INSURANCE CERTIFICATE - POLICY GLA 160198
GENERAL L1ABILlTY.AUTOMOBILE POLICY ~
~
No. GLA 1 6 0 1 98
GLA 148886
RENEWAL OF NUMBER
NATIONAL
STOCK COMPANY
II flAT ClNCnLA TION NOT AllOWtl"
INDEMNITY COMPANY
3024 Harney Street
OMAHA, NEBRASKA 68131
DECLARATIONS
Item 1. Named Insured and Address: (No., street, Town or City, County, State)
. Ernest A. Barger, Jr. & Rosalie Mulder
661 Poinsetta
Clearwater Beach, Fla. 33515
Item 2. Policy Period: (Mo. Day Yr.)
From 1-1.-80 to 1-1-81
:I 12:01 A.M., standard time at the address of the named insured as stated herein.
MUTUAL INSURANCE AGENCY.,
AT CLEARWATER, INC.
10 N. MISSOURI
CLEARWA TER,F'l.A.
446-6064
"
The named insured is:
o Individual rn Partnership
Business of the named insured is: (ENTEIl .&LOW)
Boat Yard
Item 3. The insurance afforded is only with respect to the Coverage PartlS) indicated below by specific premium chargels) and attached to and forming a part of
this policy,
o Corporation
o Joint Venture 0 Other:
Audit Period: Annual, unless otherwise stated. <mon:.. -LClW)
Advance Caverage Caverage Partls) Advance Cnerage CDveragePartls)
Premiums Part ND(S). Premiums Part No(s).
$ Automobile Medical Payments Insurance S Hospital Professional liability Insurance
$ .. Automobile Physical Damage Insurance S Manufacturers' and Contractors' liability
(Dealers) 200.00 1-6407 Insurance
$ Automobile Physical Damage Insurance S Owners and Contractor's Protective liability
(Fleet Automatic) Insurance
S Automobile Ph~Sical Damage Insurance $ Owners',landlords'and Tenants' liability
(Non-Fleet Insurance
S Basic Automobile liability Insurance $ Personal Injury liability Insurance
S Completed Operations and Products liability S Physicians', Surgeons' and Dentists' Professional
Insurance liability Insurance
S ComprehenSive Automobile liability Insurance $ Premises Medical Payments Insurance
S Comprehensive General liability Insurance $ Storekeeper's Insurance
S Comprehensive Personal Insurance $ Uninsured Motorists Insurance
$ Contractual liability Insurance $
S .. Druggists' liability Insurance
$ Elevator Collision Insurance $
$ Farm Employers' liability and Farm Employees'
Medical Payments Insurance $
$ Farmer's Comprehensive Personal Insurance
S Farmer's Medical Payments Insurance $
S Garage Insurance
rDrm nUmbers of endorsements,
1-64321'(1-76)GU-Q236a(1l-6Q)L-Q2Q4(1-73)NI-12aC;A(~ : \ Dther than thase entered Dn
$ -70 )NI_"r'I. r'_ (1 _7R CDverage Partls), attached at issue
$ 200.00 TDtal Advance Premium fDr this policy. I
" ..
-.. , . L
* 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
$ $ $
'N~le in Texas
By
ptd. In U.S.A.
.. ..----.
./ i
/.,l,/ ,
Dana Roehrig & Associates,
tf)~~~ '
Authorized Re en ative 0'
Inc.
Countersigned:
St. Petersburg, Fla.
ds 093
J _
/-.
( -"7.
OKP6300-X-F
(1-1-73)
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,
NATIONAL INDEMNITY COMPAIY
3024 Harney Street . ..
Omaha, Nebraska 68131
CERTIFICATE OF INSURANCE
RECEiVEO{
~
JAN 2 G 1979
This certificate of insurance neither affirmatively or negatively amends,
extends or alters the coverage afforded by the Policy or Policies numbered
in this certificate.
January 18th
n'1)( C Lk:.H.r~
19 79
This is to certify that the folluwing described policies have been issued and are in full force and effect.
NAME OF INSURED
Earnest A. Bargers Jr. & Rosal ie Mulder
P. O. ADDRESS
661 Poinsetta, Clearwater Beach, Fla.
33515
LOCATION COVERED
Same
, , .,..~(
,.
DESCRIPTION OF WORK
Boat Yard
GL
POLICY NO. KIND OF INSURANCE LIMITS E1=FECTiVE EXPIRES
Workmen's Compensation Legal
and Employer's Liability
General Liability: For each item show "Not Covered"
if no coverage afforded.
Bodily Injury . . . . . . Each Occurrence $ 300.000
A 148886 Aggregate - Products - January 1 s 1979 -
Completed Operations $ N/A January 1, 1980
Property Damage, , . . Each Occurrence $ 10,000
Aggregate. Operations $ 25.000
Aggregate. Products -
Corhpleted Operations $ N/A
Automobile Liability:
Bodily Injury. . . . . . . Each Person S
Each Occurrence $
Property Damage . . . . , Each Occurrence $
Covers:
Excess Liability: 0 Automobile 0 General Liabil ity
Name of Primary Insurer:
Primary Limits:
Excess Limits:
In the event of any material change in or cancellation of said policies, NATIONAL INDEMNITY COMPANY intends to notify the
party to whom this Certificate is addressed of such change or cancellation, but undertakes no responsibility by reason of any failure so
to do.
This Certificate issued to:
City of Clearwater
P.O. Box 4748
Clearwater. Fla. 33518
Attn: Ci ty Clerk
By
Title
U-100e (1/73)
NOTE TO AGENT -- Mail Copy to Home Office immediately.
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