LENDER'S CERTIFICATE OF INSURANCE (2)
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005434
One Tower Square, Hartford, Connecticut 06183
CHANGE EFFECTIVE DATE: 08-03-03
CHANGE ENDORSEMENT NUMBE~
Travelers
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LENDER'S CERTIFICATE OF
INSURANCE - FORM A
Issue Date: 12-01 -03
Policy Number: KTK-630-9312A763-IND-03
1. CERTIFICATE HOLDER: CITY OF CLEARWATER
PO BOX 4748
CLEARWATER
FL 34618
2. NAMED INSURED: CLEARWATER AIRPARK, INC. &
DAVID KING
1000 N. HERCULES AVE.
CLEARWATER
FL 34625-1959
3. CERTIFICATION - We certify that we have issued the policy to the Named Insured for the policy period as
identified inthis-Certificate;-Nolvvill Istandingany-requrrarnents-;--terrns-ot~itions of cmycotilraetoi other
document with respect to which this Certificate may be issued, the insurance is that which we customarily
provide for the coverage indicated in item 6. below. This Certificate is issued as a matter of information only
and does not amend, extend or alter the coverage afforded by the policy.
4. POLICY PERIOD: 08-03-03 to 08-03-04
5. INSURING COMPANY: THE TRAVELERS INDEMNITY COMPANY
6. INSURANCE
Buildings or Personal Property - The policy names the Certificate Holder as a Loss Payee, according to its
Loss Payable Provisions (copy attached), for the property described below:
Loc.
No.
Bldg.
No.
Description of Property
BUILDINGS
(APPLIES TO LOC. 1, BLDGS. 1-4)
Limit of Insurance
$ *847,000
Ded.
$ 1 ,000
Coverage - Covered Causes of Loss: Basic Form Broad Form _Special Form
~ Deluxe Property Form
7. SPECIAL PROVISIONS (if any):
*BLANKET LIMIT
IL TO 100494
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CHANGE EFFECTIVE DATE: 08-03-03
CHANGE ENDORSEMENT NUMBER: 0001
8. NOTICE OF CANCELLATION - If we elect to cancel the policy or the Coverage Part which applies to the .
property described in item 6. of this Certificate, we will mail to the Certificate Holder written notice at least
10 days before the date our cancellation takes effect. If more than 10 days notice to the Certificate Holder is
provided in this Certificate or is required by law, we will mail written notice according to such provision or
requirement.
9. DEFINITIONS - As defined in the policy, the words "we," "us" and "our" refer to the Company providing this
insurance. The words "you" and "your" refer to the Named Insured shown in the Declarations of the policy.
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BY:
Signature of Authorized Representative
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I L TO 10 04 94
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