CERTIFICATE OF INSURANCE (2)
. Ce'tificate of Insurance-1
[vJFLORIOA FARM BUREAU MUTUAL INSURANCE COMPANY
[J FLORIDA FARM BUREAU CASUAL TV INSURANCE COMPANY
P.O. Box 730 Gainesville, FL 32602
DATE: M"y' 1 qR~ .
THIS IS TO CERTI FY that the Company named above has issued policy (ies) to the insured named below. If
such policy (ies) are canceled or changed during the period(s) of coverage as stated herein, such a manner as to
effect this certificate, lQ days written notice will be mailed to the party designated below for whom
this certificate is issued.
Name and Address of Party to Whom This Certificate is Issued
- -- ,.
ill
The City of Clearwater
P. O. Box 4748
Clearwater, Florida 33518
RECEIVED
MAY 12 1983
ATTENTION: Terry Jenning
Engineering Departm~ITYCLERK
Descriptio.':; of
Insured Operations:
Policy
Numbers t
cc:
Policyholder
Producing Agent
File
65 acres on State Road 580 and
County Road 77 in Pinellas County,
Florida.
Kind of
I nsu ran ce
AUTOMOBILE
BODilY INJ URY LIABILITY Each Person $
Each Accident $
PROPERTY DAMAGE LIABILITY Each Accident $
Name and Address of Insured
Robert E. Smith
Evelio Palomino d/b/a
E. Palomino Dairy
366 Garden L K Circle
Odessa, Florida 33556
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Limits *
Eff.
Date
PUBLIC L1ABI L1TY
BODILY INJURY LIABILITY Each Occurrence 'iOO; oon
PROPERTY DAMAGE LIABILITY Each Occurrence 5; 0-
PRODUCTS -Col11pleted Operations Liability
BODILY INJURY LIABILITY Each Occurrence $
Aggregate $
PROPE,RTY DAMAGE LIABILITY Each Occurrence $
Aggregate $
CONTRACTUAL LIABILITY
BOOILY INJURY LIABILITY
PROPERTY OAMAGE LIABILITY
Each Occurrence $
Each Occurrence $
Aggregate $
Covered:
WORKERS' COMPENSATION
Expiration
Date
$ STATUTORY
THIS CERTIFICATE OF INSURANCE IS NOT VALID UNLESS IT IS COUNTERSIGNED 'UAY 0 s. 1983
BY A OULY AUTHORIZED REPRESENTATIVE OF THE COMPANY. ~.,
t If more than one kind of insurance is written on one policy, the policy number need nQt be repeated.
* Absence of an entry in these spaces means that insurance is not afforded with respect to the coverage
opposite thereto.
29/dsg
Serviced by Florida Farm Bureau at Valrico, FL
93.7-692 (Rev. 1/81)
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DjlRR~T J
RY~R
Authorized Signature
if
D-f'&~A fA'M _U"AU CASUALTY INSURANCE COJANY
~ FLORIDA FARM BUREAU MUTUAL INSURANCE COMPANY
ENDORseMENT
~
I
Subject" to all other terms and conditions of the pol icy to which th is endorsement is attached
it is understood and agreed by and between the Company and the Named Insured that
ADDITIOliAL INSURED:
The Insured U hereby --.Jed to iDclude: City of Clearwater,
P. o. Sox 4748. Clearwater. Florida. j,TTENTION: Terry Jenning
Enllineering Depar~t. _ (an) Additional Insured (8), but
only with respect to LiahUity .a their intereat IlIaY appear in 500 aerea
on Patteraon Road, qd 65 8cr.. 011 State !load 580 SlId County lload 77
in Pinella. County. Florida.
Attached to and forming part of policy number
GL 639383
issued to
Nothing herein contained slr:J11 .:=llter( vary, waive, o~ exte~ld any prcvisio,-I or condi~ion of the
policy except as herein provided.
Robert E. Smith and EveUo of
l'aloa1no dlb'a E. Pal_iDo Dairy
Od_. FL
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Effective dote of this endorsement
OS/24/83
Countersigned ot Gainesville, Florida
on
04/26/83
29/wbj
Aul'lorized Represenratl'le
93-7-131 (REV. 4/82)