CERTIFICATE OF INSURANCE
CERTIFICATE OF INSURANCE '~ . 02/21/94
:' PRO 0 UC ER- -----------------------------------;--------i--TRB-ctRTIHC~Tr_B-BSUtO-~S-~-H~I~rR-Or-TNrORH~TTOR-OR[Y-Alm-CORHRS---T
: MOORE & MOORE INSURANCE ASCY. I NO RIGHTS UPON THE CERTIfICATE HoLl,PR, THIS CERTIfICATE DOES NOT AMEND, )
\ P. 0 _ BOX 1 025 I-:.~~~~~~-~~-~~~~~-~~~-~~~~~~~~-~~~~~~~~-~:-~~~-~~~:~:~~_~~~~~:_______nn__ \
I PALMETTO FL I I
I 34220-1025 COMPANIES AFFORDING COVERAGE I
! PHoNE813-722-3238! )
,_____________________________________________________1______---------------------------------------------------------------------
! INSURED 1 COMPANY LETTER A AMERICAN STATES INSURANCE CO. \
, 1______---------------------------------------------------------------------
I Silver Dollar Ranch & Trap Clbl COMPANY LETTER B 1
: ~~~~t~a ~te ~,,~~ r~~~ Jacobsen ! :~~~~~~;:~~~~~~:~:::::::::::::::::::::::::::::REc:EIVEll: i
! 33556 I COMPANY LETTER 0 I
! !-COMPANY-LETTER-~---------------------------------~~tt-~ii-l~zJ------(
:) COVERAGES (::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::)
: THIS IS TO CERTIFY THAT POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ~~,EOBlJijf.POlltY
: PERIOD INDICATED, NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION Of ANY CONTRACT OR OTHER DO~E~r ~~tattPtao~lr. \
: 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
,---------------------------------------------------------------------------------------------------------------------------------,
: CO: TYPE Of INSURANCE ; POLICY NUMBER I POLICY Eff I POLICY EXP I ALL LIMITS IN THOUSANDS ;
:,~~~\~-------------------------______I______---------_____________I_____~~~~_____I_____~~~~_____I__________-----------------------\
I ! GENERAL LIABILITY I : I I GENERAL AGGREGATE i 1000 ,)
I --------------------- -----------
A! [X] COMMERCIAL GEN LIABILITY 101-CC-635794-3 f1/19/93 \11/19/94 I PRODS-COMP/OPS AGG. \1000 \
, --------------------- -----------
I (] (] IV] , I I I I 1 I
CLAIMS MADE f' OCC. I I I I_~~~~:_~_~~~~:_~~~~~'! I !:.?_~~_nJ
[ ] OWNER'S & CONTRACTORS I I I EACH OCCURRENCE 11000 1
PROTECTIVE \ 1 1_____________n_____J __~_n____J
I I I FIRE DAMAGE I I
[ ] I I (ANY ONE fIRE) I 50 1
\ 1 1_____________________1___________1
" t' [ ] I I I I MEDICAL EXPENSE I I
1 ! I, I I I (ANY ONE PERSON) I 5 \
---,--------------------------______1______-----------___________1______________1______________1____________---------1-----------
! AUTOMOBILE LIAB I I I I CSL I I
I 1 I I 1_____________n___n_I____n_____1
\ [ ~NY AUTO 1 1 I I BODILY INJURY 1 \
\ \ ~~~E~~t~~ ~~~~~ ( (( :-~~~~-~~~~~~~--------(-----------(
" HIRED AUTOS I I I I BODILY INJURY I I
: \ NON-OWNED AUTOS \ I \ \ (PER ACCIDENT) \ \
\ \ (] GARAGE LIABILITY ( I:: -PROPERTY-----nn-n (____n_nn (
, I [] I L- - ,.l--""---.?'-i-"\. I 'I
i ---) -~xc~~~::~~~~IL-rTy----I----n-n-----n------n\D~n ~.:::,@:I~:lIl~1-i~~L\~ i :----n-i-EACH-OCc"i--AGGREGATE---)
!___)__!_1_~~~:~_~~~~_~~~~:~~~_~~~~__)________________________Jj~~~;~~~------~---l----~~~-:-------l---------_1______________)
" \ \, (~~~':.b - [-\3 2 811994 I STATUTORY \
I WORKERS' COMP 1 F - I I~ I EACH ACC I
! I AND I I 1 DISEASE-POLICY LIMIT I
: : EMPLOYERS' LIAS I I I I DISEASE-EACH EMPLOYEE)
:~--:--------------------------------(------------.----------------(--------------\--i-----T; ----1---------------------------------\
,: ; OTHER / . ,n I ~ l{ I r~\ G 0 I . I
" " I 1'\ ~ 1 I \
I___~________________________________~____________________________~______________~______________~___________----------------______1
'i 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. i
\) CERTIfICATE HOLDER (-------------------------------) CANCELLATION (-------------------------------------------------------_----1
I ------------------------------- ------------------------------------------------------------/
, : 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 \
: At tn: Ms. Betty Deputla : DAYS WRITTEN NOTICE TO THE CERTIfICATE HO E NAMED TO THE ,UT I
i P. o. Box 4748 : fAILURE TO MAIL SUC TICE SHALL IMPOSE 0 TION OR L SILIT Of ,
! ~~~t~wa ter, FL 1\ E eEl V E D-~~~-~~~~-~~~~-:~~- o~~~__ _~~~_~~~~:~_~ _~E ~~~~~ T ~E :_n___ n__ _n_1
: : AUTHORIZED REPRESENTAT (
:ACORD 25-S (3/88) MAR 2 4 1994----.-------,--- - ~__J.
<~.-
ClTY CLIRK DEPT.