INSURANCE CERTIFICATE
No. GLA
109136
... . ;" GENERAL L1MmlTT-AUl UMUHILt t'UUtil
:1"
r.
I;'
New
RENEWAL OF NUMBER
STOCK COMPANY
NATIONAL INDEMNITY COMPANY
3024 Harney Street
OMAHA, NEBRASKA 68131
DECLARATIONS
Item 1. Named Insured and Address: (No., street; Town or City, County, State)
. Earnest A. Barger, Jr.
661 Poinsetta
Clearwater Beach, FL 33515
Item 2. Policy Period: (Mo. Day Yr.)
From 1~1-77 to 1-1-78
12:01 A.M., standard time at the address of the named insured as stated herein.
.,.
:I
The named insured' is:
[llndividual D Partnership
Business ofthe named insured is: (ENTER .ELOW)
Bait Sales
Item 3. The insurance afforded is only with respect to the Coverage Part(s) indicated below by specific premium charge(s) and attached to and forming a part of
this policy,
D Corporation
D Joint Venture D Other:
Audit Period: Annual, unless otherWise stated. <-TorR .E~W)
Advance Coverage Coverage Part(s) Advance Coverage Coverage Part(s)
Premiums Part No(s). Premiums Part No(s).
$ Automobile Medical Payments Insurance $ Hospital Professional Liability Insurance
$ Automobile Physical Damage Insurance $ Manufacturers' and Contractors' Liability
(Dealers) 200.00 L 6407 Insurance
$ Automobile Physical Damage Insurance $ Owner's and Contractor's Protective Liability
(Fleet Automatic) Insurance
$ Automob i Ie Physica I Damage Insurance $ Owners', landlords' and Tenants' Liability
. (Non-Fleet) Insurance
$ Basic Automobile Liability Insurance $ Persona/Injury Liability Insurance
$ $ . Physicians', Surgeons' and Dentists' Professional
Completed Operations and Products liability
Insurance Liability Insurance
$ Comprehensive Automobile Liability Insurance $ Premises Medical Payments Insurance
$ Comprehensive General Liability Insurance $ Storekeeper's Insurance
$ Comprehensive Personal Insurance $ Uninsured Motorists Insurance
$ Contractual Liability Insurance $
$ Druggists' Liability Insurance
$ Elevator Collision Insurance $
$ Farm Employers' liability and Farm Employees'
Medical Payments Insurance $
$ Farmer's Comprehensive Personal Insurance
$ Farmer's Medical Payments Insurance $
$ . Garage Insurance
GU-9236a NI-2545 L-6432f Form numbers of endorsements.
$ L-9294 NI-1295a other than those entered.... on
Coverage Partls), attached at issue
$ 200.00 Total Advance Premium for this policy. .1
. If the Policy Period is more than one year and the premium is to be paid in installments, premium is payable on:
Effective Date 1st Anniversary 2nd Anniversary
$ $ $
Ir
Countersigned: St. Petersburg, Florida 1M 1-6-77
Dana
Inc.
'Not applicable in Texas
OKP6300-X-F
(1-1-73)
By
Ptd, in U.S.A,
,If'
,,-L..'
(/! :
>K/
Itf"03~