BUSINESS OWNERS DECLARATION PAGE
~I. "'I~:C~:~=nen ,I
Page 2
ASENCY'COPV
,.7
AGEN~ MUTUAL INS AGENCV AT CLEARWATER IHC
12-005
INSURED MARINA DENTAL a DENTURE CLINIC PA
. ..........:.....1.
..
:d
ADDf'Ellll 25 CAUSEWAY BLVD STE 20
CLEARWATER FL 34630-2000
;-,>,}~
:,:':lj
:';i...:.:r
i~'
,"'ffl
.,
,:
';::,s::
Cross out old infor~ation and write in changeg.
Effective date oi change: MO DAY YR
54643 (01-90)
Issued 04-06-94
BUSI~SSOWNERSPOLJCY PECLARATJONS
Policy Revision Effective 06-03-94
POLlCY NUI1J&!.R
92-178.132-00
20-57-FL-9Z06
Company Use
DB
POLICV TERM
12:01 a.m. 1Z:01 a.m.
i:o
06-03-95
06~03-94
LOCA nON 001
LOCATION: 25 CAUSEWAY BLVD STE 20 CLEARWATER Fl 34630-2000
COVERAGES
DED
Addl In5u~ed-Managors or l@sso~s of P~emise8
54604 (07-88)
nOl1S (09-93)
ADDITIONAL FORMS FOR THIS LOCATION:
. BP0303 (04-89) 54661 (08-91)
LaC 001 BLDG 0001
COVERAGES
DED
$250
Business Personal P~ape~i:y - REPL. COST
Business Income and Extra Expense
Windstorm and Hail
,C'-;I
SECURED INTERESTED PARTIES: None
RATING INFORI1ATION
LIMITS
Included
PREMIUM
$8.42
ILOZ55 (09-93)
BPOI04 (01-87>
55081 (08-88)
BP0402 (01-87)
LIMITS
$Z5,OOO
12 Months
Excluded
PREHtuM
$223.14
Included
Occupancy: Dental
Class Code: 65121
Prog~am: Office
liability Rato Number: 00
Burglary Rate Group: 00
Office T~nant Occupied
Canst: Fire ResistiveJ Non-Sprinklered
P~otection Class: 03
Territory: 015 Pinel1as County
Inside City Limits
~OTAl POlIL~ PREMIUM
00010013150200 00000000010000
100 '
TERM
*e:71 .36
I
The To~al PolicX Premium shown above includes:
Florida Surcharge of $.27
Emergency T~U5t Fund Su~charge of $4.00
,,----
7'-Wl.1 ~.
,.-----
;/11
y 7.5:", ~ <::, tv/ So 1"1 - }o<\-rrJ,,<:'
____ //l',7l'--r
2-f U
..J-..... 7' _- ~-',
-/~ ,..~ -,.
:: _ _,/ ( 1&0,-115'_./)
J ~- ~-=-.JI--
~_.
I
IOd 800 'MlO 1~ AON38~ 30N~~nSN! l~nlnW
1516 2~b 818 S5:bl 91 90 b661
,...-#, .'
- '/tg'tmey Code 12-005
.~
~
Page :5
potey Number
92-178-132-00
BP 04 02 01 87
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - MANAGERS OR LESSORS
OF PREMISES
This endorsement modifies insurance provided under the following:
BUSINESSOWNERS POLlCY
SCHEDULE"
Designation of Premises (Part Leased to You):
ZS CAUSEWAY BLVD STE 20-23
CLEARWATER FL
,I
Name of Person or Organization (Additional Insured):
CITY OF CLEARWATER
25 CAUSEWAY BLVD
CLEARWATER FL 34630
I
Additional Premium:
A. The following is added to Paragraph C. WHO IS AN
INSURED in the 8usines6owners Liability Coverage
Form;
4. The person or organization shown in the Sche-
dule is also an insured, but only with respect to
liability arising out of the ownership, mainte-
nance or use ofthcd part ofthe premises leased
to you and shown in the Schedule.
B. The following exclusions are added:
This insurance does not apply to:
1. Any "occurrence" that takes place after you
cease to be a tenant in the premises described
in the Schedule,
2. Structural alterations, new construction or de-
molition operations performed by or for the
person or organization designated in the Sche-
dule.
"Information required to complete this Schedule, if not shown on this endorsement, will be shown in the Declarations,
I3P 04 02 01 87
Copyright, Insurance Services Office, Inc., 1984, 1985
Ii:
"MlJ l~ AJN39~ 3JN~~nSNI l~nlnW
I.SL5 ct>t>
.Auto-Owners.
Page 2
54643 (01-90)
Issued .04-06-94
BUSINESSOWNERS POLICY DECLARATIONS
I
INSURANCE COMPANY
AGENCY MUTUAL INS AGENCY AT CLEARWATERINC
12-005
INSURED MARINA DENTAL & DENTURE CLINIC PA
Policy Revision Effective 06-03-94
POLICY NUMBER 92-178-132-00
Company Use 20-57-FL-9206
DB POLICY TERM
12:01 a.m. 12:01 ..m.
ADDRESS 25 CAUSEWAY BLVD STE 20
CLEARWATER FL 34630-2000
to
06-03-94
06-03-95
This pollcy is ...ended in consideraUon of the eddiUonal or return pr_iUII 8hown below. This Deolarations
voids and replaces all previously issued Declarations bearing the .... policy number and p,...iUII te,...
_':'" ':. ':-~~..,.' . i ".Jo ;...:
LOCATION 001
LOCATION: 25 CAUSEWAY BLVD STE 20 CLEARWATER FL 34630-2000
Addl Insured-Managers or Lessors of Premises
Included
;
PREMIUM
:~~..t It '1? ,':.(l. '~"~'f_>,l.~:,;,\~t
.8.42
1{1
COVERAGES
DED LIMITS
'~
-',,"
~
~
~
I
..,
~,- , i'~~' (~':i';'::~':r.;."'.""\'\'
ADDITIONAL FORI1S FOR .THIS LOCATION:' 54604 (07-88)
BP0303 (04-89)' '. 5466l'~ (08-91) '!.,. n0l75 (09-93)'
Loc 001 aLIG 0001
COVERAGES DED
Business Personal Property - REPL. COST .250
Business Income and Extra Expense
Windstorm and Hail
IL0255. (09-93) 55081 (08-88)
BPOl04 (01-87> ,,:< BP0402.(Ol-87>
LIMITS
.25,000
12 Months
Excluded
PREMIUM
$223.14
Included
.-.--'--------SECURED INTERESTED PARTIES: Hone
,i
.;
'i
..~
'I
1
:a
'~
11
;1
:i!
'!
!
j
1
.~
RATING INFORMATION
Occupancy: Dental
Class Code: 65121
Program: Office
Liability Rate Number: 00
Burglary Rate Group: 00
Office Tenant Occupied
Const: Fire Resistive, Non-Sprinklered'
Protection Class: 03
Territory: 015 Pinellas County
Inside City Limits
I TOTAL POLICY PREMIUM
.TERM
$271 .36
I
"~~
~
:~
~
:~
,
~
~
l
:'i
The Total Policy Pre.ium shown above includes:
Florida Surcharge of $.27
Emergency Trust Fund Surcharge of $4.00