CERTIFICATE OF INSURANCE (3)
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10:
FROM:
COPIES:
SUBJECT:
DATE:
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CITY -= CLEARWATER
Interdepartment Correspondence Sheet
Elizabeth S. Haeseker, Assistant City M~~~
William C. Held, Jr., Harbormaster (t;f.5VI
Cyndie Goudeau, City Clerk ~
Insurance Policy - Clearwater Beach Seafood, Inc. - Bill Goodwin
June 4, 1987
I have received and reviewed the insurance policy for Clearwater Beach
Seafood, Inc.. This policy meets the requirements of his lease
agreement with the city. Expiration date is May 31, 1988.
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Issue Date 04/20/81 At ST. PETERSeURG BR. OFFICE
ORIGINAL .;
068 042081 00509
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l\EfIlESIIl\EII , "ell"GES 0"'''
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060 IJ'.;:'U'u'i Ov?ur:,
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~amed Insured
DESCRIPTION OF HAZARD:"
RESTAURANTS-WITH SALE OF:;:'
ALCOHOLIC' BEVERAGES THAT'ARE
LESS THAN 15,% OF THE TOTAt".>
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ANNUAL RECEIPTS OF THE ':.":\" ....., '
RESTAURANT-WITHOUT DANCE- flOOR<';,
CLASS CODE - 58259 ' ',;," !.' ":',:<
PREMIUM BASE -295,000. DOLLARS OF 'RECEIP.TS"')~;' .
.. " .."....\",._' ':-1-
RATES -' PER 1,000 DOLLARS. Of' RECEIP.TS"'<';'\', " ..'
, . RATES'
CUMBINED SINGLE LIMITS 1.524
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~*~ TOTAL SCHEDULE
COMBINED SINGLE
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THE FOREGOING DISCLOSES ALL HAZAROS INSURED HEREUNDER KNOWN TO EXIST AT THE
~FFECTIVE DATE OF THIS POLICY, UNLESS OTHER~ISE STATED HEREIN.
Ubb U"t2U131 UU5U9
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GENERAL ENDORSEMENT
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l.31S
lEd. 4-68)
This endorsement modifies only such coverage parts designated by an "X" and/or other forms indicated below:
o COMPREHENSIVE GENERAL LIABILITY INSURANCE
o COMPREHENSIVE AUTOMOBILE LIABILITY INSURANCE
o OWNERS'. LANDLORDS' AND TENANTS' LIABILITY INSURANCE
o OTHER
DMANUFA,CTUREBS' AND CONTRACTORS' LIABILITY INSURANCE
Cl CONTRACTUAL LIABILITY INSURANCE
o COMPLETED OPERATIONS AND PRODUCTS LIABILITY INSURANCE
This endorsement, eHeclive
112.01 a. M, .1I"d"d timo,
, lorms a part of policy No, GLW (88) 13 59 89
End, No,
issued to
CLEARWATER BEAClI SEAFOOD.INC.
by WEST AMERICAN INS.
4/1.'87;:7
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V 'L~,zed Represe"tatlve
In consideration of the additional premium of H $386.,
it is agreed that endorsements L9109(316.00) and L6349($70.00)
apply to the policy.
Total policy premium reads $4846.
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ADDITIONAL INSURED
(Premises leased to the Named Insured)
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l 9109
(Ed, 7.66)
This endorsement modifies such insurance as is afforded by the provisions of t~e policy..!.elating to the following:
COMPREHENSIVE GENERAL LIABIlITY INSURANCE
MANUFACTURERS' AND CONTRACTORS' LIABIlITY INSURANCE
OWNERS', LANDLOROS' AND TENANTS' LIABILITY INSURANCE
STOREKEEPER'S INSURANCE
This endorsement, effeclive
(12:01 A, M., standard time)
, lorms a part of policy No,
issued to
by
SCHEDULE
Premiums
Bodily Property
Injury Damage
liability Liability
Designation of Premises
IPart leased to Named Insured)
Name of Person or Organization
(Additional Insured)
37 Causeway blvd.
Clearwater,fl., 3351~.
".----' .
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It is agreed that the "Persons Insured" provision is amended to include a~ an insured the person or organization designated above, but only with respect
10 liability arising out of the ownership, mainlenanc!! or US!! of lhat part of Ihe premises designated above leased to the named Insured, and subject to
the following addilional exclusions:
The insurance does not apply:
I. to any occurrence which takes place alter the named insured ceases to be a tenant in said premises;
2. to structural alterations, new conslruction or demolition operations perlormed by or on behalf of the person or organization designated above.
316.
Incl.
City of Clearwater
P.o. BOX 4748
Clearwater,fl., 33518
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Issued by lbe StockCompanlHerein~alled The companyfL'C:~W;!;>,;~,~;;;::.~ :ia}})i:~~:t:Si(~,~~G~~T'~UM~~f~&lifl:~~rpo.uCY' NUMBER '" ,i
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..W€S T,.AME RrCA N I NS~R~NC~.'.C . . ..,At:4.Yr:':;~;"':, :;?';,:'.;:'; :",;:i,~J::::~:;;:.;:;::::;::09,~~9~~f~}t~W,~~tf.'t~.iji~1.ftq9TR;~~:? z;
2420EAS.. T.LI NC. .OL.. NAVE 'I".'.. .,..,;;,..) ")".".i":"I"".:>':..:'.i:~i:~. i.. ::';' '~.:;<'\- ;;:t...,.::,.;'L'f,~<'Y.;;'I~:1 ;.;."f':.~'!;j'~l.j'..(. ;,H"',i,'.:,. :.':;.I't.J.~':~'l:;:;I::}li.'.i.:'."'.':',,:, '."
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ANA Ii fiHt CALI F' ';', 9280~): . .'.' :'; .};:,;,:! ::j::" ,j~:::;;"i,~~,:':':::{.>~:;J(:<>!;YT:':':?}";~:"r(~Pjl.~~;:r\II~Y:':;'"
. 'tfCORPORATED UNDER THE LAW.S OF,.:, CALIFORN.IA,~U; ',:::~":;I.r.,:,:.;t~)...,; ".;' :'~; 'f~i;:;~I~',: ii:::: l' . .;. .
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"-,, ." . .' . ...... "I ...,:;;> ..". .. .'. ;'.":"};".;",~...,<" INFORMATION'PAGE ...
~.The ,()h io ;qas.u~lty:.,G.~ouRHnr,!rt~;}~/i.~t~~liJ:woRKERs~;co.. ~I'ENSATION AND; \
,'. W of Insurance Companies " .. .... ,., ':,; .:" 'EMPLOYERSt LIABILITY, POLICY
Item 1. NAMED INSURED & MAILING ADDRESS PRODUCER'S NAME.& MAILlNGAD~RESS,
......'A....
CLEARWATER BEACH SEAFOOD
31 CAUSEWAY BLVD
CLEARWATER FL
Item 2. POLICY PERIOD ~tl~: i~~~;e~I~~d~~~~r Illhe address
Item 3, A.
B,
STORE: MEAT, FISH OR POULTRY
RETAIL
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RE STAURANT NaC ( .
PREMIUM DEVIATION (lO.at)
PREMIUM AFTER DEVIATION
TOTAL ESTIMATED ANNUAL STANDARD
PREMIUM DISCOUNT. IF APPLICABLE
PREMIUM
.3 %'
....,.
EXPENSE CONSTANT (EXCEPT WHERE APPLICABLE BY STATE)
iI,; "J.
MINIMUM PREMIUM $ 375 FLORIDA
If indicated below, interim adjustments of premium shall be made,
Semi-Annuall Quarterly Monthl
ENDOHSEMENTS(fORM NUMBEH)
WC00030B CW3001
TOTAL ESTIMATED PREMIUM
. " De osit Premium $
0037.00
~
e, 3010 (we 00 00 01)
Issue Date03/11/81 02 ST PET::;RSBU"tG BR.ANCH OFFICE
INSURED'S COpy
Auth. rill'd Rerresflrtalive
Copyr'g"t 1 !l9:1 rlllllonal C.ouncil on C'.ompMSiJ""" 1""IJ"-l"Cf'!
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PARTNERS, OFFI~~RS A~,D O~H,~~~:'~~R~~~J~~~::~N.o,9,~~~~,~.~;T,t\J ~;{;;:t'i:";~.':(':'! 'r.:,',. ';'
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Jhepolicy does not cover bodily injur~, to an~pe~S~~';d~~Cn.b.~?j~mt!:~l~~~~~'?:H",q!r:rs,;r'iJt;;V;n;-;~h;,lr((.. "
The preml um basi s for the policy does' not include .the' r~m~n~ratlon' ~f. ~uc~ '~e~s~~s:!:f)JJ.{ \;J~;(:,,~C. ;,i,':,;
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You will reimburse us for any payment.we must'make becauseofbodilyinj\JryCtosUch-;p~r'spnf;;\~'{I";r
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WILLIJIM F. <IXDlIN -' PRESIDENT
JO\N V. CImlJN- SEC/lBEAS:~
Schedule,
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Partners
Officers
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This endorsement changes the polley to which It Is attached and Is effective on the date issued unless otherwise stated,
(The information below Is required only when this endorsement Is Issuedsu.bs~quent to preparation of the policy,)
Endorsement Effective 5/31/87 Policy No, \oGI (00) 400-04-92 ' EndOrS~~~o,
Insured. Qf!\IW.TER BfJlCH SfPfOO) It<<:. . rl ;1;t ~ lll"m I
CountersIgned By 111 ~~_ 'l':!-
.- ST. PETERSBURG ~1301 I
MI\RCH 19, 1987 tis
we 00 03 08
(Ed. 4-64)
Copyrlghl1983 Nallona' Council on Compensation Insuranc..
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GEN 1-1
THE ~AVELERS C
PANIES
HARTFORD, CONNECTICUT
GENERAL DECLARATIONS
. SPECIAL BUSINESS (809) · POLICY NO, 650-607G812-1-TRI-87
. BUSINESS RESTAURANT
NAMED INSURED AND MAILING ADDRESS
. CLEARWATER BEACH SEAFOOD, INC (SEE 8000(1)
. 37 CAUSE\<JA Y BLVD
. CLEARWATER, FL. 33515
lOC,
NO.
1
05-31-87
(Month, Day. Year)
BlOG,
NO,
1
05-31-88 -X-- 12:01 AM _ 12 Noon Standard Time. at the Named Insured's address.
(Month. Day. Year)
Effective from
to
OCCUPANCY
RESTAURANT
ADDRESS (Same as mailing address unless specified otherwise)
SAME
The Named I nsured is:
_ Individual
_ Partnership
_ Corporation
X JOINT VENTURE
POLICY SECTIONS AND INSURING COMPANY - The Travelers agrees with the Named Insured to provide insurance under a section
of this policy as designated by an "X" and in the company (each a stock companyl for which an abbreviation is shown.
-L PROPERTY _INLAND MARINE _BOilER AND MACHINERY - SECTION I. Insuring Company:TRI
---X- GLASS
Insuring Company:TR I
_ GENERAL LIABilITY - SECTION II.
Insuring Company:
_ AUTOMOBilE LIABILITY
_ GARAGE LIABILITY - SECTION III.
Insuring Company:
_ AUTOMOBilE PHYSICAL DAMAGE _DEALERS PHYSICAL DAMAGE - SECTION IV.
Insuring Company:
_ CRIME - SECTION V.
Insuring Company:
SUPPLEMENTAL POLICIES - Each of the following is a separate policy containing its complete provisions:
Policy Policy No.
Insuring Company:
"NOTICE! This Policy Does Not Cover Flood Loss:"
PREMIUM SUMMARY
.
NUMBER SUMMARY - Except for the following, numbers of forms and
endorsements are indicated on the applicable coverage declarations:
General Endorsements: GEN 1-1, GEN 51,8000(1)
Provision Dividers: PR 1-2
Coverage Declarations: PR 16
r::
Provisional Premium $
Payable at Inception $
Payable at the end of each
month period. $
2014
2014
IN WITNESS WHEREOF, each company designated for the sections of this policy for which such company is designated as insurer has exe-
cuted and attested these presents, but this policy shall not be valid unless countersigned by the duly authorized Agent of such company.
THE TRAVELERS INDEMNITY COMPANY (lND)
THE TRAVELERS INDEMNITY COMPANY OF AMERICA (TlA)
THE TRAVelERS INDEMNITY COMPANY OF ILLINOIS (Till
THE TRAVelERS INDEMNITY COMPANY OF RHODE ISLAND (TRI)
THE PHOENIX INSURANCE COMPANY (PHX)
THE CHARTER OAK FIRE INSURANCE COMPANY (COF)
THE TRAVELERS INSURANCE COMPANY (INS)
~ f~b-
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President
~ 12 AL.... ~~\.~ w-:~~f ~
/~.... -r;)- rw '\ 'd
~.,
AUTHORIZED AGENT
COUNTERSIGNA TURE DATE
GEN ,-,
Page , of 2