ANNUAL PREMIUM NOTICE
o NO CHANGES FROM PREVIOUS TERM.
[J CHANGES ON ENDORSEMENT BELOW ARE APPLICABLE WITH ABOVE INCEPTION DATE.
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In consideration of the renewal premium stated, the above numbered policy is renewed for the period specified. subject to the terms and conditions thereof, except as t':.
otherwise specified herein. 'l: I
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CLS01509S
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~Renewal, Certificate I
)~ Scottsdale Insurance Company~
Property/Casualty Division
8877 North Gainey Center Drive
Scottsdale, Arizona 85258
A STOCK COMPANY
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Policy Number
ITEM 1. NAMED INSURED AND MAILING ADDRESS
. DVIII JIADlS ALL .AlCDICAII108I'R CLDa. DC.
1250 Holt Av..e
Clearwater. PiDella. COU11ty. 'loricla 34615-0000.
AGENT NAME AND ADDRESS
.
Agent No.
040005
ITEM 2. POLICY PERIOD
From:
11-10-94
To:
11-10-95
12:01 A.M., Standard Time at the address of the NAMED INSURED as stated herein.
ANNUAL PREMIUM
SI TAX
POLICY and/or INSPECTION FEE
TOTAL PAID
$
1008.00
$ 53.65
$ Policy 'ee:
$25.00
$ 1126.65
It is here})" air... that the Mditioual llmlrtMl. khool Boarel of Pinella. County is
el1a1Dated fro. this ,ear. policy.
It i. &180 acre.. that the Utlit:1OMl I_red - State or 'oliU.eal Subdivisions _
'el'll1ta ae1aU", to Pr..s.ae. EMon~t. fol'll CC2013 i. revis" a8 per attached.
UTS-1 (4/91)
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TUO" SOUTH lie.
Ft. Lavclerclale. Ploritla
12-%3-94 _
"T'hla I~ Ie Iaa
UAes Laws. Perlona ~~~~u.~t to t~e FJorlda Surp,...
not have !he protection of Ih : Urpl~s Ltrres Carriers do
Act 10 the eX1ent ot any righl ~ lorrcJa "'Swanco GUtlf/'lnt)'
en inliOlvent unllcenaed lna::r~~very fOf" the obllQation (If
MEMORANDUM COpy / u '02.3 -() I
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POLICY NUMBER:
CLS015095
I
THIS ENDORSEMENT CHANGES THE POUCY. PLEASE READ IT CAREFULLY.
COMMERCIAL GENERAL LIABILITY
ADDITIONAL INSURED - STATE OR POLITICAL
SUBDIVISIONS - PERMITS RELATING TO PREMISES
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
State or Political Subdivision: n City of Clearw'afer
Department of Parks and Recreation
P.O. Box 4758
Clearwater, Florida 33518
ADDITIONAL PREMIUM: $83.00
(If no entry appears above, information required to complete this endorsement will be shown in
the Declarations as applicable to this endorsement)
WHO IS AN INSURED (Section II) is amended
to include as an insured any state or political
subdivision. shown in the Schedule, subject to
the following additional provision:
This insurance applies only with respect to
the following hazards for which the state or
political subdivision has issued a permit.. in
connection with premises you own, rent, or
control and to which this insurance applies:
CG 20 13 11 85
1. The existence, maintenance, repair, con-
struction, erection, or removal of advertising
signs. awnings, canopies, cellar entrances,
coal holes, driveways, manholes, marquees,
hoist away openings, sidewalk vaults, street
banners, or decorations and similar expo-
sures; or
2. The construction, erection, or removal of
elevators; or
3. The.. ownership, maintenance, or use of any
elevators covered by this insurance.
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Copyright. Insurance Services Qffice. Inc.. 1984
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