CERTIFICATES OF INSURANCE
May-OS-OO 02:31P COMMUNITY SERV FOUND
LC: 'Wftr'll I:.&.+...').......~~ r.:.....~~;: '\~<I"'.'" ...........-
8134436287
P.04
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#,~ e' . Burns & Wile!: Ltd.
NA TIOHAI.
UfC)eRWAmNO MANAoeRS AlCl IlROK!AS
TO: BURKE.LEHMAN INS. AGENCY . GARY BENSON
RE: COMMUNITY SERViCe: FOUNDA~iCN 1.'\10:.
I
3821) NORTHOALE 9LIID t108-B, T.\NPA. fl33G2~
.PI:IOHE: 111319OJ1.33010R (!I0!)l Z1I2.5tT5 fAX; nn319".4093
G.....
DATE: 1';'711999
RENEWAl. OF: sami
WE ARE PLEASED TO OFFER THE FOLLOWING QUOTATION:
1. INSURERlS):
COPENHAGEN RE. [1/Qg)
UNIONAMERICA [119_1
ST.PAU~ REINSURANCE 7;99
TERRA NCVA 1'0199)
A 20.COOO"'~ CCLCNY INS. CO. [S-..:8)
A 1 s.~QOO % eNA REINSU!;ANCE (1/99]
A 15.::000 ",0 S- PAUL REINS'JRANC=. 719;1
A I 5.CCOO %
A , 5.000C ).,
A ~O.0002 ~.~
8 'OC.:~QO ".
2.
3.
FORM OF COVERAGE:
UMrTSlOEDUCTlBLES:
A-PROPER'I'Y
l-Bt1ILDIHC
~-BUILDINO
3-CON'l'EN'l'S
4.-
COMM~RCIAL ~ACKAGc OCCURRENCE
$
$
$
$
limi t.
980,000
145,000
37,000
c:oins baa1.
80.00% RC
eo.OO% RC
80.00% ACV
%
a.auc:t1ble
$ seo
~ SOD
.$ 500
.$
form
Broad
Brc...!
Sroa.a
..1-LIDILI'1'Y
aD. ACQ.
PJtOD . AQQ .
PDS/ADV/INJ
EACH OCC.
P IIUl D.UQO&
NXOICAI. EXP.
$ 1,000,000
$ 1,000,000
$ 1,000,000
$ 1,ooa,ooo
$ 50,000
$1,000/10,000
$
D.CUCTI~t $ 0
PRl!:llIIVl!I, POUT
D8reNle Coee: OUt.lc1e 11..m1t
4. PREMIUM: f 8, U 0 . 00 '1'DJ4 MINIHUH Ii DBPOSI'1'
2' % !'ULI. "! EARN!:D, KIN. PRDIOM: $
POLICY rEI: $ 45.00 FULL"! DRNIW
INSPECT. rEI: $ 100,00 POLLY EARNBD
FIRE lUUBAL $ 4.00 ruLLY EARNED
$
S'fATE T~ f 4.52.75
SERVICE FE! $ 27.11
5, TOTAL CHARGE:. ).538.92
&, COMMISSION: 10.0000 % OF PREMIUM
7. EXCLUSIONS AND ENDORSEMENTS:
EXC1.USIONS: ASBESTOS. lLI.O. PI,;NITIVe. SOU.c.\. ABusE C~SSES N:)T
SCHEDULEO rCTAL L:O\.iOR. POLLUTION. EMPLO"MENT.~!<!..ATED PRACTICES.
Y!:AR 2000, PROFeSSICNAL. ASSAULT l BATTERY
E~O~SEIJIENTS DESIGNATED PREMISCS. S'.WI:ljt,S:OAM O~ HAIL OEl;UCC"'18LE.
LOS$ PAYA9L.E P~O".SIONS
CI-I~NGE: AMENO ALL PROPERTY AATES T(I 50
8. CONDITIONS: PLEAS! ~fVleW-t1'S CAFl:FULLv AS IT MAY' O!FFE, F~OI.1 CO:;\'ERIl,GE~ ANC ~.r.HS t;EcX.EST!C'
INSP!CTION.
2,232.50
....PROP~~T'f ANOUNTS SC"iEDUL.EO A3 PEA eXpIAINO'."
9. PAYMENT: $ 6.645.92 DUE ,N 30 DAYS.
WE APPRECIATE YOUR BUSINESS. NO BINDING AUTHORITY IS CONVEYED TO ANY AGENT.
FLAT CANCELLATIONS NOT ALLOWED. QUOTATION IS GOOD UNTIL 12102r1999 .
BY: KEVli'Il HALABY EXTENSION 229 ''':NO:AWRITING MANAGER
(f'OR\I ria52?1.'33896j
May-OS-OO 02:31P COMMUNITY SERV FOUND
8134436287
P.03
(~.
COMMtRCIAL POLl9~ COVERAGE P4RT
SUPPLEMENTAL DECLARATIONs'
COMPANY PARTICIPATION
These Supplemental Declarations form a part of Certificate Number 5805
This Declaration Page is attached to and forms part of the common policy declarations.
EFFECTIVE WITH
Amount or
Section ComDanv Contract 1/ Percent
TERRA NOVA INSURANCE CO 98AT775 15 %
ST. PAUL REINSURANCE CO SP906 15 %
UNION AMERICA INSURANCE CO UAM754 15 %
COPENHAGEN REINSURANC CO PCR818 20 %
I CNA INTERNATIONAL REINSURANCE CO 329.876 20 %
I COLONY INSURANCE CO 15 %
II ST. PAUL REINSURANCE CO SP906' 100 %
%
%
%
FORMS AND ENDORSEMENTS (other than applicable forms and endorsements shown elsewhere in the policy.
Forms and endorsements applying to this Coverage Part and made part of this policy at time of issue:
SEE SCHEDULE OF FORMS AND ENDORSEMENTS
Dated at: 12/14/1999
By:
(Correspondent)
LONC02B (10-93)
ORIGINAL
May-05-00 02:30P COMMUNITY SERV FOUND
8134436287
P.02
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6.
. >Ii
., , . . ~
~ . ~ ..
Renewal of RENEWAL CERTIFICATE Policy Number
5805 580~
COMPANIES
as listed hereon
(hereinafter called the "Underwriters")
Item 1. Named Insured and Mailing Address: Surplus Lines Agent W. (J..,.;ar Dunaway
l.Jcens.. A0131S3
COMMUNITY SERVICE FOUNDATION, INC. 3820 Northdale 8~Uite '~ Tampa FL 33624
925 LAKEVIEW ROAD p'OOudng~r": ~ ~~
~~~~ ~ .. "I~._~ .. -?J-
CLEARWATER Fl 34625 Tnis insurancfl ~~ issued pursuanl 10 the Flc-rn'&a SurplllS
A.aent Name and Address: Lines Law. P8f9OnS insure<' by SurplUS lines Call111r~ 00
no! Ilave ,he prol8C11on 01 1M FIO'lda Ins'Jrance Guaranty
BURNS & WilCOX LTD. Ad 10 IhA extent ot Bny "gtH ;:>1 ror:;OVllry lor Ihe OO'i9lIllQr:
olin insolvent unlicllASed In!;ur(JJ.
3820 NORTHDALE BLVD.#10aB
TAMPA FL 33624
Item 2. Policy Period From: 12-02-99 To: 12.02-00
12:01 A.M. Standard Time at the address of the Named Insured as stated herein.
In consideration of the renewal premium stated. the abOve numbered policy Is renewed for the period specified. subject to
the terms and conditions thereof. except as otherwtae specified herein.
P . g RENEWAL PREMIUM:
remlum POLICY FEE:
COMPANY FEE: EMPATF jSC
$ 8 930 INSPECTION FEE:
, . 5 % STATE TAX:
STAMPING FEE:
TOTAL:
$
$
$
$
$
$
$
8930.00
25.00
4.00
100.00
452.75
$27.17
9538.92
o No changes from previous term.
00 Changes on endorsement below are applicable with above inception date. NO flAT CAN CEtlAT\ONS
ENDORSEMENT LONC02B(10-93) IS HEREBY AMENDED PER THE ATIACHED.
PROPERTY RATE IS HEREBY AMENDED TO .50 IN LIEU OF .60
ALL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.
KH/km
Countersigned 12/14/99
DATE
ByJJ. ~e.~7
LONCORC (8.99)
ORIGINAL