CHANGE ENDORSEMENT
ec: 639 FL cv 9-17-80 FL ISO
~ /12 I . C~ANGE ENDORSEMEN1
THIS ENDORSEMENT FORMS A PART OF THE POLICY NUMBERED BELOW:
ENDORSEMENT EFFECTIVE DATE POLICY NUMBER
--
COMPANY Nationwide Mutual Fire Ins.
INSURED'S NAME AND MAILING ADDRESS
Denveney, Nelson & Cashion Bldg.
Street Executive Condominium
817 Court Street
Clearwater, FL 33516
MP 12 01
(Ed. 02 79)
Co.
AUTHORIZED REPRESENTATIVE'S NAME AND MAILING ADDRESS
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Endorsing policy under section II to add City of clearwater % for BI & PD,
class code 65121. Revised premium is $417.00. Section I premium remains
the same. t,J~r-
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RODUCER CODE
POLICY CHANGES
30 () tJ 0 () .", ~=,;"-,, oV
E-::J= P b '
SPECIFY FORM NOS. AND EDITION DATES AFFECTED BY POLICY CHANGES:
,~~0013,56,200~201,999],OOqO,~~04)G
SECTION I-PROPERTY COVERAGE
LIMITS OF LIABILITY RATES
Coverage
Description
Loc. Bldg.
No. No.
e
COVERAGE
SMP Liability Insurance Form: $
Bodily Injury and Property
Damage Liability $
(Combined Single Limit)
Premises Medical Payments $
o SMP Liability Insurance
Form
o Medical Payments $
Coverage Part
o Forms other than
SMP Liability Insurance
Form $
Specify Coverage Part
$
Add'l Insured
~J $
~ ~ 'v~ $
\~ o Revised Dual Limits:
e
$ $
$ $
$ $
$ $
SECTION II-LIABILITY COVERAGE
LIMITS OF LIABILITY
Previous New Previous
$
ea. Occurrence ea. Occurrence
$ $ $
Aggregate Aggregate
$
ea;Person ea,Person
Previous
New
$
$
$
$
PREMIUMS
Previous
o Add'l
o Return
$
$
$
$
Previous
New
New
$
$
$
$
PREMIUMS
New
o Add'l 0 Return
$
$
ea. Accident ea. Accident
BODILY INJURY LIABILITY
Aggregate Aggregate
PROPERTY DAMAGE LIABILITY
$
$
ea. Occurrence
$
$
ea. Occurrence
$
$
$
ea. Occurrence $
$
$
ea. Occurrence
$
$
$
Aggregate Aggregate
INSTALLMENT PAYMENT PREMIUMS
Previous
Installments
$
$
Additional
Premium
38.
Revised
Installments
$
$
Dates of subsequent installments, 2.
if payable in annual installments: 3.
PREMIUM DUE AT EFFECTIVE DATE OF ENDORSEMENT:
Total for remainder of policy term: "
MP 12 01 (Ed. 02 79) ~ P 'tv~
Return
Premium
$
$
$
$