Ir--.! TEmESSEE.
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