CERTIFICATE OF INSURANCE (7)
eERTIFICATE OF INSURANCE: PALO-l CSR LO
loakes & Associates Insurance I CONFERS NO RIGHTS UPON THE CE TIFICATE HOLDER. THIS CERTIFICATE
,Agency, I nc . , DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORD EO BY THE
,4111 Land 0' La kes Blvd. #108 I---~~~~~~~~-~~~~~:------______________________________m_____________
ILa nd 0' La kes FL 34639 1
I I COMPANIES AFFORDING COVERAGE
I-~~~~~-~-~~~~~~_~_~~_~_~_______________________________1______________________________________________________________________
i INSURED I COMPANY LETTER A Auto Owners Insurance Co.
I :-COMPANy-LETTER-Ej----------.-----------------------------------------
IE. palomino Dairy, Inc. :-COHPANY-LETiER-C-------m---------------------------------------m
Patsy Smi th -----------------------_______________________________________________
:6~~~~a G~[d3~5~~ke Ci rele : -~~~~~~:-~~~~~~-~____m____________________m___________m________ i
, I COMPANY LETTER E I
II COVERAGES j",:,:,::::""::":::"::::",,::,,,,:::,,,,::,,,:,::":::":::"":::",:::,,::::,,,,:,,,,:::,,,:::,,::::",:::,,:1
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMEO ABOVE FOR THE POLICY
: PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR .CONOITIO.N. OF A[t C~NTRACl_080THER__lliltllMErJl WI-TH_RESPEtlJO .nl
.-1- --WHICH THIS CERTIfICATE Mr BDSSUED-Ill<MArPtK I A1N ,I t1tlNSUmrrtAFFORDED BY TIlE POLICIES DESCRIBED HEREIN IS SUBJECT TO ,
I ALL TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. I
:-coi------;ypE-OF-iNsuRANcE--------i-------POLicY-NUHBER-------i---POLicY-EFF--i--POLicy-Exp--i--------------LiMiis--------------
JLTRI , I DATE , DATE 1
i---:-G-E:tjE:fl-~i:--L-i~El-ii:i-;r~-I---------------------------:---------------I--------------jGENERAL-AGGREGATE--i:3C;C;~-(;C;()--
: Ai [Xl COMMERCIAL GEN LIABILITY I 20363781-861912: 07/21/97: 07 /21/98IPROD=coMPiOP-AGG:--I:3C;()~-(;C;om
: : [] CLAIMS MAOE ~] OCC. : ::: PERS:-&-ADV:-INJURY ::3C;()~C;C;O---
: I [ ] OWNERS'S & CONTRACTOR'S : I: :EACH-OCCURRENCE----::3C;C;~C;OO---
, PROTECTIVE ___________________ ______________
I , j I' 'FIRE DAMAGE I
I If] : 1 I i(ANYONEFIRE) [50,000
~ J [ ] I I: MEO:-EXPENSE------- I __________m_
, 1 , ' I ,(ANY ONE PERSON) ,5,000
\---1---------------.---------------,--------------------------- ---------------1--------------,-------------------,--------------
I I AUTOMOBILE LIAB , 'I ICOMB. SINGLE LIHIT ,
I I ANY AUTO 1 i I 'BODiLy-iNJURY------1--------------
, \ ALL OWNED AUTOS I I 1 ,( PER PERSON) I
1 i SCHEDULED AUTOS 1 1 I I___________m____-'______________
1 , HIRED AUTOS 1 'I' BODILY INJURY I
: I NON-OWNED AUTOS: I : (PER ACCIDENT) :
i i GARAGE LIABILITY I 'I ,_____m______:____,______m_____1
-I-----j- - . ----C--n_---- .,.. +..-- --____ _j_ _n n __/E.RQPERTj'j)jMAGt _+_n_. I
1---I-E:)(cE:;5~--L.-i~Eli-L:j[;ri(---I---------------------------I---------.-----I--------------IEACH-OCCURRENCE----I--------------1
i i U ~~~~~Lf~A~O~~BRELLA FORM ii' i AGGREGATE---------- i -------------- i
'---1- -------- -------------------,---------------------------1--------------- --------------I--;SiAiuiORY-LIHiisl--------------,
: : WORKERS' COMP : I lEACH ACCIDENT: i
" AND , 1 , ,DISEASE-POL. LIHIT I ,
'I , EMPLOYERS LIAB I I I IDISEASE-EACH EMP. I I
j---'-C,lrfiE:fl----------------------,---------------------------,---------------1--------------1----------------------------------,
; I , I' I I
, 1 , I', ,
i-OESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/SPECIAL ITEMS----'---------------,--------------,----------------------------------1
, I
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I) CERTIFICATE HOLDER (------------------------------------) CANCELLATION 1----------_____________________________________________i
I ------------------------------------ -------------------------------------------------------1
I ' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE I
I ' EXPIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL ,
, 30 OAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE
ICi ty of Clearwater , LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO A1ION OR I
IP.O. Box 4748 , ,lABILITY OF ANY KIND OMPANY,ITS AGENTS OR RE ENTATlVES.,
,Clearwater FL 33518-4748 '_____mm___m____ ________m _ _ _______m
1 ' AUTHORIZED REPRESEN lIVE :
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