INSURANCE RENEWAL CERTIFICATE AND BINDER
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Com mercia) Package Policy
Renewal Certificate
IX] A = AETNA INSURANCE COMPANY
o U = AETNA FIRE UNDERWRITERS INSURANCE COMPANY
DC'"' CENTURY INDEMNITY COMPANY
o M= AETNA INSURANCE COMPANY OF THE MID-WEST
PLEASE ATTACH
TO YOUR POLICY
RENEWAL OF
POLICY NO.
CW 39 99 39
(A stock insurance company herein called the Company)
Named Insured:
ADDRESS:
(Number & Street, Town, County & State)
t~..!EB. Q&F au, DIC.
1.175 AURa IaIVE
1'"l~""'IER, IL J3S18
REPRESENTATIVE: Sub-agent or broker
Reporting Agent
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POLICY
TERM
PROVISIONAL
PREMIUM
COMPANY
A
Name
and
Code No,
.. Ir AISCJCDTES, me.
...... I'L 22 19497
....1-.3
1 .....1-12
D CONTINUABLE POLICY
Years Inception
If Paid in Advaiia
$........ .....SJO
Expiration
First installment. if paid in installments, (Annual Prl!mium if a
Continuable Policy)
$
Part I
Part II
Part III
Part I V
Part V
Part VI
Part VII
Insurance is afforded only under those parts of the policy designated by the Company initial.
Property - Business Income
Boiler and Machinery
Inland Marine
Automobile 0 a cae; ~
Comprehensive General LiabilitWnsent
Crime
In consideration of the payment of the premium. it is agreed that the policy and coverage parts are continued in force
for the policy period stated above, subject to the terms and conditions thereof,
In Witness whereof, the Company has caused this certificate to be signed by its president and a secretary at Hartford.
Connecticut, and countersigned by a duly authorized representative of the Company,
Mc;~
tItutii tfI. kit
President
T9"~TIFY THA'r THIS IS A TRUE
PYc-.O THE POLIC.;Y.-L 0.'
.,CU~17,
Uh~:60-n-.2:~ A..ft J (JUT V)
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2.800.101 Printed in U.S.A.
Page 1
MEMORANDUM
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INSURED
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o AETNA INSU~NCECOMPANY
o AETNA FIRE UNDERWRITERS INS. CO.
o CE~TURY INDEMNITY COMPAN'y
o
PREMIUM PAYMENT AGREEMENT
POLICY NUMBER
CD J9 II 39
DATE
.....1...2
IT IS AGREED THAT THE ESTIMATED ADVANCE PREMIUM IS /$...,IIMI.
I AND IT SHALL
BE PAID AS FOllOWS
.
DATE PAYMENT DUE AMOUNT
UPON DELIVERY OF POLICY .1.11&.
7-)",12 1..212.
19.,1..12 1.212.
TOTAL .. .........
..
It is agreed that failure to make payments (pay an installment) when due will constitute nonpayment of
premium and in that event, the balance will become due and payable immediately. Failure to pay such
balance within days after notice of the amount due will result in cancellation.
040-530 (7-81)
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THOROZED AGE~~
SEE POLICY IN FILE