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CERTIFICATE OF INSURANCE 1110 ADDITIONAL INSURED COpy III POLICY #: 77 BP 703-356-3001 F 1..11'1111.1...1.1.1.1..1..1..11...1.1..111.1..1..11..1.1.1..1 C I TV OF CLEARWATER PARKS AND RECREATION ATTN KYLE KILIAN PO BOX 4748 CLEARWATER FL 33758 Policy For: COACHMAN RIDGE HOMEOWNERS ASSN INC ATrN KENNETH A KELLOGG PO BOX 7626 CLEARWATER FL 33758 RECl::!'VED JUt 2 5 2005 Ja ~ ;4 RISK MANAGEMENT C- Cas. 4369 ADDITIONAL INSURED COpy POLICY NUMBER: 77 BP 703-356-3001 F BU.SINESS PROVIDER THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS RELATING TO PREMISES This endorsement modifies insurance provided under the following: BUSINESS PROVIDER POLICY SCHEDULE* State or Political Subdivision: CITV OF CLEARWATER PARKS AND RECREATION ATrN KYLE KILIAN PO BOX 4748 CLEARWATER FL 33758 The following is added to Paragraph C. WHO IS AN INSURED in the Business Provider Liability Coverage Form: 4. Any state or political subdivision shown in the Schedule is also an insured, subject to the follow- ing additional provision: This insurance applies only with respect to the following hazards for which tl1estate or political subdivision has issued a permit in connection with premises you own, rent, or control and to which this insurance applies: a. The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway openings, sidewalk vaults, street banners, or decoration and similar exposures; b. The construction, erection, or removal of elevators; or c. The ownership, maintenance, or use of any elevators covered by this insurance. *Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declarations. BPP-0074 (7-94) Includes Copyrighted Material of Insurance Services Office, Inc., 1985 POLICY NUMBER: 77 BP 703-356-3001 F BUSINESS PROVIDER THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - STATE OR POLITICAL SUBDIVISIONS - PERMITS RELATING TO PREMISES This endorsement modifies Insurance provided under the following: BUSI NESS PROVI DER POLICY SCHEDULE* State or Political Subdivision: CITY OF CLEARWATER PARKS AND RECREATION ATrN KYLE KILIAN PO BOX 4748 CLEARWATER FL 33758 The following is added to Paragraph C. WHO IS AN INSURED in the Business Provider Liability Coverage Form: a. The existence, maintenance, repair, construction, erection, or removal of advertising signs, awnings, canopies, cellar entrances, coal holes, driveways, manholes, marquees, hoistaway openings, sidewalk vaults, street banners, or decoration and similar exposures; b. The construction, erection, or removal of elevators; or c. The ownership, maintenance, or use of any elevators covered by this insurance. 4. Any state or political subdivision shown in the Schedule is also an insured, subject to the follow- ing additional provision: This insurance applies only with respect to the following hazards for which the state or political subdivision has issued a permit in connection with premises you own, rent, or control and to which this insurance applies: *Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declarations. BPP-0074 (7-94) Includes Copyrighted Material of Insurance Services Office, Inc., 1985 BUSINESS PROVIDER AMENDMENT OF POLLUTION EXCLUSION - EXCEPTION. FOR BUILDING HEATING EQUIPMENT This endorsement modifies insurance provided under the Business Provider Liability Coverage Form. Under Section B. EXCLUSIONS, Subparagraph (1) (a) of exclusion f. is replaced by the following: This insurance does not apply to: (1) "Bodily injury" or "property damage" arising out of the actual, alleged or threatened discharge, dispersal, seepage, migration, release or escape of pollutants: (a) At or from any premises, site or location which is or was at any time owned or occupied by or rented or loaned to, any insured. However, Subparagraph (a) does not apply to "bodily injury" if sustained within a building and caused by smoke, fumes, vapor or soot from equipment used to heat that building. BPP-0172 (1-00) Includes Copyrighted Material of Insurance Services Office. Inc.. 1996 '0 FLORIDA NOTICE ISSUED BY: NATIONWIDE MUTUAL FIRE INSURANCE COMPANY I I Policy Number: 77 BP 703-356-3001 F Na~ed Insured COACHMAN RIDGE Mailing Address HOMEOWNERS ASSN INC ATrN KENNETH A KELLOGG PO BOX 7626 L9LEARWATER FL 33758 ~ POLICY PERIOD: From JULY 19,2005 to JULY 19, 2006 12:01 A.M. Standard Time at your mailing address. at THIS POLICY CONTAINS A SEPARATE DEDUCTIBLE FOR HURRICANE LOSSES, WHICH MAY RESULT IN HIGH OUT-OF-POCKET EXPENSES FOR YOU. FLNOTICE · D BUSINESS PROVIDER POLICY DECLARATIONS Issued By: NATIONWIDE MUTUAL FIRE INSURANCE COMPANY Policy Number: RENEWAL 77 BP 703-356-3001 F Named Insured COACHMAN RIDGE Mailing Address HOMEOWNERS ASSN INC ATrN KENNETH A KELLOGG PO BOX 7626 CLEARWATER FL 33758 Form of Business: D Partnership D Other: D Sole Proprietorship [i] Corporation Policy Period: From JULY 19, 2005 to JULY 19, 2006 at your mailing address. *Exceptions: 12:00 Noon in New Hampshire at 12:01 A.M. * Standard Time Described Premises: Premo No. Bldg. No. Location Address 001 01 STAG RUN BLVD CLEARWATER FL 33765 Description of Business HOMEOWNERS ASSOCIATION Mortgage Holder Name and Address: Premo No. Bldg. No. Mortgage Holder Mortgage Holder IN RETURN FORTHE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE TO PROVIDE YOU WITH THE INSURANCE AS STATED IN THIS POLICY. PROPERTY COVERAGES D Standard Form [K] Special Form LIMITS OF INSURANCE Premises No. Building No. 001 01 Buildings - Replacement Cost $ 4,504 Actual Cash Value $ Automatic Increase 2 % Business Personal Property $ Deductible $ 250 I This Policy Includes Business Income and Extra Expense Coverage. BPP-0001 (7-94) Page 1 of 3 , '. D , BUSINESS PROVIDER POLICY DECLARATIONS OPTIONAL PROPERTY COVERAGES - Applicable only if an .X. LIMITS OF INSURANCE is shown in the boxes below: D Outdoor Signs $ Per Sign D Exterior Glass D Basement/ground floor level D All floors D Interior Glass o Basement/ground fioor level o All floors o Burglary and Robbery (Standard Form only) $ Inside the Premises $ Outside the Premises or $ Inside the Premises o Money and Securities (Special Form only) $ Outside the Premises o Employee Dishonesty $ o System Protector o Earthquake % Deductible $ 0 $ 0 $ 0 $ D $ 0 $ 0 $ LIABILITY AND MEDICAL EXPENSE COVERAGES LIMITS OF INSURANCE Liability and Medical Expense $ 500,000 Any One Occurrence Personal and Advertising Injury Included in Above - Any One Person or Organization Medical Expenses $ 5,000 Any One Person Fire Legal Liability $ 50,000 Any One Fire or Explosion General Aggregate Limit (other than Products-Completed Operations and Fire Legal Liability) $ 1,000,000 Products-Completed Operations Aggregate Limit $ 500,000 OPTIONAL LIABILITY - Applicable only if an LIMITS OF INSURANCE .X. is shown in the boxes below: 0 $ 0 $ n $ LJ Page 2 of 3 BPP-0001 (7-94) oD BUSINESS PROVIDER POLICY DECLARATIONS FORMS APPLICABLE TO ALL PREMISES AND BUILDINGS: BPP 0004-0794 BPP 0007-0704 CAS 2527 B-0794 BPP 0083-0794 CAS 6283-0403 BPP 0172-0100 CAS 6216-1102 CAS 6217-1102 BPP 0006-0102 CAS 4847-0501 BPP 0019-1197 BPP 0065-0794 BPP 0121-0794 BPP 0162-1196 CAS 3228 CAS 3880-0897 CAS 6234-1102 IL 09 85-0103 BPP 0074-0794 BPP 0096-0794 PREMIUM Total Annual Premium includes the fOllowing miscellaneous charges FLORIDA DOR SURCHARGE F.M.A.P. SURCHARGE $ 807.80 $ 0.80 $ 4.00 $ $ $ In the event you cancel the policy, we will retain not less than $ 400 premium. Date of Issue: 07-19-05 P.O. BOX 147080 Issuing Office: GAINESVILLE, FL 32614 Countersignature Date: Agency At: SEMINOLE FL 33776 Agent: BARRY J SCARR 0001084-09 BPP-0001 (7-94) Page 3 of 3 oD FORMS APPLICABLE ONLY TO SPECIFIC PREMISES/COVERAGES: Premises Bldg. No. No. Form Number BUSINESS PROVIDER POLICY SUPPLEMENTAL DECLARATIONS Policy Number: RENEWAL 77 BP 703-356-3001 F 001 BPP 0117-0794 * Coverage 01 * If information required to complete the coverage section is not shown, refer to the form indicated at ieft. BPP-0003 (7-94)