CERTIFICATES OF INSURANCE (2)
COMPANIES AFFORDING COVERAGES
Burke-Lehman Insurance Einc.
2348-B Sunset Point Road
Clearwater, FL 33575
COMPANY A
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY D
LETTER
COMPANY E
LETTER
Excelsio~:..Insurance
NAME AND ADDRESS OF INSURED
Jo Ann Hamsher d/b/a
Tne Bait House
205 Dolphin Point Road, Apt. 1
Clearwater, FL 33515
ERK
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
A
GENERAL LIABILITY
~ COMPREHENSIVE FORM MP 3 73 20 71
~ PREMISES-OPERATIONS
D EXPLOSION AND COLLAPSE
HAZARD
D UNDERGROUND HAZARD
~ PRODUCTS/COMPLETED
OPERATIONS HAZARD
D CONTRACTUAL INSURANCE
D BROAD FORM PROPERTY
DAMAGE
D INDEPENDENT CONTRACTORS
D PERSONAL INJURY
eff
thru
9-6-83
9-6-84
80DIL Y INJURY
$
PROPERTY DAMAGE
$
$
80DIL Y INJURY AND
PROPERTY DAMAGE
COMBINED
$ 300
$ 300
PERSONAL INJURY
D COMPREHENSIVE
DOWNED
D HIRED
D NON-OWNED
FORM
BODILY INJURY
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT)
$
$
AUTOMOBILE LIABILITY
PROPERTY DAMAGE
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
EXCESS LIABILITY
BODIL Y INJURY AND
D UMBRELLA FORM
D OTHER THAN UMBREl.LA
FORM
PROPERTY DAMAGE
COMBINED
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES
Cancellation: Should any of the above desc'i~d 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 HOl.DER Additional Insu
City of Clearwater
P. O.Box 4748
Clearwater, FL 33515
d Jebruary 29, 1984
DATE ISSUED:
AUTHOR~ED REPRESENTATNf
/9-03.2-
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FORM 166
ARC/SYSTAMS CORP, - TAMPA, FLORIDA
18y1
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T City Clerk Office
o PO Box 4748
Clearwater, Fla. 33518
'I BURKE-LEHMAN INSURANCE, INC.
FIRE. AUTO. BOATS. COMMERCIAL. LIFE
2348-8 SUNSET POINT ROAD
CLEARWATER, FLORIDA 33515
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SUBJECT: T~~_~~!:!.!:1(),::~:::__~eneI'_al LiaJ>i l~ '!::y Policy GL:50~E)25 2E~!~_}L18 /?.~______~__,_~
__ ~~!~~_~ec!___:pl:~~~~_f_~n~__a__9():Py__o_f.:_Cl_1::()~~_~~p~ioned PO~~~! which we are
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EC~~\IED
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PLEASE REPLY BELOW
NO REPLY NECESSARY
DATE
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SIGNED
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COUNTERSIGNATURE OA.n:' ! REfiEWP.l OR REPl',Ca,U,T ;i[). :
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I I. REPRESENT,mVE:
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...--.---..-- "POLIC'rf\[WXrEP~- G L
~amed .J.nJured
,J oAnn Hamsher
d/b/o Bait House
Apt. it1, Dolphin Point Road
Clearwater, Floridn 33515
DECif\RATIOW;
:2/19 83
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Insurance, I1189-lIECEfVE'1J'
Florida 33515 .
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