INSURANCE CERTIFICATE - POLICY GLA 123263
~ GENERAL L1ABILlTY'AUTOMOBILE POLICY ~. "'"
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No. GLA 1 2 3 26 3
GLA 109136
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STOCK COMPANY
RENEWAL OF NUMBER
NATIONAL
INDEMNITY COMPANY
3024 Harney Street RECEIVED
OMAHA, NEBRASKA 68131
DECLARATIONS
Item 1. Named Insured and Address: (No., Street, Town or City, County, State)
Earnest A. Barger, Jr. & Rosalie Mulder
661 Poinsetta
Clearwater Beach, FL 33515
Item 2. Policy Period: (Mo. Day Yr,)
From January 1, 1978 to January 1, 1979
12:01 A.M., standard time at the address of the named insured as stated herein.
JAN -
16 197fJ'
\ MUTUAL ,INSURANCE AGe'N~t,~1.l4W.!
i AT CLEARWATER, INC.
10 N. MISSOURI
CLEARWATER, FLA.
446-6064
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The named insured is:
o Individual rn Partnership
Business of the named insured is: (EHTER BELOW)
Boat yard
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,
o Corporation
o Joint Venture 0 Other:
Audit Period: Annual, unless otherwise stated. <-n:R BELOW)
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 L6407 Insurance
$ Automobile Physical Damage Insurance $ Owner's and Contractor's Protective Liability
(Fleet Automatic) Insurance
$ Automobile Ph~sical Damage Insurance $ Owners', landlords' and Tenants' Liability
(Non-Fleet Insurance
$ Basic Automobile Liability Insurance $ Personal Injury Liability Insurance
$ Completed Operations and Products liability $ Physicians', Surgeons'and Dentists' Professional
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
G~9236a, L9294, ~I1295a, NI2~t5,(L6432f Form numbers of endorsements,
other than those entered, on
$ '11Ie;a\ (117":l 1":l7n) (F..I7F.. 117'::;) Coverage Part(s), attached at issue
$ ?(VI nn .'Total ~dvance Premium' for this policy. r
. 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
$ $ $
093 slb
Countersigned: St. Petersburg, FL
*Notapplicable in TJ/aJ/78
OKP6300..X-F
(1-1-73)
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By
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Dana Roehrig & Asso~tutes, Inc.
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