COMMERCIAL INSURANCE POLICY AND CERTIFICATE OF LIABILITY INSURANCE
i
J
). -.
- ~ .,,'
~',->~,f\ ;'
,\ ""-' :.-~'
:"'. '~;j.;~.,"'ER~CAN '.S.I. AtE. S.lIilstJRA. N. a::, ..' '. '.;...~.oa...:... ...MY:
,.1I1DIMAPOLIS.,INOIAtU~."..,
'," ..........,..",CO"",ERCIALt INSURANCEIPQU,Cl,;'
~....:,...,:"..."......" ,..
"-;.,......'......~....... ........... ......... ~,A! ..~POt.ICY'); HUBBEll:
",..,.:......; CO""GN';POLICY: DEQ.ARATIONS ,'. .~,RENEWAL%OF: '.
. ....................*.........*~*,..*..**:'A!:~~;. ,',
,- . .... '-," '.....'., ..,~' ..,...... .. ,,' , ," o,~" ,~''',' \..,.,~.,~l-,-;::'~
,; N AMEO-;:.: ~o- ~ANN lHOHSHER:COBA1 IHE~ 8A I'~
; INSURED' .:HOUSEr .' ". .:;
! K.AILI NG"".l, SL-IP t4S3,:....5 ~. CAUSE":AY ~8LVo...~{~:: '
: ADDRESS:~' .;: CLEARWATER ~BEAah;F.L; 3:5515.,:,
JPAGE'l
)AGl.
, fJl';"C~8"8032~1
JNE'" ..
n
';'i A6ENJ::MUROOGERsr,:, WMINGS; INS.; tNe
, /r.;PO, DRAUERI 5148'
;"~( ~::~~~fl r1499,6ULFtlO' BAY: BLVD
....:leLEARU. lER.ir:-L, 33518... '.
:.: 09~50366' ..,~: 1317. "
'>> '8111 j.61~6111 .
W'i'U) <'i;;<, ;1 ...~.l..52L.;:......:,...;.., !....."....~,t!,..,tt~,: 0'. :-:;". .~ , ?,l~~t~~k'l"(~~ 't
~.. ~ '. '. ,10.;.,.,., ..Ilt- tNi' ",,:'~-:' ":,,;:;.<~,~::'-l; ::' ~~~1'~;'_~
POLICY:; . '..IFROtt::..G9.06-86~TO. 09-06-871-1r,,; '",. :." '.",., ','
; PERIOD:t;;~ ~!::!12:01lAJ~L$:r ANDARD {TI"E.~.;AT.:;YOtJR' "AILlDllnAODR~SS'l"St.tOU,~1:~~QVEr, ~
.",.~,:._;~.::.:;_".':.'.":~..,:.,P'.A~-;f:~~. .;,~..,~.,t~'~~ ,i'('. - ;..... .' ';', ";,, - ',' ','",,-' ,', '" '-,..,: ',1i"~-,'''- "",ftt}L-~, ,',;'..~: :. _.
.....*~ ....... .................... ... ..~...llt*..........,.............*.. ........... ......
· '~.~ ~t.\. .~; <~.j.J.,;.',. .'f'."~~.;~" ",' ,~,;,.. ;.,;..'/i'.!''';;-.... "~,t' 'l!'~lt:..i'!iJil." ti\t'~ ~L .~ y...." ..
.t-~;;;,;,:'i({1i1h~~.~tlIfIS~.POLICY~IS.SUB..ECTll'O}FINAL';;'AUDI1~':.,:'l;m'~'~f,,~:. .... ~ .f.
a;. .".,~.........."""!!'.~TOTAt;!ES:JI"A1ED;ANIf[JAL1PREJtI.u"2.~",.......-........".;"~\, ~""~U<''''-'''; ""'"'~'''_~''H''' . ..
· :, . l !h;. n f$:OUE ! ON' EFf7:EtJl VE .DA TE :~; i ".tit. ..~:$.~j\~t:r~j.29.... 0 i' ..1:~ l~:. ';, .
..,."..-.. . ..... .......- . . ". '. .. . , '. .' .' ". .... .. .
..................................,..............................**...........*~.....*. .....
;.: r- ~.f ~~ ~ .,.' '!." r.. .;', "....,;'~',~~:.. '': ",' '",r,. .
}IN~ RElURNii FOR ;lHE','P"Y"ENT~OF.JJHE ~ PREItIUft.~rANOtsU8dECT:,IOfAU.:~'THE;#'ER"S'OF; tHIS
; POLICY. ~WE; A6REE .;IlITHI'OU!TO,~ PROVIDE,: 'HE JINSURANCE tAS; STATED.t 1.1.,"1$.; POLICY. ".
,CO""EItCIALl PROPERTY)COVERA6E"iPART~ lU:'tJ;~'..~..~.;a.Ii.'......~.~~.......: $
\
\
\
\
"".""~'.";'J'~".""''''' '.<t
'.., :tJ:(..:;~;~j ~t.::;~L:2k; ':'l~'~':
~ .:'7:::.'\.:t.."i":,:::-'~.~~.;~:.",:r'1 .
".,,,,c~ > ~':;",t'l\.. 'l\,~.J'
::;~~;' ~.~. ~~~Jf~~;;'~5)"
~
\
l' \
,~~~ \............
/'"..
~: ~
H'
.., ,':J \
\
\
\
\ "\Pi~~!fEDt' I DL iJ 1 , 1(~
\ '\ e \ "",.' "",:~"IJ"i .-r
Ie '~(Q~')~'h . URUNDO;
~~..,
"
: ~:; ~
:~~~::~~".
c.,"~".
: 98.00
331.08,
. " ...:~ ~~ .', 'J
R E C.., 'r.:'.", "" C'"
, . ".'~..J! ,1. -"t' f-~ .'i.)
"
~.;.~ ~:'
'-f'
NOV 10 1986
,-t!--
Cll~X CLEHK
~8Y.
i' 18 ..~
, ,~ ';, .
. ;,,' .',. .. . .
ISSUE JATE (MMIDDfYV)
8/5/88
Rodgers & Cummings Insurance, Inc.
Post Office Box 10000
Clearwater, F1 34617-8000
THIS CERTIFICATE IS ISSUED AS"A MATTER OF INFORM A TION ONLY AND CONFERS
NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND.
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
COMPANIES AFFORDING COVERAGE
it:.
.
GE,Sp _, f ~,;...;,., ,-' I . ~ ~.'.. . :' '<. - . '': ~ '.' ,".:~:,.,<'''";~~-..1':: ....::l.-e;, :1'..,........,,:- -)~_.. .-..~".:>-~,. ...~:.L':.... ...._; ","'t
COMPANY A American States
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY D
LETTER
COMPANY E
LETTER
t
f
i:.
f~'
I
~>
l
l
,,~
~,
INSURED
Brad Young & Charles Pollick
C/O Bait House
P.O. Box 899
Clearwater, F1 34617
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.
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 CONDI-
TIONS OF SUCH POLICIES.
TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE POLICY EXPIRA nON LIABILITY LIMITS IN THOUSANDS
DATE (MMJODIYY) DATE (MMJODIYY) EACH AGGREGATE
OCCURRENCE
BODILY
INJURY $ $
9/6/88 9/6/89 PROPERTY
DAMAGE $ $
BI & PD
COMBINED
PERSONAL INJURY $
BOOIL Y
INJURY $
(!'fR PERSON)
BOOIL Y
INJURY $
IP!:R ACCIDENT)
PROPERTY
DAMAGE $
BI & PD
COMBINED $
BI & PD $
COMBINED
GENERAL LIABILITY
COMPREHENSIVE FORM
X PREMISES/OPERATIONS
UNDERGROUND
EXPLOSION & COLLAPSE HAZARD
PRODUCTS/COMPLETED OPERATIONS
CONTRACTUAL
INDEPENDENT CONTRACTORS
BROAD FORM PROPERTY DAMAGE
PERSONAL INJURY
01-CC-048032-3
AUTOMOBILE LIABILITY
ANY AUTO
ALL OWNED AUTOS (PRIV, PASS,)
ALL OWNED AUTOS (OTHER THAN)
PRIV, PASS.
HIRED AUTOS
NON-QWNED AUTOS
GARAGE LIABILITY
EXCESS LIABILITY
UMBRELLA FORM
OTHER THAN UMBRELLA FORM
WORKERS' COMPENSATION
AND
EMPLOYERS' LIABILITY
(EACH ACCIDENT)
(DISEASE.POLlCY LIMIT)
(DISEASE.EACH EMPLOYEE)
OTHER
DESCRIPTION OF OPERA TlONSlLOCA TIONSNEHICLESlSPECIAL ITEMS
:l .
/"
~'n.:~:l CHANGE ENDORSEM';,~ H .
THIS ENDORSEMENT FORMS A PART OF THE POLICY NIWBERErJ RELOW
--_._,._--~---------_. ._-~ .-----,--------.----------_.._-
ENDORSEMENT EFFECTIVE DATE POLICY NUMBER
3/11/84 MP 373 20 71
COMPANY Excelsior Insurance
INSURED'S NAME AND MAILING ADDRESS
Jo Ann Homsher
d/b/a The Bait House
205 Dolphin Point Road, ~pt. 1
Clearwater, Florida 33515
\/
(
~I
MP 12 01
(Ed, 02 79)
"I' _._"..._.._.,_....._._____~...-_..-.._.n_._..-
TERM
3 YRS
FROM
9/6/83
TO
9/6/86
Com an
AUTHORIZED REPRESENTATIVE'S NAME AND MAILING ADDRESS
Burke-Lehman Ins., Inc.
9-162
Clearwater, Florida 33515
RODUCER CODE
POLICY CHANGES
It is -hereby understood and agreed that Premises address
amended to Clearwater Municipal Marine Slip #153, ~ Causeway
B1vd~ Clearwater, F1 33515 e.5' wad--
SPECIFY FORM NOS. AND EDITION DATES AFFECTED BY POLICY CHANGES:
(
LIMITS OF LIABILITY RATES PREMIUMS
Coverage loco Bldg. Previous New Previous New Previous New DAdd'1
Description No. No. D Return
$ $ $ $ $
$ $ $ $ $
$ $ .. $ . $ $
$ $ $ $ $
SECTION I-PROPERTY COVERAGE
COVERAGE LIMITS OF LIABILITY PREMIUMS
Previous New Previous New D Add'l 0 Return
SMP Liability Insurance Form: $ $
Bodily Injury and Property ea, Occurrence ea, Occurrence
Damage liability $ $ $ $ $
(Combined Single Limit) Al!gregate Aggregate
Premises Medical Payments $ $
; ; SMP Liability Insurance
Form ea, Person eJ. Person
"I Medical Payments $ $ $ $ $
- Coverage Part ea. Accioent ea. ACCIdent
------ ------------
U Forms other than BODILY INJURY LIABILITY
SMP liability Insurance . 'I>
Form $ $
Specify Coverage Part ea, OCCllrrence ea. Occurrence $ $ $
$ $
A~_gregate Aggregate
PROPERTY DAMAGE LIABILITY
$ $
ea. Occurrence ea, Occurrence $ $ $
$ $
D Revised Dual Limits: Aggregate Aggregate
SECTION II-LIABILITY COVERAGE
Da~es of subsequent installments, 2.
if payable in annual installments: 3.
PREMIUM DUE AT EFFECTIVE DATE OF ENDORSEMENT:
Total for. remainder of policy term:
INST~LLMENT PAYMENT PREMIUMS
Previous Additional
Installments Premium
$ $
$ $
$
$
Agency, ByL
Return
Premium
Revised
Ir.stallments
,
$
$
MP 12 01 (Ed, 0279)
BK/gm 4/9/84 .
"'
/1- ~ 3;}..-U~L
~rll;'-I"'''' I.'V'" '-1 ...,.- . --.-.
__~~,; ~ l
.~
f
~ISiorREq1E\\!EO
OCT 4 1883
INSURANCE COMPANY OF NEW YORK
SYRACUSE NEW YORK 13221
IKl NEW
o RENEWAL OF
CAB/rg 9/23/83
Policy No. MP 3 7 3 2 0 71 DECLARATIONS
(NQ, Street, Town, county,)
Item 1. Named Insured and Mailing Address State and Zip Code
Jo Ann Hamsher
d/b/a The Bait House
205 Dolphin Point Road, Apt. 1
Clearwater, Florida 33515
Item 2. Policy Period: 12:01 A,M" Standard Time at location of Designated Premi ses
From: 9/6/83 To: 9/6/86
CITY CLERK
Representative
Burke-Lehman Ins., Inc.
'9..;.162
Clearwater, Florida 33515
Audit Period: Annual, unless otherwise stated below:
In Consideration of the premium Insurance is provided the named insured with respect to the designated premises shown in Item 4 below and with respect to those
coverages and kinds of property for which a specific limit of liability is shown, subject to all of the terms of this policy including forms and endorsements made a
part hereof: "
, r;l.INOI. DPARTNER. OCORPORA. OJOINT 0
Item 3. The Named Insured IS UlVIOUAL SHIP TION VENTURE OTHER
Item 4. Designated Premises (ENTER "SAME" IF SAME LOCATION AS ITEM 1 ABOVE)
1. 250 Dolphin Point Rd. #1, Clearwater, Fl.
2.
3.
Occupancy of Premises
Clearwater City Marina - Joisted Masonry
Retail Store (Pine11as Co.)
o Multiple buildings or premises as designated on Supplemental Declarations attached,
Item 5. Insurance is provided with respect to the designated premises and with respect to those coverages and kinds of property for which a specific limit of
liability is shown subject to all the terms of this policy including forms and endorsements made a part hereof
,
COIN- LIMIT OF LIABILITY
URANCE
COVERAGE % Loc. Bldg, Loc, Bldg, Loc. Bldg, Loc. Bldg,
APPLI. NO'1 1 No, No, No. No, No. No, No,
CABLE
SECTION Building(s) $ $ $ $
I Personal Property of the Insured BO% $ 10.000. $ $ $
PROPERTY Personal Property of Others $ $ $ $
COVERAGE Add!. Cov, (Specify)
Reo1acement Cost Form 0420
Deductible: $ Form Attached each occurrence, $ aggregate each occurrence,
If no deductible stated above, the deductible shall be $100 each occurrence, $1,000 aggregate each occurrence,
Bodily I njury and Property Damage
Liability Form MP.200 Combined Single limit $' '.l.nn nnn each occurrence $ 'lnn nnn aggregate
SECTION Premises Medical Payments $ each person $ each accident
II Bodily Injury Liability
LIABILITY Property Damage Liability I o REFER TO COVERAGE PART
COVERAGE Premises Medical Payments
Add!. Cov. (Specify)
Arl,H " ~ . _ l<'nrm r." .?nll
SECT. III CRIME COVERAGE 0 As stated in the endorsement, made part of this Policy, if indicated by l8I,
SECT. IV BOILER AND MACHINERY COVERAGE 0
Item 6. Forms and Endorsements made part of this policy at time of issue
(Insert No, and Ed. Date):
a. Section I. Forms and Endorsements only:
MP0127(12/79) MP0090(7/77) MP9950(7/77)
MP0336 (2/82) 31P0012 (1/83) ,HP0420(1/83),'
50277(6/61) GU236
c. Section In. Forms and Endorsements only:
b. Section II. Forms and Endorsements only:
MP0090(7/77),MP9950(7/77),MP0093(7/77),
L101(1/73),L6432f(1/76),GL9906(7/66),GL2011(7/E
d, Section IV . Forms and Endorsements only:
Item 7. Mortgagee: (Name and Address)
None
TOTAL
ADVANCE PREMIUM
Payable at Inception
Pa able at Each Anniversar
Item 8. Unless indicated by an X in the box below as "NOT APPLICABLE". the pre mium for installments subsequent to the initial installment shall be subject to
adjustment on the basis of the rates in effect at each anniversary date. 01 NOT APPLICABLE.
~~~~
Authorized Representative
:,', ,1' i0~'.'Q.';') /.l:',j, ;",'"
"" <,. "'", ..., \.'- ''-, --". '-'"
F rm No. M 7150 8/77
I 'i -032-
/ ,I
-'---",-T',---'-' -.-.
SET TAB STOPS AT ARROWS
"
"
EE
:' Certificate of Insurance~
THIS CERTIFICATE IS ISSJL:.D "s A MATTER OF INFORMATION ONLY AND CONFERl jN~ RIGHTS UPON THE CERTIFICATE HOLDER,
THIS CERTIFICATE DOES NUT AMEND, EXTEND OR ALTER THE COVERAGE AFFORl1tO "Y THE POLICIES LISTED BELOW,
. . '...
BU'rke-Lehman Insurance Einc.
2348-B Sunset Point Road
Clearwater, FL 33575
NAME AND ADDRESS DF INSURED
Jo Ann Homsher d/b/a
Th'e Bait House
205 Dolphin Point Road, Apt. 1
Clearwater, FL 33515
COMPANIES AFFORDING COVERAGES
COMPANY A
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY 0
LETTER
COMPANY E
LETTER
Excelsio~:.,Insurance
RECEIVE ;:'
-
STArU10RY
I
I
-
~
1
I
--
II
II
..
LERK
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,
I
.1
TYPE OF INSURANCE
POLICY NUMBER
A
GENERAL LIABILITY
~ COMPREHENSIVE FORM MP 3 73 20 71
~ PREMISES-OPERATIONS
o EXPLOSION AND COLLAPSE
HAZARO
o UNDERGROUND HAZARD
~ PRODUCTS/COMPLETED
OPERATIONS HAZARD
o CONTRACTUAL INSURANCE
o BROAD FORM PROPERTY
DAMAGE
o INDEPENDENT CONTRACTORS
o PERSONAL INJURY
AUTOMOBILE LIABILITY
o COMPREHENSIVE FORM
DOWNED
o HIRED
o NON.OWNED
EXCESS LIABILITY
o UMBRELLA FORM
o OTHER THAN UMBRELLA
FORM
WORKERS' COMPENSATION
I
and
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES
Limits of Liability in Thousands (
OCC~~~~NCE AGGREGATE
POLICY
EXPIRATION DATE
eff
thru
9-6-83
9-6-84
BODILY INJURY
$
PROPERTY DAMAGE
$
$
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
$ 300
$ 300
PERSONAL INJURY
BODILY INJURY $
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT)
PROPERTY DAMAGE $
BODIL Y INJURY AND
PROPERTY DAMAGE $
COMBINED
BODILY INJURY AND
PROPERTY DAMAGE $
COMBINED
E.ACH ACCIDtr-;--,
Cancellation: Should any of the above desc1~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,
d Jebruary 29, 1984
DATE ISSUED:
NAME AND ADDRESS OF CERTIFICATE HOLDER Ad di t i onal Insu
City of Clearwater
P. O. Box 4748
Clearwater, FL 33515
. ...
AUTHORIZED REPRESENTAT IY[
~i J 0 I
..J/af'YU]{;' \,Jn6u!I'I%'
rDf.c.E~~.s!ol !NSURANC1E COMPANY, s'~itl;;us~J
Gr:~.]r:r../\!~ UAB!UTY D/dL';' [n:ror:~T!
. " l-- .!~:';C,i'\':' G ~
" :"
"x (';l~;n~ 1 ;>-',~~::-:s'~. .r:;~~~'
~";lbl{1 !:'~-~~'t. j-:~'L:2.e
r\T)~'~ ill ~ :,")-0~,,'~'~"~.~,:~_,::l T,'(rr.:;~ ~:~:"tLI
.:: ,j ~) ~. :"~
~ C\ ~~.." f}
t~Gm:
I\[";r.l or DrO!\9f
nffiC8 t<ddresc
Town end !jIlIn
c,:.t(:-i1'~.";:~;~.: ~~ C'~~~" r:"0~:fi (',:'} <;' ~l~;~, r~
)' "''I ,'""" r:~I. /
t c;:,<l "" e;J,.. (i qr,
C;,) / ,
./ oe!, ,,' f~-;(l, f/
., ~-( / ::~~-!::~~c "11"~,,,,,~.(~t.~~'l<,!\-<<>
RSC€.\\J~O
\983
H,B
9
crt'< CLSRK
d, ~-:'i'~:.n :., ,I"
>"1
c
r, ;(~
" ;~':-F"'>~
i~ ''''~_''~'r:A^...~'
!.'~,;~:T:) rl~- ; 'r,'-'r: :T'..
, ~.,
.: "~'~r:1;
..".. r;-.... "-~.
""r"'" r ,
:+y ~ ',"::lJ!''2;-'~r)
F'lU~!-: nf.~f\!f{~;?Jr:~
,
"
r,;"'"\
~. n ,(I;', "
Fr:~ij r ~ !
fr:')I,,:r.lrr:iJ
I -' (~ 1: ~:- -;
[/u
, '-',,'; ~; ~,~ ,.' '-:;!_~
!,IJr::s:,!,-, rJ:2dic;-11
p~'vs!r:a: DJ:.:.~G8 fn
X)O~XXX
i
is
)',._\,l.
"t~', h r.~f~~r',; r-'".'~._':~"$:)'~ re'~':'n~ Ir1~,~2'ln e:'l~"': ri':;8:~1
r
,
.,
\/:~)!l.1C ,-,:t r\'rccr 'Il'T ~':,'r: ~-"~~:1 'In',....),':'!:
:~>~J r.~-!,'''-,;, i :''''.-'~~(i.~; rla(":; !~
0':'": ,.--,,--, - -,'
(. ~ r~ n... f'~ l"~' r;;_
,,:~.)
T:" r:-r'1~.1 rr:~CI~;-I';~>
1', '~'l(".. nn
"" ,~ ,~~ . ':" I ~
"7'1 ::, t" (~' ") ~ ",
",
T {' I ,~I'
: ~ 1 " '~i: ':' "
'')'": T"(; y'~:;
~~ ;j' I ,::' ! : i r: , (' -1 I r
).-:! ")f1"'li'H" 3':1[ ~l_ ~ ,. ~~
/.. ct"f-'l' .4~/'
,.1:',_ J~~,""
t'''''.' ;,' '.. '."-'"
",,; 'f . ,i"filff'
,...' :~,' r' r'!
"1 "
/'.''"'1:-', T'" ,))
.,., ~..., ,..,,, i"_ ,- ":"t j
'I~< t;::r::-:J:-i l~?' ~crJ [, it~<;\ f'r '.J!
'!n :
~:'J ~~'~', J:f~;.~::~':j
;'~:1t ':~n>' fl;
~ j. -.1 r.j
:.:, I'
:~ ~"'~~ ~'~-1 r'~.r;(~ "", r~ i: ;',;crr ~lY~
f ~ :.' .-:" [' ~ . ': ~
'"~'. ~ ;,-, ~
E',1.
ri ~.') ~1'0 r:~r:;:~:.1 i:v':~7"crt (
:'...,~C"~ (1':" ;i'\'! ~"l
~~,~~,:'1 b!~"r!~."d'
:~..___.L;:'~:~~., i~::-~~~', ~~~ l_f ~rT:=::~rp,;~F""rr~,~':!i
, )'
, i'
fe
1 ;':'/1 r,< '::' :<",
COllntcr~ir:nc~ by.
'r '
" r.' . "
{9-D3 J.r
Ins1ULJr,,:=,O=Gram
// I
SENDER, REMOVE YELLOW COPY
FORWARD WHITE AND PINK COPIES
REPLIER, RETURN WHITE COPY
RETAIN PINK FOR FILE
I
FORM 166
ARC/SYSTAMS CORP, . TAMPA, FLORIDA
1Sy1
./-
I
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
L
~
~
SUBJ~~!~~~~~_I3~it.~<:>u~._Gene:,i3._J.:_ Lia"bi l~"J:;y Policy GL5.0~~55 5E~!.~ ".}L1t?L~2_..~._.__._._.
~1::1::l:i~tt~~.._Fl:~~?~_!J-n~_-C3._~o:py o_~._C3..E.<:>v.~_?_~:p~~<:>ned policy which we are
_._.r~...9.~j.:r:'e<:l_"J:;Q-~~l!.<:l~,t..Q.YQu e~~ear f oT'. your reg.<:>rds ...__._~l:?:aD:k..x_<?~~_......._____,_~__.~~
IlEC:~ID-..--.,~.._. -...
i
, ........-...---".,--.-----.---;:JAtt2:4~.--'-:....--------
r-
IBl 0,'"
PLEASE REPLY BELOW
NO REPLY NECESSARY.[]
DATE
.
SIGNED
f2QjcL~ ft
cc; -(/J(](~3
,.
[CO, U,N, TF.RSI,GNATU, ,RE, ", D,-, A,TE,'-,"-, ",',i ,R"E.,:..,NE.."",.:w,~Cii, ",R" ,R051]:;L.",../;;".i,ll.i,i.6.:"
t " ; I
-I.Rr li____~UlQL8J_L..JZ1...2Qj:i_".Q~'.,f)Oi
!e'
;.
",
fC
.
~\J[ei\L i.I/\ljll_ITY
Port Two" This Cccl:yotions pogo and Coveroge F'mds) with "!)olicy Pi'('Vis;ons-~ort On:?" (:oril~)lete3 the below
-..........".- ...,---,,---."...., --"-'... ...-.-..--.-,,-., _"_'___~__~"_"_'''''''__''__'_'_'''''''.m.... G
U!en14_u_,_,.___..__,.__DECL8RATIDNS ' _. PO~:I_CX_,~UMCER.JL
],1
I I AnDRESS fiameJ !JnJureJ .
i -.-L__._(~u,m.ber ~_Stre!.~J!!w.!!...Qo~nty,..S!at~,&Jip NoL.."
C2, 1 Pf:,j~CY Period: ~i~:QlH~' ~Mi~A.~~$tl~pri!r;~ f~~'r~',':il r;7rr0[':: FrlJr'j: .
- --_~_".__,,__,_.,__~________._~___,.__..__,_._.____"' ____._________, ____ ._", ,~...__,___ ____n__" ...__.
1:1' ("'or.t or 'llrnkor
I ,'.I1EPRESENTATIVE: .. "~~fice' Ad~;e~)
r . L... -.-..... r "'" "d 5' "0
I
I
I
I
I
I
I
!
I
JoAnn Homsher
d/b/a Bait House
Apt. 111, Dolphin Point Road
Clearwater, Florida 33515
To:
Burke-Lehm2n Insurance ,1ngg-il!cEIVrlJ
Clcnrwater, Florida 33515.
JAN24 '83
~
~
~eISi~c
aa~
INSURANCE COMPANY
YRACIJSr NEW YORK 13221
l_c
3, The insurance affcrdcct ir; only with rrsprcl 11) :;l~rh (If PI:l f('i~ri\'_'inp P;lJts di~:\jrn,lt{'['! hy ~n [''X'' (lnd Coverage') th~r(':) :;:; ?fC ;n~>J~,ed b~}
sr/,~ci'f.i"r'; 'prern!uiTl charec nr ch;JrEI~S. Th0 limii- n! 1tJr': r;c.:n1p;~m/:, l.i;l,hj1~tv ;-:i';,liIF:t C" --h ~;ur,~l r'-wr,:i":'2'I} ~:!J.'-:i!1 hn n:.~' ;\(:1"",-:,1 l':',~r~,~i:~1. t~"'~"\((":ct,, ~:'! idl ~,\~~~
term" of this policy h~ving refer~ncelhereto,
C;J;rl[Jrehen'$i've'(;cneritll.ialJility In-;urimce " "",.
" Landlords' ani! Ten~nts' l:iliJili~y In::urnnec
Ma:H!)f;.~cturers' and Contr;l~tors' Unb:!i~y In~,~lr;H~r.e ..".
i:n
: lJ !
I
i
UMI rs OF U/\PIIITY
.._--~
Af1VI\NCE !
rrF'1'I.J\1 .
.. j
Contractual Uabj~i~'y 11-; urance ....... ..........."... I
Comr:!e'cd Opm']ow: 2cd ProrJuets Liability [nsurimee ,. i=_='~._~\Cfl~gr,GI!r,Y.[-.~~C,=.~~'r:~~='=~~_~SC'~'7J'Q~_TE___~
: [Jodi!y Injury Liability I $ 300, noo. 1$ :$
;---" ____nnmm.____._...___~r.op~rtLQ;Jil1 ilr e...Liabl~~v..ji -~--.---;^21~?;~~;~~-,-,,--+$--Eft,Gfi"l~c-r;nfNT--..--i $__
;~r.::.:12;:o,; ~~3!cal ~~~::;('n's Insl~~~-.:_:.:..:..::..:~..'~~:...:.:.:.JJ ~T==.:==.==_~._.'.,_...==..:=.Ji:::' - .-" , ..,.- ._~
I 10 '; II:J 1100 , .,." . . . , , , . . . . I [lief! 'f/I,CII !C!iGH
il,Farmer's Comprehensive Personal InsuriJOce """"'" 0 11'__'__ PERSON I OCCURRENCE ACCIDENT
I Personal LiJhility XXXXXX , $ XXX XXX
PersonJI Modiciil Paymorrts' $ XXXXXX $
I r:lysical Dam:JEo to Pro,perlY I XXXXXX 1,$
i.'lp~:.Ilo!-"-~"!."-'..r~'_c...~,,",,.>;,, pc,san,II",",,"o., ..11) Animal COlllsion-L,_,__.. Mlrk,ot vabe nol,cx.r-~",".dj~g. $400 each aninnl
j Endors(;r;l!::~ts and Additionfl! Coverage Parts :It
I i (IDENTIFY BY fORM NUMBERS) 60004 (3 / 7 5) : c, i
I' j---'--'-~"-"-"""."-"------c--'----"'--'""-'-""-"""~._..,-_.---._------,..-.".,--......,,--_._--..--.._..~..~-'_._._....._..__~._.L.O.,,_,..._c..._"___,._._ ..-....-i
I : ~a POne\! Period more than one year and the premium is to be paid lJ!!!9~~,ance prer.1ium.lL__1Q.Q.J)JLmpj
i til'1.I.r'~ta!lm~!s.,.~~.!:fliUm,i~p~y.~:J!e.=..Ql!.effect~~~date_oJpolicy_$_. . Is!...~~f!l~r~_~U .._" _ 2nd Anniversarv L u :
I I ^~r!it !'~~:;')1. ,'\~n~;0r, ;;r::;S~ 11~:r/~f '{;'lu ')(;l(('d, .. ,
j4~-: - ...- ,------".. Thl~ named ins'jre'li$~ individual f- ,- x- ~l P~~l n~;~,h;r I"-:=-J;~~~=~__ c~~po.r;t!o'~= ~---:.~.~~.~~~- ~1
h:tu,,',i tho ,;;i.ihrnP .,;;,,;-;;,;0;;;;;,-,;;; . ;;~;,i:;'r~:;"~~,-;-,;,,,i,'- "h.";;';" ,::::~. "m,l" " ,";, ,",,',",,'" ",,; ;-. ..-. . - n.!
~~~SENCE or AN WTRY ~~~~;1;'~rJ~{Q~~.:~~_.__ . ," ".._L~=~,!p:[c~~ii)!~}exad
56.00 mIl ;
, i
20.00mp_.l
,
"
~
XXXXXX
>
::
("
'r<'....,
q
111-,-~..,. ',"