NOTICE OF CANCELLATION, NONRENEWAL OR CHANGE IN POLICY PREMIUM/COVERAGE
NOTICE OF CANCELLATION, NONRENEWAL
OR CHANGE IN POLICY PREMIUM/COVEAGE
INSURANCE
COMPANY
International Special Events & Recreation Association, Inc.
A Risk Retention Purchasing Group, Qualified Under The
Risk Retention Act of 1986; Federal Law 97-45.
PO Box 526148
Salt Lake City, UT 84152-6148
KIND OF POLICY: General Liability
POLICY NO. : LAP 0218 IF 00 2201 002
NAME AND
ADDRESS
INSURED
Emerald Coast Bungee, Inc
924 Mandalay Ave
Clearwater Beach, FL 33767
Cancellation, Expiration or Change will take effect at:
(Date:) 12-22"04(Hour) 12:01 AM MST
DATE MAILED: 11-17-04
ISSUED THROUGH AGENCY OR OFFICE AT:
Salt Lake City, UT
(Specific information concerning the Cancellation or Non-Renewal has been giving to the insured.)
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o To Lien-holder:
You are herby notified that the agreement under the Loss Payable Clause payable to you as Lien-holder, which is a part of the above policy,
issued to the above insured, is hereby cancelled or non-renewed in accordance with the conditions of the policy, said cancellation or non-
renewal to be effective on and after the hour and date mentioned above,
o To Mortgagee: DA TE OF MAILING:
Effective at (Sta' lard Time), we hereby cancel or non,rel'r'v trp, Mortgagee Agreement which is made part of the
above mentioned policy and_ also the ab..,ve mentioned policy issued to the insured named above covering on
At
And made payable to you as mortgagee (or trustee), in the event of loss,
~'7~
Authorized Representative
INSURANCE
COMPANY
International Special Events & Recreation Association, Inc.
A Risk Retention Purchasing Group, Qualified Under The
Risk Retention Act of 1986; Federal Law 97-45.
PO Box 526148
Salt Lake City, UT 84152-6148 USAGE INSTRUCTIONS
See reverse side for usage and mailing instruction
NAME AND
ADDRESS OF
LIEN-HOLDER OR
MORTAGEE
City of Clearwater Florida
Po Box 4748
Clearwater, FL 33758-4748
Gll 881:;;: (Ed. 8-97) Uniform Printing & Supply, Ir!c.,@,1997_
"_LIEN-HOLDER'S/MORTGAGEE COPY
Pursuant to the Consumer Credit Reform Act of 1996, effective September 30,1997, you are informed that:
The consumer reporting agency identified on the front of this form did not make any decisions regarding the stated insurance policy.
Therefore, the consumer-reporting agency would not be able to provide you with the specific reasons why the insurance company is
taking the present action.
You have the right to obtain within 60 days of the receipt of this notice a free copy of your credit report from the consumer-reporting
agency, which has been identified, on the front of this form. (Prior to September 30, 1997, you have the right to obtain a free copy of
your credit report within 30 days of the receipt of this notice.)
You have the right to dispute inaccurate information by contacting the consumer-reporting agency directly, Once you have directly
notified the consumer-reporting agency of your dispute, the agency must, within a reasonable period of time reinvestigate and record
the current status of the disputed information. If after the reinvestigation, such information is found to be inaccurate or unverifiable,
such information must be promptly deleted form your records. If the reinvestigation does not resolve the dispute, you may file a brief
statement setting forth the nature of the dispute with the consumer-reporting agency. Your filed state will then be included or
summarized in any subsequent consumer report containing the information in question.
For complete information regarding the Federal Consumer Credit Protect Law, please refer to The Code Of The Laws Of The United
States Of America, Title 15, Chapter 41, Subchapter 1/1, (15 U.S.c. 1681 et seq.).