INCREASE IN PAYROLL FOR WORKERS COMPENSATION REQUIREMENT
I nterdepartment Correspondence Sheet
Elizabeth S. Haeseker, Assistant City Manager
Bill Held, Assistant Harbormaster ~
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Lucille Williams, City Clerk
SUBJECT: Clearwater Beach Seafood - Insurance Policy
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TO:
FROM:
COPIES:
DATE:
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June 20, 1985
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!T'tUF cifiRWAr'ER
The enclosed form shows an increase in payroll for the Clearwater
Beach Seafood workers compo requirement.
They have provided me with an insurance binder until their complete
policy arrives, which should be within the next few weeks.
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RECEIVED
JUN 24 198~
CI'~
.L I ClERK
/90/6- I 7
'!Me- ~NCI.OSURE
is fo. your records
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Date: 6-6-85
The enclosed contains a Mortgage Clause, or Loss Payable Clause
in your favor.
Owner:
CLearwater Beach Seafood, I nc.
Company and Policy No. .
West AmerLcan Insurance
Company WCW400-04-92
Thank you, Pam Zeyak
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INSURANCE AGENCY INC.
620 BYPASS DRIVE
P. O. BOX 5025 P z
CLEARWATER. FLORIDA 335~B,4985
Phone: (813) 797-4499
Tampa: 229,8208
CLty of CLearwater
TO P.o. Box 4748
CLeorwoter, FL. 33518
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. A1TACHED TO AN RM ING PART OF EFFECTIVE DATE
POLICY NUM BER
ktW (86) 400-04-92 05/31/85
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ENDORSEMENT
POLICY ATTACHING DATE
POLICY EXPIRATION DATE
NAME OF COMPANY
WESt AMERICAN INSURANCE COMPANY
INSURED'S NAME & ADDRESS
0~/31/85
ENDORSEMENT NUMBER
05/31/86
AGENT NUMBER
09-00-1301
PRODUCER'S NAME & ADDRESS
LEARWATER BEACH SEAFOOD INC
37 CAUSEWAY BLVU
CL EAR WA lE;R FL
AIM INSURANCE AGENCY INC
POBOX 5025
33515 CLEARWATER FL 33518
IN CONSrUERATION O~ AODITIONAL PREMIUM DUE NOW $2,914.00
IT IS AGRElO THAl fhE POLICY IS AMENDED AS FOLLOWS:
CLASS 8031 (02) ($CH. NO. 010900) IS AMENDED TO READ:
5.70 30,000 $1,710.00
CLASS 9079 (05) (SCH. NO. 010900 ) IS AMENDED TO READ:
3 . () 7 116,000 $4,605.00
RECEIVED
JUN .J 0 198~
CITY CLERK
AUTHORIZED REPRESENTATIVE
INSURED(S COpy
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~LL OTHER TERMS AND CONDITIONS REMAIN UNCHANGED.
SSUE DATE
:omp 1703 (7-76)
OS/29/85 STP 03 C.
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