CERTIFICATE OF INSURANCE (2)
CERTIFICATE OF IN~UDANCE I -.~ 01/24/95
i-p~nnU~!~-------------------~--~~-----~ ----------i--TRI~-CtRTlrl~ATt-I~-I~~U!n-A~-A-~TtR-Or-TNrORRATlnN-nNIY-ANU-CnNrtR~---T
! HOaRE & MOORE INSURANCE AGCY. ! NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS CERTIFICATE DOES NOT AMEND, )
:, P.O. BOX 1025 \ --:~~:~~-~~-~:~:~-~~:-:~~:~~~:-~~~~~~:~-~!-~~:-~~:~:~:~_~::~~:__n__n_n__ \
I PALMETTO FL 1 I
: 34220-1025 I COMPANIES AFFORDING COVERAGE I
I PHONE813-722-3238, I
,-----------------------------------------------------,---------------------------------------------------------------------------,
! INSURED I COMPANY LETTER A AMERICAN STATES INSURANCE CO. \
, \_--------------------------------------------------------------------------
I ~ilyr~m D~~lir B~~~a & J~~~CS~~b: _:~~~~~~_~::::~_~n__________uu______n_n_n_______nnn_nn_____un:
! 17000 Patterson Road I COMPANY LETTER C :
I ~sa FL 1---------------------------------------------------------------------------
! 33556 ' ! COMPANY LETTER D !
, ,_____________________________________________________----------------______1
! ! COMPANY LETTER E I
:) COVERAGES <:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
: THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY I
: 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. I
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, ,
: CO: TYPE OF INSURANCE ; POLICY NUMBER I POLICY EFF ) POLICY EXP; ALL LIMITS IN THOUSANDS ;
\:~~\_-------------------------______I______----------____________\_____~~~:_____\_____~~~:_____\_________________________________\
! ,i GENERAL LIABI LITY ) !)) _~:~:~~:_~~~~:~~::___) !:?_<?~____!
Ai, [)(} COMMERCIAL GEN LIABILITY \ 01-CC-635794-4 ~1/19/94 ~1/19/95 L~~~~~=:~~~~~~~_~~~:J~_?~~___J
,! (J (] CLAIMS MADE t< J OCC. ! !! I_~:~~~_~_~~~~~_~~~~~~! !:?_<?~nn)
! [] OWNER'S & CONTRACTORS I I I I EACH OCCURRENCE 11000 I
: PROTECTIVE 1 \ \ I________________nn_ \ _______nn \
, I I I 1 FIRE DAMAGE, 1 I
! [] I I, 1 (ANY ONE FIRE) I 50 I
, I \ I I _____________________ I ___________ I
, , I I I "
, , [] , I MEDICAL EXPENSE' I
! ! I I I 1 (ANY ONE PERSON) I 5 I
,---,--------------------------______1______----------____________1______________1______________1_____________________1___________1
! ! AUTOMOBILE LIAB ! I I I CSL I 1
I I , I I 1_____________________1___________1
': : J ANY AUTO 1 \ 1 I BODILY INJURY I \
\ \ 1 ~~~E~~~~~ ~~t~~ \ (\ l_~~~~_~~~~~~~n____n (__n____n_ \
: I HIRED AUTOS' I I I BODILY INJURY I I
: 1 NON-OWNED AUTOS \ \! I (PER ACCIDENT) \ :
:: :: ~ ~ GARAGE LIABILITY \ \ \ (-PROPERTY--n--n---- \ _n__n____ \
,___,________________________________1___________________________~=~-----------,--------------I~~-----------____________________,
) ,:: EXCESS LIABIL~TY ,) " '" . ,."", ",' i)')) r;0',~1n v~ iT: ~ '. ,I EACH OCC,:AGGREGATE )
i -:: r::LH~!1~~!;~;~~~~~~~~~-:~~~-: i ~-~---~ :::~::-: --~-- ---:- :--If-\L~:-~- -~--~---~- --~:-~SdR;- :_~_::J ---------~:---_r ...
I I WORKERS' COMP 1 I JAN 016 i99S I EACH ACC I
I ! AND I I '-I I DISEASE-POLICY LIMIT I
I : EMPLOYERS' LIAB I I I I DISEASE-EACH EMPLOYEE)
1___,________________________________1____________________________1______________1______________1_________________________________
) :: OTHER ) [J:';,>~{ ii1[;/',.J,:,:t.,~E'Qi;n"' )
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I___~________________________________~____________________________~______________~______________~___________----------------______1
, I
i ~~~{T:i~I~~~:AT~~Sl~~~IO~~VE~~~SP~i+~bNAL INSURED AS IT PERTAINS TO: i
I PART OF THE SOUTHEAST 1/4 OF SECTION 19, TOWNSHIP 27 SOUTH, RANGE 17 EAST i
, HILLS80ROUGH COUNTY, FLORIDA. I
, I
\) 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 AIL 10 \
i Attn: Mr. Leo Schrader : DAYS WRITTEN NOTICE TO THE CERTIFICATE ~O MED TO THE L FT, BUT I
I P. O. Box 4748 : FAILURE TO MAIL SUC#-~E SHALL IMPOSE NO OBLI ION OR LI ILITY '~F I
I ~l~~~~~~~' FL. E eEl V E D ~--~~~-~~~~-~~~~-!~~-~2~~,..,T~-~~~~!,~2 _~~_~~~~~~~-~-, :-___", _,--..\,...'",---'
:' : AUTHORIZED REPRESENTATIVE 'rL/IY\-,v'~ I r ,~//!,';,/) i/ :>, .'
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