CERTIFICATE OF COMMERCIAL POLICY
.
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;:;..~. "I}'- t'LF \ ri3 :\I;E'lCY
31 ! r~ST OAf DR #D
LP, (,D FLClfi If)f\ 335.11
fJl _~1J7 0
P.O. BOX 20027
ST. PETERSBURG. FLORIDA 33742
(813)577-5775 . TAMPA 223,5314
FLORIDA WATS 1 -800-282-2841
P.O. DRAWER 5888
FORT LAUDERDALE. FLORIDA 33310
(305) 525-2081 . MIAMI 945-8282
FLORIDA WATS 1-800-432-3705
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EXCESS
Hull & Company, Inc. LIMITS
AUTOMOBilE
~..... APPLICATION
D' PRIVATE PASSENGER' :.'
,~COMMERC'Al . "
'".tuu'tJn~r & R"in.uNJrt.u '",~""rd.itJ,;tJ
I 0
EXPIRING.POLICY NO,
.:I..AJ C-
CITY
COUNTY
ZIP CODE
-a 3 S-/~~
EXPIRATION DATE
w-q-~8 12:01AM
2
3
LIST ALL. DRiVERS \,~~:i:r:l~":DATItO..,:BiRT~'!
1 tFi-fE"FTIUi-RIOS (J 55~' I~' ''i,J?
2
.,'>STATE'
FtA
3
BRIEF DESCRIPTION OF ACCIDENT (AF OR NAF)
LIST ALL VIOLATIONS PER DRIVER - LIST MONTH. DAY, YEAR
, ' , LOSS EXPERIENCE - CURRENT AND PREVIOUS THhEE (3) YEARS . ' I, . , ";' .
PFORL~~V PE~~OD '~':"'?,:~~~~~~'~'~J~~~~'~~:~~:~\~;~]Jfl~:;~rt ;~i~,gt,i;11: ffi~~~i
,<{?/~:~
.". '" ' LIMITS AND PREMIUMS
Excess Required: BI qt-l.} / /) 00 PD ') 00 Or CSL
BI /OV/3Du PD 30D Or.CSL
L. ''.J}()OQ;~''() PD dJll~~;I)O"'~ OrCSL
I 1 (;) tJcJ} 0""
I Y DO;). 000
I ,D""J<>tO
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CAR 1 BI S
CAR 2 BI S
POS
POS
UM S
UM S
In Iccordance with Florida Law. UnInsured MotorIsts Coverage ISlVallable under thIs policy up to the' Bodily Injury LIability LImits of the
polley. II the Insured desires such coverage, pleue IndlClte the limits desIred below:
Uninsured Motorists Coverage Is desired under thIs policy for limits of:
$ each perso~ S
Inlury each aecldenQ whIch will be excess of UnInsured MotorIst limits of
$ each perso~ $
Inlury each accldenQ purchased under the Primary Pollcy(s).
Blch accident or $
,000 (Bodily
each accident or $
,000 (Bodily
If no limits are Indicated above. It Is usumed that the local producIng agent hu explaIned to the Insured hIs options as far u Uninsured
Motorists Coverage under this policy Ire concerned and he hu decIded not to elect such coverage under thIs policy.
" ' coNFIRMAtioN" , ; ""', '.
I UNDERSTAND THAT THE ABOVE INFORM
ESSENTIAL FOR RATING PURPOS E
~
SIgnature 01 Applicant:
E COMPANY'S DETERMINATION WHETHER TO ACCEPT THE RISK ANo.lS
ALL SUCH ':FORMAT'ON IS CORRECT. t- / t t'y.
Title. Date:
INED UNINSURED MOTORISTS COVERAGES TO THE APPLICANT,
NAME OF PR~?~8R~A~'(fNC.Y: . ...: ','
PHONE
SIGNATURE
OF
PROOUCER
STATE
ZIP CODE
. .
: :. I
PRODUCER NO, WORKSHEET NO,
CHECK NO
DRAFT NO.
0"0' 1011/84
------r--
NAME 'AND MAILING ADDRESS OF INSURED
NaHm
Effective 12,00 m, 6/9 ' 1988
Expires 0 12:01 am 0 Noon , 19
o This binder is issued to extend coverage in the above named
company per expiring policy #
(except as noted belowl
Description of Operation/Vehicles/Property
Cl~m:water I.it1ous1ne
1484 Ga1f TO Bay , 2
Clearwater, F1orl.cla 33515
Type and location of Property
Coverage/ Perils/Forms
Amt of Insurance Oed.
P
R 1984 Lincoln Tottrl Car t1.IBJP6FXBr608147
o
P
E
R
T
Y
Per
Person
$
Per
AccIdent
OA
DB
DC
limits of liability
Each Occurrence
Bodily Injury $
Property
Damage $ $
Bodily Injury &
Property Damage
Combined $
Personal Injury $
limits of liability
Bodily Injury (Each Person) $100
Bodily Injury (Each Accident) '300
l
I 0 Scheduled Form
o Premises/Operations
I 0 Products/Completed Operations
l 0 Contractual
I 0 Other (specify below)
T 0 Med, Pay. $
y 0 Personal Injury
Type of Insurance
Coverage/Forms
o Comprehensive Form
A
U ~ Liability 0 Non-owned
T 0 Comprehensive-Deductible
o 0 Collision-Deductible
M 0 Medical Payments
o
B 0 Uninsured Motorist
I 0 No Fault (specify):
l 0 Other (specify):
E
o Hired
$
$
$
$
Property Damage
$300
Bodily Injury & Property Damage
Combined $
o WORKERS' COMPENSATION - Statutory Limits (specify states below)
o EMPLOYERS' LIABILITY - Limit
$
SPECIAL CONDITIONS/OTHER COVERAGES
NAME AND ADDRESS OF 0 MORTGAGEE
I;J LOSS PAYEE
o ADD'L INSURED
LOAN NUMBER
Signature of Authorized Representative Date