CERTIFICATE OF INSURANCE (143)
iURE
Icords
1
~
Date:
t4/88
dosed contains a Mortgage Clause, or Loss Payable Clause
favor.
Carole Johnson
'Y and Policy No.
American Reliance H9150393
, of Clearwater
Box 4748
rwater, Fl 33518
ITALIANO INSURANCE SEl
2506-A SOUTH MacDILL A VB. P
TAMPA, FLORIDA 33679-
Telephone: (813) 831-77!
-.....__, ,,; - ,,-- Homeowner Policy
, 'AftE.RICAN RELIANCE INIURANCE COt'PAJ'4Y. I. Declaralions
This' RENEWAL DECLARATION' ,effective 02/27/86 ,12:01 a.m. Standard Time
" at the location of the Residence Premises insured, rePlac. es all previous Declarations, if any, issued under:
: POLICY NUMBER H9150393 ,issued for a term of 1 year(s),from 02/21/88 to 02/27/ 9
. ' .
;; .
Insured's Name and Mailing Address Agent's Name and Address
C.ROlf A. JOHNSON ITALIANOINSURANCf SERVICES
1300 BEACHWOOD AVENUE 2506 A "AC DILL AVENUE
CLEARWATER FL P.O. BOX 18425
33519 TA"PA
33679
, j Tbe~~ce Premises covered by this policy is localed at lhe above address unless otherwise steted:
, ;.Name~
i,', Str$~it'
~ :.7 CIty. . ,;"
:: .. ~~ ; . .. 0-
F' .
r~ J)~e~
Fl
Agency No. 009357
Coverage is provided where a premium or Ilmll of liability is shown for the coverage.
SECTION I COVERAGES
B. Other C. Personal D. Loss Of
Slructures Property Use
~ 54,00 $ 5,400$ 27,000$ 10,800$
POLICY PREMIUMS AS OF THE EFFECTIVE DATE OF THESE DECLARATIONS
-;" ;-B8ie------Additional rremiUfl'lS"---- - ---rotar--'~ --'lOiar--------~~ --AaCllttonal
Policy Other Scheduled Annual Policy Or Return
Premium EndorsemenlS Personal Property Premium Premium Premium
COVERAGES
AND
LIMITS OF
LIABILITY
A. Dwelling
SECTION II COVERAGES
E. Per nal LiabTl F. Medical
so II y Payments To Others
Each Occurrence Each Person
50,000 $ 500
PREMIUM DUE ON
ThlfDate These ',,--' Each
Declarations Anniversary
Are Effective
$ 1 $ $
Form And Endoreemenls Made Part
Of this Policy At Time Of Issue: H 0 3
Insert Nurnber(s) and Edition Date(s) H 0 3 2 2
$ 17
$
$
17 $
(7-77) t\0300
(10-85) H0325
(9-82) GIA661R(5-79J
(12-85) H0184 (11-80)
H0330
(09-8 _
DEDUC-
TIBLE
Section I Other In case of loss under Section I,
$ we cover only that part of lhe loss over the deductible stated.
er nsured locations: (No., Streel, Apt., Town or City, County, State, Zip Code)
SECTION
,\':"11
MORTGAGEE
(NAME AND
ADDRESS)
1~ FREEOO" ~ORTGAGE AND/eR ITS
SUCCESSORSANO ASSIGNS
2nd
CITY OF CLEARWATER, DEPT. OF
COMMUNITY OEVElOP"ENT
P. o. BOX 25017 P. O. BOX 4748
TAMPA, FLORIDA 33623 CLEARWATER, FLORIDA 33518
Loan No, Loen No.
(a).The Residence Premises Is not seasonal; (b) no business pursuits are conducted on the Residence Premises; (c) the Residence Premises Is lhe only
premises where the NBmed In8ured or Spouse maintains a residence other then business or farm properties; Cd) the Insured has no full lime residence
;,~~~\~\: ~~l ~(~)~Ured has no outboard motor(s) or watercraft otherwlee elCClude~ under thle policy for which coverage 18 desired, Excepllons, If any,
,..;;',l.
-, ..,
. .~ ":
. Absence of an entry means "no exceptions"
When these Deetaretlons are Issued 10
'ametld the Policy ContrBCt, the amendment Is:
COllnterslgnature Date: 11/23/87
'-' TA"PA FL
Agency At:
Rating Inlormallon
No, VI Construction
Fern, Const Code Type
Agenl
G IA999( 8/86 i