CERTIFICATE OF INSURANCE (2)
COMMON POLICY DECLARATIONS
This Declaration Page Is aUached to and forms part of certificate provisions.
Previous No. NEW
Authority Ref. No. 0 4CWL32 8
Certificate No.4 7 8 4
1 Name and address
of the Assured
Foundation Village
Neighborhood Family Center
918 Woodlawn St
Clearwater FL 33756
Broker
Alvina Davis
Greg Roe Insurance, Inc.
9851 State Road 54
New Prt Richey FL 34655
Business description: Tutoring For Children
Effective from 02 - 2 2 - 0 4 to 02 - 2 2 - 0 5
2 both days at 12:01 a.m. standard time
3 Insurance is effective with certain
UNDERWRITERS AT LLOYD'S, LONDON.
4 This Certificate consists of the following Coverage Parts for which a Premium is indicated. This
Premium may be subject to adjustment.
Commercial Property Coverage Part
$
$
$
$
$
$
$
Fees: $
Taxes: $
Total $
Commercial Inland Marine Coverage Part
Commercial General Liability Coverage Part
Commercial Crime coverage Part
Commercial Auto Coverage Part
Service Office Fee $ 9.05 ,Surplus Lines Tax $ 150.70
Countersignature Fee $ 35.00 ,Inspection Fee $ 100.00
FL Surcharge $ 4.00
5 Forms Applicable to all Coverage Parts:
See attached list of endorsements.
Percentage
100%
Premium
2,879.00
Not Covered
Not Covered
Not Covered
Not Covered
139.00
159.75
3,177.75
6 Service of Suit may be made upon: Mendes & Mount, 750 Seventh Avenue, New York, NY 10019
In return for the Payment of the premium, and subject to all the terms of this Certificate, we agree to provide the insurance as stated
in this certificate.
D~ed February 26, 2004
Surplus Lines Agent: Donald E Waters, Jr
Lic# A278403
, lED PI iHSUANT TO rHE-
THIS INSURANCE IS 1::>5.\ Pv,J 'PEE'Oi'iS ll-.JSURElJ
FLORIDA SURPLUS L~"F~'R'I:~'~ Dc) ii'CiTrWjF THe.
BY SURPLUS LINE'; (l':~", f:'l>"R\'r)!, !~,iS\,Ff',f'-ICF
TIO~I OF lot ,I" . ' ~.. ~r
PROTEC ",', TC 'F -, ", "f'e NT or '-\"" !~,.!C,H fUr
RANT'r' AU TO ,', , t.~ 'C,., , ",', '. '- ENT
GUA. _ LJ[: nB'Gt'T\O~i OF i\N iI,~()LV
RECOVERY FOR r, IL', LI '
UNLICENSED INSURER
by
Correspondent:
Clearwater Underwrit
2433 Gulf to Bay Bl a
Suite E
Clearwater FL 33765
(OMNI+ DC0544-031002l0402260959)
Other Interest Copy
~.; ~ 'A/f; <Lc /dai ~
COMMERCIAL PROPERTY- COVERAGE PART
SUPPLEMENTAL DECLARATIONS
Certificate No.4 7 8 4
Effective Date: 02 - 2 2 - 04
12:01 A.M. Standard Time
Named Insured: Foundation Village
BUSINESS DESCRIPTION
Tutoring For Children
DESCRIPTION OF PREMISES
PREM.NO. BLDG.NO. LOCATION, CONSTRUCTION AND OCCUPANCY
01 01 918 Woodlawn Street , Clearwater FL
33756 /Joisted Masonry /Tutoring for Children
CrntERAGES PROVIDED~ .... INSURANCE AT- THE OESCRIBE~ APPLIES GNhVFORGOVERAGESFORWHICHAtlMlrBFtNSURANCEIS-SH0WN:
COINSURANCS' .
PREM.NO. BLDG.NO. COVERAGE LIMIT OF INSURANCE COVERED CAUSES OF LOSS RATES PREMIUM
01 01 RC-Building $303,000 SPECIAL 80% $.95 2879.00
OPTIONAL COVERAGES - APPLICABLE ONLY WHEN ENTRIES ARE MADE IN THE SCHEDULE BELOW I t IF EXTRA EXPENSE COVERAGE LIMITS ON LOSS PAYMENT
AGREED REPLACEMENT COST
PREM.NO. BLDG.NO. EXPIRATION DATE COVERAGE AMOUNT BUILDING PERSONAL PROPERTY "INCLUDING STOCK
INFLATION GUARD (PERCENTAGE) r r MONTHLY LIMIT OF rt MAXIMUM PERIOD r r EXTENDED PERIOD
PREM.NO. BLDG.NO. BUILDING PERSONAL PROPERTY INDEMNITY (FRACTON) OF INDEMNITY (X) OF INDEMNITY (DAYS)
MORTGAGE HOLDER(S) l t r APPLIES TO BUSINESS INCOME ONLY
PREM.NO. BLDG.NO. MORTGAGE HOLDER NAME AND MAILING ADDRESS
DEDUCTIBLE
Wind/Hail Deductible 5% of TIV
Deductible All Other Perils Per Occurrence $1,000
FORMS AND ENDORSEMENTS (other than applicable Forms and Endorsements shown elsewhere in the certificatel
Forms and Endorsements applying to this coverage Part and made part of this policy at time of issue:
APPLICABLE TO ~L gOVERAGES:
See attac e Ilst of endorsements
APPLICABLE TO SPECIFIC PREM. NO. BLDG. NO. COVERAGES FORM NUMBERS
PREMISES/COVERAGES:
THIS SUPPLEMENTAL DECLARATIONS AND THE COMMERCIAL PROPERTY DECLARATIONS, TOGETHER WITH THE COMMON
POLICY CONDITIONS, COVERAGE FORM(S) AND ENDORSEMENTS COMPLETE THE ABOVE NUMBERED CERTIFICATE.
(OMNI+ DCCV5442-030609/0403020953)
Other Interest Copy
Attached List of Other Interests
Reference number: 4784
Date: 2-22-04
* Mortgagee
City of Clearwater Risk
PO Box 47418
Clearwater
FL
33758-4748
Page 1
* - Receives Other
Interest Copy
Other Interest Copy
(OMNI+ DCPRTINT-020BOB/0402261 000)
.. .' I
SCHEDULE OF FORMS AND ENDORSEMENTS
Attached to Policy number: 4784
Date: 2-22-04
FORM NUMBERS
FORM TITLES
CUl1010 (A) (4/89)
CU I 2055 ( 10/96)
CP0010 (10/91)
Brit Mold Excl
NMA1331
CP1030
CP0090 (7/88)
IL0017 (11/85)
NMA2 802 -(1-2117/97)
NMA2915 (25-1-01)
IL0175 (9/93)
NMA2340 (11/24/88)
IL0021 (11/85)
MK007
CUI2050 (10/96)
MKP-9
NMAl191
CP0121 (11/85)
NMA1998
NMA2920
CP0321 (6/95)
25% MINIMUM EARNED PREMIUM
ALARM MAINTENANCE WARRANTY
BUILDING PERSONAL PROPERTY COVERAGE
Brit 2002 Mold Exclusion
CANCELLATION CLAUSE
CAUSE OF LOSS SPECIAL
COMMERCIAL PROPERTY CONDITIONS
COMMON POLICY CONDITIONS
EDRE
ELECTRONIC DATA EXCLUSION
IL0175 (9/93) Florida Changes
LAND WATER AIR EXCLUSION
NUCLEAR ENERGY LIABILITY EXCLUSION
US PRIVACY NOTICE
PROPERTY ENDT
Protective Safeguard Endorsement
RADIOACTIVE EXCLUSION
STANDARD FIRE POLICY PROVISIONS
SERVICE OF SUIT-MENDES & MOUNT
Terrorism Exclusion
WINDSTORM OR HAIL % DEDUCTIBLE
Page: 1 of 1
Other Interest Copy
(OMNI+ EFLlST.020808/0403020953)