CERTIFICATES OF INSURANCE
.... (iI!;N.UtAL IJU~INES~ DECLARATiONS I-OHM }<'LUIHUA WINlJ~T01{Nl UNlJEHWIUTINGASS~lATION if
~li'ol'U8eqnly With the Windstorm InsurancePolic,Y). .4070 BOULEVARD CENTlm DRIVE, JAf:KSONVILLE,FLORIDA32207
~.;:p~~'lf~Pt~\~Ypmi~;1td8hgu~d~~~~A\%~~;~Bl~fs~g:~~~~dto~~~s~~~b~~~frJ~t~W;raso~i;~~t~r;:hu~d:~~~hirtt'f.;~:E;T~~n~~itl' 01
.;.. o. f....th... ~,~...i.lJ). ~~h. e,p.o..li~Y'I's issu. ed tot. he el....... ....'-;.>.f..,i.r. atE;!.......a. b. .'..e..,..p. .a..r.. ticiP. at!onin ~he.As. !loc.iat... ion.. accordance with. t~e F.'lor. ida. .Win. dsto. .rm"~. o. [
Underwriting )\sBOClat on's Plan of OpetatIQn.,A lst,oftnemembers IS on fIle III the Department of Insurance. '. ....... .... , .
.':Thll: ~lorida..:Windstorm Underw~jtll')g.ABs6ci.a~io.n,ls..the:.~0Ie age~t of Its merp~ers with r~spect.to all matters.. pertaining to the 10.
Inlfuranc~ afforded hereunder.. All nobCes ()r otbercOQPl}li~~cll:~,ons r~q~1l"ed by the}>ohliY to be given J;o the Cqmpany. shall be given to / .
such. agent, at the address stated herein and such n()ticetothe.As~ocll~tlOn shall be COnS!der.ed to constitute notice to the members: Any I':> f
r~quests;Fdamand8()r agreements made 'I:!Y8ndany.cancell~t!on notJcel8Sued by such ag-~nt I!hall be. deemed .to h!lve b~en madeor Issue(J ,.tt
dlreetly by the> members. Mutual and reciprocal, pohcyprovlSlons:ofsuch members partlclpatmgas Illsurers In this polIcy shall not apply. (,P ."
T. his. lis' a')no~seS88b. Ie, ..bonparti~ip~tingpo.licy,an<J tne insured,:shall . not by reason.'. of the,<1ss'Qance of this policy become am. ember of'; . I
any,metn'6er:1DsurerQf the ASBOClatlOn.: ;',. '.' .... .. . ~,. r} I ,y
Insur.nlle.is,rptovJded only (1) &gainstthe peril of windstor!J1 as defined in the policy to which this form is attached, (2) with respeet I,')
to those'items specj(ically described herein and for which ll'specific amount of insurance is shown below, and (3) for the policy term lP
specifieqbe1o~raDdj unless otherwise provided; all conditions'snd provisions of this form and of the policy to which it is attached shall
app~r r~~~~~~~; ~~\~,~ch., item covered. . .
InlUl1Id'l J'j'atzonell Shel1S$Nice, '& City of File/Policy No.1 rNUA 19841
Nlme .ClearwatEll:'
M:~~,. 49Caus~ay Blvd. ~ v8.:)-',Y,:L,
AddnIII. Cle~ater Beach, FL 33515
'{,'T~r,I.'.-: ,;''>t"',._.': '}', ' ','" _:,' "!,' ", '."' '" ,.',:'
Policy Tern1......,I;.,,~;~l; d. ,2~2~'a\::I: I, nEAR FROM INCEPTION DATE at 12:01 A.1'v1.(Stanrlard Time), provided, however, with
ii',;'" .,., '. !NeE 10 0.. . ay Ye8r) EXPIRATION
re8~tto,81'1:y:mOrtgagee(or trustee) narnedl.>elow,thisin'surance shaJlcontinue in. force only for the. benefit of suchplortgagee (or
tl'Ustee)~?r\JP ~~yt ~(~:r;. *rittJIlnotice. ..t:9 ,ti!em()~tg~g.ee . (~t J.r:~tee). of termination. of this policy , and shall' then ter?;1inate.
'\~t i',
Rate'
J
,,,,,,,,LUll'" ,'i ,.,.. ,..'/ '.'"
. .PremluM Due
'Atlnceptlon
.285
$
88.
Description of ~roperty COllared (Location Must Also Be Oescrlbed It Olffere';t From Melling Addresa)
::Show,'conBtructlon, type of roof and occupancy of bulldlna(s) covered or
containing the 'proPS_ny. covered.
$ ,"
$(~8._ .;J:.~:l.:~1'
One stoxy, masonry, FillinqStation, located:4~
causewaY~lvd., Clea.tWater Beach, Pinellas County,
FL 33515
COnt.eQts in above Filling stat.ion
Subl.tt~'!~.'~r~,,~.o('.F' ;~A' ;'18' (ED 4-77)
rNSERl H)RM NUM8f~n:(sl AND EDITION. DA1'Elsl
att.ached hereto.
",-,
Mort,I,.'CflullI:.Subjeet' lothe prOVisions 'of the mortgage clause attached hereto, loss, if any, on building items, shall be payable to:
r'~ .;:. " I, "I ~ " ,., . '. "I" . - " : ,,:' . :
INSERT NA'-'E(S) OF MORTO....GE1;:(S) AND MAILING ADDRESS(ES)
,,<,p~'ucjI~I~~~d~ss Participation~lause: In event of loss the Company shall be liable for only 90 % of the amount of
the ,1088 in exce.s of .,mf) . ..' . ; subject, however, to all other terms and conditions of this policy. This provision shall apply
(1) .iepara'tely to'each building at structure, If two or more huildings or structures be covered hereunder, and (2) scparatelyto Quilding
and lieptatate'iW'co~nts, if's building and its contents be ('overed her"llnder, and (3) separately to the contents of each building, if the
conteffis~t'two Or more buildings be covered hereunder, and (4) separately to personal property in the open, and (5) separately to all
BCreening,~dl1Upp()r.ts eX,cept window and door screens, whether such insurance be written under specific schedule or under blanket form;
.;.,.;""";...."......"..., '.' PRODUCER
';~;t;'\;E~~~;';,~:.i$~.,.;tinq"'rn.ur~nce, Inc~
i;'~'r"',.ij~qr~34\;hAV8JlUeNorth, P.O. Box 7278
'}r:';i'rJ~:t.::'et,.rsburv;' FL 33734
;,,:..,',[aaY;'i;":\'";';''''' .,.
'V:,,':'..~:t4,afi~(,:::'r,;-~ I ~~},'i'".': ,. ,:,' ,
~:.~A.:'L';~:',.'."....~......~,.. ,~. .
~,"i":"''''''""""",
..J 2/4/81
, O.te
{J {h.' "~'a' j
. . A~. Raprea~nt.tlll"
c;..
l;<.GENT'$ (Of'"
~ / - 053
:11... 4: .st.ll~ Iuaraaoe. 180.
P. o. !lox 1278
st. rntrnbart:,.iI'lozoUa J.llJ4
COMPANIES AFFORDING COVERAGES
COMPANY
LETTER
A
B
C
D
E
C~ OakFt:n I.uva~
{~o.
COMPANY
LETTER
NAME AND ADDRESS OF INSURED
Fal.... '$Mll Serri._ I-.
., C.....,. Blvd..
Cleu'la1.w ~. F1eft.d& 33.51;
COMPANY
LETTER
COMPANY
LETTER
COMPANY
LETTER
This is to certify that policies of insurance listed below have been issued to the insured named above and are in force at this time. Notwithstanding any requirement, term or condition
of any contract or other document with respect to which this certificate may be issued or may pertain, the insurance afforded by the policies described herein is subject to all the
terms, exclusions and conditions of such policies.
TYPE OF INSURANCE
POLICY NUMBER
POLICY
EXPIRATION DATE
Limits of Liability in Thousands (
OCC~~~~NCE AGGREGATE
GENERAL LIABILITY
BODILY INJURY $
D COMPREHENSIVE FORM
D PREMISES-OPERATIONS
D EXPLOSION AND COLLAPSE
H AZA RD
D UNDERGROUND HAZARD
D PRODUCTS/COMPLETED
OPERATIONS HAZARD
D CONTRACTUAL INSURANCE
D BROAD FORM PROPERTY
DAMAGE
D INDEPENDENT CONTRACTORS
D PERSONAL INJURY
PROPERTY DAMAGE
$
BODILY INJURY AND
PROPERTY DAMAGE $
COMBINED
$
PERSONAL INJURY
$
AUTOMOBILE LIABILITY
D COMPREHENSIVE FORM
DOWNED
D HIRED
~DLla.btl1
2-2-82
BODILY INJURY
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT)
PROPERTY DAMAGE
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
$
$
$
65Q-l42I:3n ~
$ 300,
EXCESS LIABILITY
D UMBRELLA FORM
D OTHER THAN UMBRELLA
FORM
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY
OTHER
DES~N Ckairm~,AT!Q!:!SIN ~E~E~_
DU..-_ j.:j DiCLIII>>iJt AS AllDftlOlllL ~IJ AS BElP.1C"ftS POt.IOt A.m
S50-342E3~..
Cancellation: Should any of the above deslQbed policies be cancelled before the expiration date thereof, the issuing com-
pany will endeavor to mail _ days written notice to the below named certificate holder. but failure to
mail such notice shall impose no obligation or liability of any kind upon the company.
NAME AND ADDRESS OF CERTIFICATE HOLDER-
em OF e~
DATE ISSUED:
2-la6-81
GInaI . S~IZ~~E DC.
,.
'l.~"'~,
Su-'-
RENEWAL OR REPLACEMENT NO.
..:'_:
."
~..
EXCELSIOR t
TR/pr
;URANCE COMPANY, SYRAC
GENERAL LIABILITY DAILY REPORT
POLICY NUMBER GL
------
.JoAnn HOID8her
d/b/a Bait House
Apt. 1 Dolphin Point Road
Clearwater. Florida 33515
G!f 505 17 28
0\ '\ ","' J
co(oU/
J ,',
i~ t,,(.c.-
U
~
..
~~--
I J. I
DECLARATIONS
~ar.neJ~nsureJ
2.
ADDRESS:
(Number & Street, Town, County, State & lip No.)
Policy Period: b~oM N':;MW~~:::.J'~ ~';^v::~ A~f",~~s From:
REPRESENTATIVE:
Agent or Broker
Office Address
Town and State
2/19/82
.Jack Ranaom Agency
To:
2/19/83__~_______
-J
C)
09-168
Clearwater. Florida
33515
!.
-RECE1!EaJ
APR 20 _
.,.,. CLERx
3. The insurance afforded is only with respect to such of the following Parts designated by an "X" in ~ and Coverages therein as are indicated by
specific premium charge or charges. The limit Qf the company's liability against each such Coverage shall be as stated herein, subject to all tile
terms of this policy having reference thereto.
Comprehensive~eneral-Tiability Insurance ............ D --------T--- ---P-
Owners', landlords' and Tenants' Liability Insurance a I
Manufacturers' and Contractors' Liability Insurance .... D EACH OCCUR~RENl~IM~ ITS__ OF L$IABILlTYAGGREGATE ~.,,~~_,_--_,-_,I '$
I Contractual Liability Insurance ....................... D__ ~ ,
I Completed Operations and Products Liability Insurance .. D
I " ',: Bodily Injury Liability $ 300,000.00 50.00
,-- ------ ----- __,_u____~rgp~rtyJla.mag~~~~lt'[ $ 10~~~E~~-~- $---EACH-ACCIDENT _-:_$ 20.00--1
i Premises Medical Payments Insurance .... -.. . . . . .. ... D $
r -", _.~- , ' , ' -
1 Comprehensive Personal Insurance ;......... ....... . .. D'
i Farmer's Cornprf:hRllsive Personal Insurance ........... D
. Personal liability
I Personal Medical Payments S XXXXXX ' $ :$ I
Physical Damage to Property XXXXXX I $ ! XXXXXX J l'
, "",i...,. t. Fa,m.,', C.~""'e.,i'. 'er,o.al I.,.,a." o.'J) Animal Collision Market value 'not exceeding $400 each anim,,1 -I _
I I ~ -n--Elldorsemenls and (I~dE~~I~~aI8~0;~~~e :Ua~~E~) 60004(3;;~;---~--i ' .
I ~____~_~,______________'__n___-;-______-,---'-__~~__;""":"'____-,__~______n_ ,__+$_ ,_-, ,___ ,,__ _____J
1.~:;::~~:~~;~~;~~~:;:i::F~;~:~~ti~~;~~r:-- - . I" """""'L_ U OI"-3~i~,:' I~O(),()O =~
G", ..,D~':':h';",~,.th~,-<:"~;::~~:~~;~:;;::!i:~~',lf{~i~~;: "~""d. ~.~. ";~;:"~~~:~timi '"'~:'h"-'~::~::~:d"'.. .. L=_. ..,1
f'A8STNC80-F 'AN'ENTR'i -MEANS"NOEXCEPTION":"-~-- - -------,---------- -- ipplicableirii e,-as-j
---.,-----,-.,...-:-:~~'~-:--~-------..--. --.. - ----------~---_.--------.__~_ - .. .._~,...,.___J._,_'_,_.,_.._.. ...u_ ,_
ADVANCE
PREMIUM
-'---~--1
I
I
I
I
Countersigned by ~-
~~ ~;;'O~;;'d".w"n'o';,'
form No. L4050DR Ed. 10~1-66 Rev. 1-1-73
11~. ii J
#
p,
OWNERS', lANDlORDS' AND TENHtrS' LIABILITY INSURANCE COVERAGE PART
I I ~
,...
SCHEDULE
for Ittachment to Policy No. GL 506 OS 60
.NEW. LIAIILJn IIAZAIDS
. to complete said poIlcr.
DESCRIPTION OF HAZARDS
CODE NO. PRUlIUM BASES
(a) Area (__. ft.)
(II) 'r....
om
IOOll' "OPEIln
INJURY DAMAGE
fI) .... 1110 Ill. ft. of ArM
(II) Per .... ft.
ADVANCE PRUlIUII
IOOll' PROPERn
'''AlR' OAMA
Premises - Operations
Reta11 Stores NOC
59991 a) 200
a) 11.088
.082
50.0OMP 20.0OMP
Escalators (Number at Premises)
Humller lUUrH
.... Undln&
Location of lasured preues
(000 "SAME" IF SAME AS ITEM 1.)
Interest of named insured in Insured premises
Plrt occupied by UIlII' 1.,rId
Slip
71-75
Total Advance 8.1. and P.O. Premiums
Total Advance Premium
153, Clearwater Mar na
Causeway Eoulevard, Clearwater, Fl
"OWNER", "GENERAl lESSEE" OR "TENANT"
TR/pr 1/14/82
When used as a premium bdSis:
"admissions" means the total number of persons, other than employees of the .med Jasund, admitted to the event insured or to events conducted on the premises
whether on paid admission tickets, complimentary tickets or passes; .
"cost" means the total cost to the named insured with respect to operations performed for the named Insured during the policy period by independent contractors of
all work let or sub. let in connection with each specific proJect. including the cost of all labor, materials and equipment furnished, used or delivered for use in the
execution of such work, whether furnished by the owner, contractor or subcontractor, including all fees, allowances, bonuses or commissions made, paid or due;
"receipts" means the gross. amount or money charged by the omed Jasund for such operations by the named Insured or by others during the pOlicy period as are
rated on a receipts basis of her than receipts from telecasting, broadcasting or motion pictures, and includes taxes, other than taxes which the named Insured collects
as a separate item and remits directly to a governmental division.
60004 03/75
fMrt
~;"'~i,:.'..:..:':";~o.d:..:::~;;:;:.:.:~~~~;.;.;,,,,,~-,.:~:blli.r~;i,';';'~"'~;"-;_...~.,,,,,,~,,,
,. ......_."..;;_.::.,_'~.l.-:;:,' U.:,l,\'J..:.jN'
'..L~-:
HE~_E~~~;~~H_:~~~M~NT>~~. J
f,.
."
,.
r--cOUNTEHSIGNATURE DATE
l_.Ig;ljL-I,~:!-4jJit,,-
I'U[ Ie '( -,-
I
CJLN I}~/\L I 1/\1) I L I I Y
Part Two, This Declarations page and Coverage Part(s) wilh "1'01 r'loVlsions-I\Jlt One" completes the below numbered
r~~~~~1v=~:: JnjureJ:~i::';~::::t~d~~~~s7ti~]~ ------
ADDRESS: Clearwater, Florida 33515
<Number & Street, Town, County, State & Zip _No,) ___ ___
2 Pol:cy Per,'lod IHl "- M. ST"DA'D TIME AT THE ADDfI[SS From UlWi.L81 To .2L19 /82
,t : OF THE NAU(D IHSUR!D p.s STATED HERElri. :. :
- -_._-~_. --------~- - ----~._~-_._~_.
Agent or Broker . Jack Ransom Agency
Office Address . 09-168
.____---'-'-_____-------~<J!I..I1-~-d-~~~~...:-g.tef-l.I~ a !:..cX.LJn9_r.i~1~__lJjl?_
J~lf7
----...-.----.--..----..,.--..---.-------
"T'( _ nO"", '
i?J>r'7r@fl(CU~~ ' / , ' " ..".
~~~'8li~fl~.~ ,RA~~~C?M, A?.ENC'l
INSURANCE COMPANY cg> 446-1365
S Y RAe USE NEW YO R K 17MB CAUSEWAY BLVD.
P.O. BOX 3344
CLEARWAtER. FL. 33516
~~'ihe insurance afforded IS o-;l;-~itil resp~Zt to sucll~of [he followinG Parts deslBnated by an "X" In [21 and Covel ages lhereln a'j are indicated by
specific premium charge or charges, The limit of the company's liability against each such Coverage shall be as stated herein, subject to all the
terms of this policy having reference thereto
Compr-ehenslve--Gi)n-eraiTiabilltYlnSurance-. . . . . . . . . - .. IT\ - -- - --.-----r\OV-ANCE
Owners', Landlords' and Tenants' liability Insurance .... [] PREMIUM
Manufacturers' and Contractors' liability Insurance .... 0 LIMITS OF LIABILITY - - ----
Contractual Liability Insurance....................... 0 bl
Completed Operations and prOd,uct"S, L".bHit, ,,""""" H [J_ EAell OCCURRENCE -l~"", -P.GGR-EGATE, ----, ,
Bodily Injury Liability $ 300,000.00 $ $
Prop~~tLJl_ama~e Lia~.l\.il.Y $O_QQ~QD___ $ ~------------- $
EACH PERSON EACH ACCIDENT
Premises Medical Payments Insurance ............,... 0 -$----------- $-------------------- $
I. ---- , -
Comprehensive Personal Insurance .....,............. 0 ~ -i~CH I tACH EACH I
Farmer's Comprehensive Personal Insurance ,............ 0 PER~O~___ !IOCCURRENCE AC(;I[)Ern.---J ]
Personal Liability XXXXXX $ xXXJ..xx -1
Personal Medical Payments I $ XXXXXX $ J-$
Physical Damage to Property 1 xxxxxx i $ I xxxxxx
1__ I..,lio"'. '0-'''''''''' c"m.n'm'.. ''''0,,1 '""''''' '"',I. Ani~Collision Market value not exceeding $400 each animal $
I Endorsements and Additional Coverage Parts # I
I (IDENTIFY BY FORM NUMBERS)I
I "'Foil" i';"" ;,;;" Ih'"'' ,,,,,0' th' p;,~,~" ,; 10 b",1d 6 000 4 (3/7 5 )Lr o,;IAd""" P,e m",m: 7 0 - DW
~jnst2!lm€i'ilS,premiumiSpaYable: On effeclive date of policy $ 1st Anniversary $ -----2~;j-A;;i,~~~;a;y $--- !
i\',---kditp~iod:--A~~I~-~~I~~~th-;;~s.~.s:I~~d,** __-==~--=----==~~======- - ;
4.~, ", The named insured .is~ individu;;l[,l _~; partnership r=-b _ _~orpola!ion I i; ;
JOint venlureL_J; othp.rL-_ =~_j
5. Du-ring-ihe p2St three years no insure, r has cancelled i~~uran~issued to the named-i-nsur-;d, slmll~ to th;~furdedhere~d~, --
unless otherwise stated herein*'
"ABSENCE OF AN ENTRY MEANS "NOEXCEPTIoN". ______ ___________________~~t...a~l'lIcabl-"--'-'2 Texas.
50.00
20.00
;1
1
~
1
I
j
;\
.~
~
'j
~
j
G,0
t;
~~ -=-~'-L
Countersigned ~'-------------..-'-----------
Authorized Representative
~
Form No_ L40500 Ed. 10-1-66 Rev. 1-1-73
/9-032-
,. ~