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DESCRIPTIVE SCHEDULE - CERTIFICATE OF INSURANCE CERTIFICATE OF INSURANCE \Ao~ ;,0.. -..' , DESCRIPTIVE SCHEDULE '~:'~ Name of Insured Palm pavlion ot Olearwater. rne. - I~A slJn~ Fon~ Address of Insured 10 Bay Esplanade Clearwater B..ch, FL 33515 Location Covered State ot Florida 332 nul l' Vi AW Rl vel . C1e8PwatAY' ReAch, WI. 33515 RECEIVED Operations Covered THIS IS TO CERnFY TO CERnFICATE HOlDER: Mailing Address (SIr.. And Number. City, Slate, Zip Code) City of Clearwater Post Office Box 4748 jUN 2 1916 Clearwater, Attention: CITY Cl.ERK COVERAGE is provided in Company initialed below: [i] A=AETNA INSURANCE COMPANY D U=AETNA FIRE UNDERWRITERS INSURANCE CO. D C=CENTURY INDEMNITY COMPANY Effective that on the above date the following describeQ insurance policies, issued by this Company, are in full force and effect, subject to all the tenns, conditions, limitations and exclusions, thereof. Co Name of Coverage Policy Effective Expirotion Limits of Number Date Date Liobility A Worlcmen's Compensation WC051767 5/19/76 4/1/77 Stotutory *Public Liability-Bodily Injury (Not Auto) 5/19/76 $ 300,000 each person A CG283592 n/1/77 $ 100 ,000 each occurrence *Public Liability-Property Damage (Not Auto) $ 50,000 each occurrence (Explosion, CoUapse, Underground Hazards A Not Covered Unless Otherwise Stated Herein) .. .. 50,000 aggregate " $ Products-Compleled Operations- S 300,000 each person Bodily Injury $ 300,000 each occurrence A n .. " $ 300,000 aggregate Products-Completed Operotians- $ .20 ,000 each occurrence A Praperty Damage If " " $ 50,000 aggregate Specific Contractual-Bodily Injury $ ,000 each person (Other Than Incidental Contracts As Defined In The Policy) $ ,000 each occurrence Specific Contractuol-Praperty Damage $ ,000 each occurrence (Other Thon Incidental Contracts As Defined In The Policy) S ,000 aggregate , Additional Named Insure ~: Howard G. Hamilto 1. (Owner 0 Corporation) Automobile-Bodily Injury $ ,000 each person $ . ,000 each occurrence Automobile-Property Damage $ ,000 each occurrence Burglary Pia" Glass -Includes coverage for the following incidental written agreements: 0) lease of premises, (2) easement agreement, except in connection with construction or demolition operations on or adjacent to a railroad, (3) undertaking to indemnify a municipality required by municipal ordinance, except in connection with work for the municipality, (4) sidetrack agree- ment, or (5) elevator maintenance agreement. Should any of the above described policies be cancelled before the normal expiration date thereof, the Company will endeavor to give written notice to the above Named Certificate-holder, but failure to give such notice shall im- pose no obligation or liability of any kind upon the Company. By A uthorized Agent licate Copy for each Policy listed hereon) 1'1-004- - 3 THIS CEJmFICATE OF INSUIlANCE NEDHEI AFRlMAnvElY NOlI NEGA ON THIS CEJmFICATE UNDER POLICY NU.-aI. (Agent or Branch Office to selld H FORM 600-35 ED. OCT, 69 PRINTED IN U.S.A. -- 1NSW ..~, -.. RECEIVED ~MP~t_ - _ -- ..9Q~:tINj;N~AJ,_IliS.1lLN.9E_Q.O~!rrY___ --- _ -----1-'- _ __ ____ _ _ ___ T (Herein called the company) - 'JUN 2 1976 CERTIFICATE OF INSURANCE NAMED INSURED AND ADDRESS rThe Four Suns, Inc. 332 Gulf View Blvd. Clearwater Beach, FL 33515 and Palm Pavilion of Clearwater, Inc. LlO Bay Esplanade Clearwater Beach FL 33515 -, CITY CLERK. The company hereby states that it has issued to the in- sured named herein a policy or policies of insurance providing the types of insurance and limits of liability set forth herein. This certificate of insurance neither affirmatively nor negatively amends, extends or alters the coverage afforded by the policies scheduled here- in. It is furnished as a matter of information only, confers no rights upon the holder and is issued with the underc standing that the rights and liabilities of the parties will be governed by the original policy or policies as they may be lawfully amended by endorsement from time to time. -.J TYPE OF INS URANCE (Indicate by "X" In Box) POLICY NUMBER EFFECTIVE DATE EXPIRATION DATE o Comprehensive Automobile Liability $ $ LIMITS OF LIABILITY BODILY INJURY LIABILITY PROPERTY DAMAGE LIABILITY =~on $ ~i~rrence each occurrence o XI Comprehensive Generol LIability o Manufacturers' and Contract,()rs' Liability D Owners', Landlords' and Tenants' Liability o Contractual Liability L6734628 4/1/76 5/19/76 $300,000. each occurrence $ 50,000. each occurrence o o $300,000. aggregate $ 50,000. aggregate $ each occurrence UMBRELLA LIABILITY $ aggregate-products-completed operations Subiect to self.insured r.tained limit and underlying insurance described in the policy. WORKMEN'S COMPENSATION WC2046607 4/1/76 5/19/76 Coverage afforded in accordance with the Workmen's Compensation Law of the States specifled in subdivision (a) below and the Occupational Disease Law, If any, of such States, unless otherwise .tated in subdivision (b) below. EMPLOYERS' UABIUTY " tI tI (a) (b) COVERAGE B-EMPLOYEES SUBJECT TO COMPENSATION LAW IUnleu atherwlse stated, the policy 'Iumber, effedive and expiration dates DIe the same as those shawn for _rk- .0', compen,atloa insurance) $ 100 000. COVERAGE B-EMPLpYEES NOT SUBJECT TO COMPENSATION LAW INJURY BY ACCIDENT INJURY BY DISEASE $ $ each employee $ each accident $ each employee aggregate leach oIate) REMARKS MEDICAL $ eac employee State of' Florida Additional Named Insured: Howard G. Hamilton (OWner of Corporation) This certiflcate is issued at the request of the person or organization named below and the company will mail to such person or organization, at the address shown, notice of cancellation and, where possible, notice of any material change in any of the described policies. r City of Clearwater Post Office Box 4748 Clearwater, FL 33518 -, L Attention: City Clerk .J L1AB.1618T 752 PRINTED IN U.S.A. ; ,:~j~':~~' . I I .~ CtRTlFICA TE OF INSURANCE ~';.~.: '~ , ~, ~~~ ~ .. :'I.~" -~ - ~-~ ,~~~. The Continental Insurance Companies GENERAL OFFICES 80 Maiden lanerNew York, New York 10038 DEPARTMENTAL OFFICES 1111 East Broad Street, Columbus, Ohio 43216 80 Maiden Lane, New York, New York 10038 80 Maiden Lane, New York, New York 10038 333 Glen Street, Glens Falls, New York 12801 100 Pine Street, Sa~ francisco, California 94111 161 Peachtree Street; N.E., Atlanta, Georgia 30303 1810 Commerce-Street, Dallas, Texas 75201 360 West Jackson Boulevard, .Chicago, Illinois 60606 Buckeye Department Eastern Department . Foreign Department . Northeastern Department Pacific Deportment . Southeastern Department Southwestern Deportment Western Department " '\ Branch and field Offices in all Principal Cities ,\' "1-.,.