CERTIFICATE OF INSURANCE (4)
. .'
CERTIFICATE OF INSURAhACE] I 12/26'96
i-PRO~UCER--------------------------~~----------------:--f~r~-CrRfnrrCAfE-rs-rSSaro-As-A-MAffER-Or-rNrORMAfrON-ON[Y-AN~-C~F[RS---:
: MOORE & MOORE INSURANCE AGCY. ! NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, ~
: I EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. \
i P.O. BOX 1025 : ---------------------------------------------------------------------------,
I PALMETTO, FL: 1
34220-1025 'COMPANIES AFFORDING COVERAGE
! PHONE941-722-3238! !
,-----------------------------------------------------,-----------------------------------------------------------------,----------,
! INSURED ! COMPANY LETTER A AMERICAN STATES INSURANCE CO. !
I ,___________________________________________________________________________1
I Silver Dollar Trap Club, Inc. I COMPANY LETTER B :
I (lJi 11 ialR L. & Barba ra Jacobsen 1______________________________________________________________________-----
I 17000 Patterson Road ! COMPANY LETTER C !
I ()chBssa, FL :---------------------------------------------------------------------------:
! 33556 : COMPANY LETTER D I
I 1___________________________________________________________________________
! ! COMPANY LETTER E
:> COVERAGES <::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
: 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 TERMS, EXCLUSIONS, AND CONDITIONS OF SUCH POLICIES, LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. :
,-----------------------~---------------------------------------------------------------------------------------------------------,
, ,
: CO: TYPE OF INSURANCE ) POLICY NUMBER ; POLICY EFF ! POLICY EXP: ALL LIMITS IN THOUSANDS :
:LTR: \ \ DATE \ DATE \ :
,---,-------------------------------- ---------------------------- -------------- -------------- ---------------------------------,
,i I! GENERAL LIABI LITY ) ))) _~~~~~~~_~~~~~~~~~___ i !:?_~~____ ,!
!, A!, [X] COMMERCIAL GEN LIABILITY (01 CC 635794 6 f1/19/96 !,ll/19/97l_~~~~~~~~~~~~~~_~~~:J~_<!~~___J
I I [] [] "'] I I I I I I
I I' CLAIMS MADE" OCC, " I I I_~~~:~_~_~~~~~_~~~~~~ I !:?_~~__u"
! ! [] OWNER'S & CONTRACTORS I I I I EACH OCCURRENCE 11000 I
:: PROTECTIVE \ \ \ \ --------------------- \ ________n_
, J I I I I FIRE DAMAGE I I
I ! (] I I I I (ANY ONE FIRE) 1 50 !
, \ \ \ 1 _____________________ \ ___________'
, , , I I ' "
J I []' , MEDICAL EXPENSE' I
! ! ,! !! ((ANYONEPERSON) l 5 !
'___1________________________________1____________________________1______________1______________ _____________________ ___________1
I ! AUTOMOBILE LIAB ! I I I CSL ! !
, , / 1 1_____________________, ___________,
\ ANY AUTO \ \ \ \ BODn Y INJURY \ I:
ALL OWNED AUTOS ' ,I (PER PERSON) I :
SCHEDULED AUTOS \ \ 1---------------------1-----------,
HIRED AUTOS' I 1 BODILY INJURY I
NON-OWNED AUTOS \ \ \ (PER ACCIDENT) \
, GARAGE LIABILITY I I In__________________J -----------
: \ \ \ \ PROPERTY \ ,
'--- --------------------------------,----------------------------,--------------,--------______'______---------------------------,
-- ': t EXCESSLIABILITy--_Lt - --.-J-----___._L_u___L-f~~I- ACCRECiIT-f--l-
: I (1 UMBRELLA FORM I I I 1 IT. I
: \ I 1 OTHER THAN UMBRELLA FORM \ \ \ ) \ 1 )
,---,--------------------------______'______----------------______1______--______1______-------- _________________________________
" \ \ \ \ \ STATUTORY \
I I WORKERS' CDttP I I I I EACH ACe I
, I AND I I II DISEASE -POLICY LIMIT I
! I EMPLOYERS' LIAB I I I I DISEASE-EACH EMPLOYEE!
,___1______--------------------______'______----------____________'______________1______________1_________________________________1
1 , I \ \ 1 '
, I OTHER ' I
" I I I I I
" " \ \ \ \
, , I "I
,---------------------------------------------------------------------------------------------------------------------------------
,
i DESCRIPTION OF OPERATIONS!LOCATIONS!VEHICLES!SPECIAL ITEMS
Ceertirficate holder is also additional insured as it pertains to:
I Part of the Southeast 1/4 o~ Section 19, Township 27 South, Range 17 East
, Hillsborough County, Florida.
,
,
:> CERTIFICATE HOLDER <:::::::::::::::::::::::::::::::> CANCELLATION <::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
, : SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX-
! City of Clearwater PIRATION DATE THEREOF, THE ISSUING COMPANY WILL ENDEAVOR TO MAIL 10
i Attn: Mr. Earl Barrett : DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT
I P. O. Box 4748 : FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF
I Clearwater, FL : ANY KIND UPON THE COMPANY, ITS AGENTS OR REPRESENTATIVES, I
, 34618-4748 :----------------------~~--------------------------------------------- I
i~_~~~__~~__:~__~~~~_~~________________________~_~~~~~~~~~~_~~~~~:~~~~~~~~-~~~----_-----i