CERTIFICATE OF INSURANCE (12)
Part 2: THIS DECLARATION PAGE, WITH POLICY PROVISIONS - PART I AND ENDORSEMENTS, IF ANY ISSUED TO FORM
A PART THEREOF, COMPLETE THE BELOW NUMBERED CITIZENS PROPERTY INSURANCE CORPORATION POLICY.
CITIZENS PROPERTY INSURANCE CORPORATION, WIND ONLY POLICY
7077 Bonneval Road - Suite 500, Jacksonville, Florida 32216-6064
~lI~~.~~
INSURED NAME AND ADDRESS
CLEARWATER BEACH SEAFOOD AND RESTAURANT
1901 ULMERTON RD #750
CLEARWATER, FL 33762
THIS IS A
GENERAL BUSINESS
POLICY TERM 6/04/2003 TO 6/04/2004 AT 12:01 A.M. (EST) CITIZENS POLICY NO. 150904
INCEPTION DATE EXPIRATION DATE THIS IS YOUR POLICY DECLARATION PAGE - This is not a Bill
PAGE 1
$ $
1 255,000
171,000
'Ii
$ $
7,650 T-42
$
90
90
5,130
T-42
691
463
. TWO STORY MASONRY RESTAURANT LOC:
37 cAUSEWAY BLvD CLEARWATER BEACH,'" -PINELtAS--n--3376T20CJ3
TOTAL AMOUNT OF COVERAGE
$
426,000
Subject to Form No(s):
Tax- Exempt Sur
CIT CP2
Mortgagee/Loss Payee:
CIT-W06
CITY OF CLEARWATER
C/O RISK MANAGEMENT
P.O. BOX 4748
CLEARWATER, FL 34618
Agent:
STAHL & ASSOC INS INC 0483
8200 SEMINOLE BLVD
SEMINOLE, FL 33772
(727) 391-9791
CIT-W03 (7/02) 0483 Team 2
ACTUAL PREMIUM
P - I
TOTAL PREMIUM
DO NOT PAY
PREMIUM SURCHARGES
Florida Hurricane Cat Fund
$ .00
Rei ns/Cat Fi nanci n9
$ 173.00
1,154.00
20.00
$
1, 347. 00
RETAINED
-\C CJ.,~
<!..e..'.. ~
Payor:
INSURED
Date: 6/05/2003
MORTGAGEE COPY {Cj _ 0 / &. - 0 I
R 40111
1924