CERTIFICATE OF INSURANCE
08/21/2001 15:31 7274451938
FOUNDATION VILLAGE
PAGE 01
'~
Foundation Village N. F. C.
918 Woodlawn St.
Clearwater, Florida 33756
(727) 445-9504
Fax (727) 445-1938
Fax
"--'
.... Insurance on Building
F..- Roy Nurse
.... September 5, 2001
...... 2 + Cover
CCI Executive Director
T.. Marie Orsello
Fu: 562-4037
c .,..... X Fer....... 0 ....... e. .JLIlea." X ......1IapIy 0 ...... ..~
.c-u...: Marie.....
Attached are certificate of insurance and declarations page for insurance
on the building which we occupy. Expiration date is 2122/02.
Liability insurance is to renewed on 10/1/01. You shan receive notices
from our insurance agent at the time all policies are renewed.
Thank You,
Roy Nurse... -.....
08/21/2001 15:31
7274451938
FOUNDATION VILLAGE
PAGE 02
~.u~I1~......~n ._l: _500_~~ __. ,"'J.._
o.tIIc8te No.: 190539 I!ffeclt.... DatIl: 02/Z2/2IXJ1
,.0' A.M.. a.nca_ Time
NM1ed InIurtd: FOUNDATION VlUABE NEIGHBORHOOD FAMILY CENTER INC.
C/O ~v NURSE
I Bust NESS DESCRIPTION
TutORING
Dl!SCRIPTION OF PREMISES
PAEM. NO. 1IlOO. NO. LOCAl1ON. O()NITRUCTION AHD OCCUPANC'f
1 1 918 YIQODLAWN DR.. ClEARWAT!R. FI. 33758
NON-COMBUSTfBLE
FAMlLV CENTeR
I CO~AAGES PROVIDE[).IN9lJfWlCE AT T~ DESCRIBeD PREMISES APPliES ONLY FOR coveRAGES FOR \\'HICH A LIMIT OF INSU"ANCE IS SHOWN.
PREM. NO. BlDG. 1lIO. 00\IliM0e UMIT OF IN8UIWC1I! c:cNeRED CAU8E8 01' l.OS8 CQlN!!UMNCE t RATES
1 1 BUILDING 303.000 SPECIAL 80 .60
OPTIONAL COVERAGES .APPUCABLEQNlYWH9I son..eaNlfi. ~.. tHE llCHEOUl.E ea.ow I T IF &X\"IIIA l!lll'9lIE <XJVaUlOE. UMITS ON L088 flAYMeIT
AON!eD VIllUE ~008T AI'f'UU..CtECMED( xl
....,... NO. BLDG. NO. EXPIM110N QlTE OOYERAOE 1MOI1Itf IlU'.DINO fIEAI!lONAl. fIFIlfIEATV INCWClNCll 'ITOCK'
1 1 X
INFLATJON GUNlO~. ' , UONI11lY LMT 01' t t MAlClIotUM l"&MXl tt~1'&RIOO
~.NO. BI..OO. NO. IIUILDlNG f'ERlJONAL PROPeRlY INOEIoJNI1VI"-1 0IJt1NDBH"t~ ~ INDEMNlTV p.y.)
MORTGAGE HOLOEAtSl I tt N"'UE8 TO IUSINIiSS INOOUe ONly
...... NO. llUXI. NO. ~ HQl.O&ANAMENiIOMMJIIlQ AOOAESS
1 1 CITY OF CLEARWATE~SK WWAGER.P.O. BOX 47411
CLEARWATER. FL 337U-4748
-II:
$ 1.000 excEPTIONS: .
FOAMS AND ENDORSEMENTS (other than applicable Fcxma and Endoraementa shoWn IIs1Iwh8f8In the CertIftc8te)
Fotme ft EndofMments lIPP/yIng to WIts CoweraglI Part IIf\d mllde pert of"ls c.ttif/ClIIte at lime rrll....:
AfIIIUCMlf TO All. ~
SEE SCHEDULE OF FOAMS AND ENDORSEMENTS
AfIPI.JCA8~E TO SPeCIFIC
1lMUlSEI/00000EIWJES :
I"AEM NO.
liILOG. NO.
~
~0NlI NINBEI'lS
THIS SUPPLEMENTALDECLAAATIONS AND THE COMMERCIAL PROPERTY OECI.ARATIONS. TOGETHER WITHTHE
COMMON CERTIFICATE CONDITIONS. COVERAGE FORM(S) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBERED POUCv.
BW.l-P'TY ()RIGlNAL.
08/21/2801 15:31
7274451938
FOUNDATION VILLAGE
PAGE 03
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~ Aen8W81 of Number
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~ This Declaration II attached to and forma IJIl't of C8ftIflcata prOYIsiOnS (Form SUr3 USA).
~
~ m:U 1 NAMED INSURFD ANrl UAlUNG .AnnAESS AUTHORITY REF. NO.
~ FOUNDATION VILLAGE NEIGHBORHOOD FAMILY CENTER INC. . .'
~ C/OROYNURSE - ...- ...'" n ,. ........' \', \.
I =~;:~DR. FL 33756,~~'.'.',:;;,..:r:"I.. ',,;, ~,,' =\ "(~'
.~.~' AGENT NAME AND ADDRESS '. .,.. .-. -. ~DAVIS -
" _ _ _ _ , . .' _1 STATE RoAo 54 -
;~ ,'..".'.\:.J~.,._._",.,__ ..._-...---. '..~ ---
i 8URNS & WILCOX t.. TO. 01:'{. .--NEW.P.ORf AICHEV- .--;-
.~ 3820 NORTHDALE 8LVO.#108B Thi:: il'lsurr.nce is j!plle~; pu.-.:u;nl '" !h~ Flond.
~] TAMPA FL 33824 Surplus Lines Law. P.ml~,"~ i;~'.;L:r:"~ I.:yt.urpl~ '.
j ITEM 2 PPUCY PERIOD From: 02/22/2001 To: ~~~~ ~~.~;;J' '.:'~.~YeAP:,:~
{$ " , f
..~ l>> . . ....AOLn9ht 01 rocovery !or tho ohI9:;.hon 0 an
11 .. 12.01 A.M.. S-.ndard nme at your malltna -m~nt ,,,,licensed Insurer.
..
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CERTIFICATE OF INSURANCE
COMMON POLICY DECLARATIONS
CerUftc8te Number
190539
8USlNESS DESCRIPTION: TUTORING
Insurance is effectlvewlrtt certain UNDERWRITERS AT LLOYD-S. LONDON.
FOAM OF BUSINESS: 0 Individual 0 Joint Venture 0 PartnershIp 0 Organization IX] Corporation
Audit Period: Annual unless otherwise stated:
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS CERTIFICATE.
WE AGREE WITH YOU TO PROV1DE THE INSURANCE AS STATED IN THIS CERTIFICATE.
THIS POUCY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS
PREMIUM MAYBE SUBJECTTOAOJUSTMENT.
Commercial Property Coverage Part - Section 1
Commercial General Liability Coverage Part - SectIOn 2
Commercial Crime Coverage Part - Section 3
Commercial Inland Marine Coverage Pan . Section ..
Professional L1abMIty Coverage Part .Sectlon 5
Errors & Omissions Llablflty Coverage Part. Section 6
liquor Llabftlty Coverage Part. Section 1
PREMIUM
$ 1,818.00
S NO COVERAGE
S NO COVERAGE
$ NO COVERAGE
$ NO COVERAGE
$ NO COVERAGE
S NO COVERAGE
$
~~~~FEE
TAX
EMPATF /SC
SERVICE FeE
Premium shown Is payable: $ 1.818.00
Forms applicable to all Coverage Parts:
Al;1; SCHt:=DULE OF FOIIIMA AND ENDORBI!MENT8
ThiS certificate of I nsurance Is made and accepIed subject to the foregoing stipulations and conditions together with
such other provisions. agreement or conditions as may be endorud or added hereto.
BURNS & W1L~ LT9?~
Dated lit: 03/23/2001 RM/km By: . J .I', _ ----7""
. . ~, .........
""pori
ORIGINAL
$ 25.00
$ 100.00
$ 97.15
S 4.00
$ 5.83
TOTAL . 1,818.00
10 FlA.T~ANCELLATIOIS
at Inception. $
LOVDS1A 19-i6)