CERTIFICATE OF INSURANCE (3)
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F--fp:~6'ITM.lk~tT~--Q.E_IJ~~VJ3AHC-J;;--_-~ -------r--fRr~-Ct~rrrrcAft-r~-rssuED AS AlJArl'~-lfr-Tffra~RAnaRO~~i.l~Jr~1-r
) MOORE & MOORE INSURANCE AGCY. ) NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, )
EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BElON. I
I P.O. BOX 1025 I ------------------------- --------------------------------------------------
I PAL"ETTO FL I I
I 34220-1025 I COMPANIES AFFORDING COVERAGE I
1 PHONE941-722-3238
I_________________________~___________________________I_______________________~_____________________________----------------______1
! INSURED I COMPANY LETTER A AMERICAN STATES INSURANCE CO. \
I 1---------------------------------------------------------------------------
: ~il r~~m D~~ 1: r B::~~a & J~~~CS~~ bl_~~~~~~~_~~~~~~_~______________n_________________________n__n____n____:
117000 Patterson Road I COMPANY LETTER C ,:
()dk!ssa, FL 1---------------------------------------------------------------------------
I 33556 " I COMPANY LETTER D 1
1 ,_____________________________________________________----------------------1
! ! COMPANY LETTER E I
)) COVERAGES (::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::)
THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOK HAVE BEEN ISSUED TO THE INSURED NAMED ABOYE FOR THE POLICY
I PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT NITH RESPECT TO I
! KHICH 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 SHONN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
1______-----------------------------------------------______________________________________________________----------------------1
) CO) TYPE OF INSURANCE ; POLICY NUMBER ; POLICY EFF ; POLICY EXP; ALL LIMITS IN THOUSANDS )
I LTRI ' DATE DATE
1__- ________________________________1_____________________-------1--------------1--------------1---------------------------------\
I! ) GENERAL LIABILITY I I: l GENERAL AGGREGATE ! 1000 )
~ A~ [)(] COMMERCIAL GEM LIABILITY \ 01-CC-635794-5 f1/19/95 ~1/19/96 rPRoj)s=coKPiops-AGG~-\1000----\
I I [] [] "'] I I I 1---------------------1-----------,
I I CLAIMS MADE" OCC. I I I I PERS. & ADVG. INJURY,1ooo I
~ ~ [] OWNER' S & CONTRACTORS \ \ \ \ -EACH-OCCURRENCE----- \ 1000---- \
PROTECTIVE --------------------- -----------
1 I 1 ~ I ~ I I FIRE DAMAGE I 1
) ) [J i 0 ~ ~ ~ ~ ~ ~ u i l-(~~:-~~~-~~~~~------i----~----i
I I [] , I' I MEDICAL EXPENSE I I
I (ANY ONE PERSON) 5
1---l-~lr(j;Kjiii-L-E--L-i~Ei-----\--------------lJ{;T-~-{J-1~5------------\--------------\-CSl-----------------\-----------\
I 1 1 I I 1---------------------,-----------1
\ \ ANY AUTO \ \ I \ BODll Y INJURY I \
I I ALL OWNED AUTOS I RISK M ~EMENT I , (PER PERSON) I 1
\ I SCHEDULED AUTOS I ANA \ 1_____________________1___________ \
~ I HIRED AUTOS I I I BODILY INJURY I I
:) NON-OWNED AUTOS I 1 \ 1 (PER ACCIDENT) I I
I GARAGE LIABILITY I ,---------------------1-----------1
) ) , l \ \ 1 PROPERTY \ \
___ ________________________________ ____________________________,______________,__________----,---------------------------______1
\ 1 EXCESS LIABILITY I 1 I \ I EACH OCC I AGGREGATE I
! I [] UMBRELLA FORM 1 I I I I I 1
I \ {] OTHER THAN UMBREllA FORM \ \ I \ I \ I
"___1______--------------------______1______----------------------I--------------,--------------,-------~----------~--------------I
\ I I 1 1 I STATUTORY 1
I I WORKERS' COMP I I I I EACH ACC I
I I AND I I I I DISEASE -POLICY LIMIT 1
) ) EMPLOYERS' LIAB 1 I I I DISEASE-EACH EMPLOYEE'
___ ________________________________ ----------------------------,--------______1______----____1_________________________________1
I \ OTHER \ \ I I I
1 1 I 1 1 1 1
\ \ \ \ I \ I
I___!________________________________!____________________________!______________~______________!___________----------------------1
l DESCRIPTION OF OPERATIONS!LOCATIONS/VEHICLES/SPECIAL ITEMS I,
CERTIFICATE HOLDER IS ALSO ADDITIONAL INSURED AS IT PERTAINS TO:
I PART OF THE SOUTHEAST 1/4 OF SECTION 19, TOWNSHIP 27 SOUTH, RANGE 17 EAST "
I HILLSBOROUGH COUNTY, FLORIDA. 1
\) CERTIFICATE HOLDER (-------------.----.----.-------) CANCELLATION (---.-.----...----..------------...--------.----.------------\
I -------------.-------------..-- .-.-----.-----.-----.--..--...-....---.-------------.-------1
I : SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EX-
I City of Clearwater : PIRATION DATE THEREOF THE ISSUING COMPANY WILL ENDEAYOR TO MAIL 10 I
l Attn: Mr. Leo Schrader : DAYS WRITTEN NOTICE Tb THE CERTIFICATE HOLDER NAMED TO Xf?Ef..T1',BUT I,
I P. O. Box 4748 : FAILURE TO HAIL SUCH NOTICE SHALL IMpElre-QBLIGATIOH ~IABILITY OF ,
! ~~~~:~~~, FL ~__~~!-~~~~-~~~~-~\~~, !,,~-~~~-~~~~ __~a._~~~~~, ~"~'~~",~, ~"~~,,,:, _" _....." .~-"-,..,,','-_------I
I : AUTHORIZED REPREStIHATIYE~: ~ _ f. pi' i/'\/!\ I.' ~.i 1
l€lC()E!)c_;tSc=ll-"-'!,[!l-El~-------------_________-'-----------__--------~-!j('~];~~:~J{C_"~~______l