RENEWAL CERTIFICATE
DRHR OF GA - OBERDORFER
P. D. BOX 76677
ATLANTA, GA 30358
COMPANIES AFFORDING COVERAGES
COMPANY
LETTER
COMPANY A
LETTER
B
C
D
E
RELIANCE INSURANCE CO
NAME AND ADDRESS OF INSURED
CLEARWATER BEACH HILTON
LANE CLEARWATER LTD
715 SOUTH GULFVIEW BLVD
CLEARWATER BEACH, FL 33515
COMPANY
LETTER
COMPANY
LETTER
COMPANY
LETTER
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.
TYPE OF INSURANCE
POLICY NUMBER
POLICY
EXPIRATION DATE
LIMITS OF LIABILITY IN THOUSANDS (000)
EACH
OCCURRENCE
AGGREGATE
A GENERAL LIABILITY CI67El9756\1
[Xl COMPREHENSIVE FORM
00 PREMISES-OPERATIONS
0 EXPLOSION AND
COLLAPSE HAZARD
0 UNDERGROUND HAZARD
[Xl PRODUCTS/COMPLETED
OPERATIONS HAZARD
00 CONTRACTUAL INSURANCE
[Xl BROAD FORM PROPERTY
DAMAGE
00 INDEP. CONTRACTORS
[Xl PERSONAL INJURY
AUTOMOBILE LIABILITY
0 COMPREHENSIVE FORM
0 OWNED
0 HIRED
0 NON.OWNED
EXCESS LIABILITY
0 UMBRELLA FORM
0 OTHER THAN UMBRELLA
FORM
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY
OTHER
OS/29/87
BODILY INJURY
PROPERTY DAMAGE
$
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
PERSONAL INJURY
BODILY INJURY $
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT) $
PROPERTY DAMAGE $
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
$
CERTIFICATE HOLDER IS ADDITIONAL INSURED AS RESPECTS PARKING AREA UNDER
SAND .<[Y.
Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing company will
endeavor to mail ~~O days written notice to the below named certificate holder, but failure to mail such notice shall im-
pose no obligation or liability of any kind upon the company.
NAME AND ADDRESS OF CERTIFICATE HOLDER
19~~9
CITY OF CLEARWATER BEACH
CITY CLERKS OFFICE
ATTN: SUE LOMKIN
P.O. BOX 4748
Ir:
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Risk Management Since 1921
4370 Georgetown Square. P.O. Box 76677 . Atlanta, GA 30358-1677
(404) 455-1511 . Telex 650-248-8860
JULY 28, 1966
City of Clearwater Beach
P. O. Box 4746
Clearwater Bch, FL 33516
POLICY: C16769756\1 INSURED: CLEARWATER BEACH HILTON
Gent 1 emen : ,~
Enclosed is a renewal certificate continuing the property
and general liability coverages for the captioned Insured
effective May 29, 1966 to May 29, 1967.
Please note, the certificate renews the policy subject to
the terms and conditions as expiring and notes any revi-
sions, deletions or new changes. Otherwise, it remains the
same. Therefore, your name is not indicated on this certi-
ficate because you were an addtional insured on the previous
pOlicy and that has not changed.
In addition, I have enclosed a copy of the Insured's umbrel-
la liability renewal indicating the city's interest.
1 trust you will find the enclosed to be in order. However
should you have any questions or require assistance, please
do not hesitate to call.
s~)~
Elaine S. Hunt
Account Administration
ESH:eh
RECEIVED
NJGll986
CIT~ CLERK
Republic Hogg Robinson of Georgia, Inc.
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In Consideration of
the Required Premium
and Provisions
of This
Comprehensive Insurance Policy,
the Company
Does Insure
the Interest of:
90-6501
Oberdorfer Ins. Assoc.
Atlanta, GA.
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1 RELIANCE I~SURANCE COMPANY" ' 2 PLANET INS_URANCE COMPANY
Philadelphia, Pennsylvania .. Home Offlce-~un Prairie, Wisconsin ,
. " Administrative Offices-Philadelphia. Pennsylvania
0-
Coverage IS provided In ,the Company deSignated by Number
Eact'l IS a Stock Insurance Company herein called the Company
CI 618 91 56
Comprehensive Insurance Policy
Renewal Certificate
Name
Insured
Lane Clearwater Limited Partnership
DBA Clearwater Beach Hilton Inn (S~~ C.T OOOR)
Named
Insured's 715 South Gulfview Blvd.
Addre~ Clearwater Beach, Pinellas, Fl. 33515
The Named
Insured is:O Individual CPartnershipXJ Corporation OJoint Venture OOther_
Pertod of Insurance
12:01 a.m. Standard Time at
Named Insured's Address
From
5/29/86
To
5/29/87
Deposit
Premium $167609. See Gen 1179
Audit Period: * Annual ~ Seml.Annual 0 Quarterly C Monthly
In consideration of the payment of the premium above specified it IS agreed that the policy designated above is renewed from the
inception date shown above, subject to all its terms and conditions, except as follows:
The following forms are REVISED herewith and attached:
- ------- - - -------- - -- - - - - - ------ -- - - - - - - - 'T----- -------- - -- -- ---- - -- --- -:- - -- - -- ---- ----
Form Number Effeetive This Date ,Cancels and Replaces Same Form Number Effective
Gen 1179 CI 1103 CI 0008 CI 2004 CI 2315 I Gen 1179 CI 1103 CI 0008 CI 2004 CI 2315
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The following NEW forms are made a part of this policy and attached:
CI 1117 CF0405 CF0406 CF04l5 CI 0008 CI0008 CI0008 CI0008
The following forms are DELETED from this Policy:
CI 2310 MP0030
Michigan Provision - Current editions Of forms will be substituted at each renewal date for the earlier editions, if revised during the
previous policy term. The policy is being renewed at rates in effect on the date of renewal.
In witness whereof. this Company has executed and attested these presents; but this Certificate shall not be valid unless countersigned
by the duly authorized Agent of this Company at the agency herein before mentioned.
Reliance Insurance Company
Planet Insurance Company
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Secretary
CI-0010 Ed,4/82
President
IJM~ ~R41I#NJtoGl.~O_
Secretary PreSident
~: QNL ~J,.LC~ftu
Countersigned ~ -r--
Authorized Representative
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INST1LLMENT OR T~~EN ~llL ENDORSELENT
Company Numbers
1 = Reliance Insurance Company
2 = Planet Insurance Company
6 = United Pacific fnsurance
Company
8 = Refiance Insurance Co. of
Illinois
If this endorsement is issued concurrently with the policy, the Attaching Clause need not be completed
Issued by Co. No. Insured
Clearwater Beach Hilton
Policy Period
Endt. No,
Policy No.
Cl 6789756
Return Premium Premium subject
o toaudit
Effective Date
Uneamed Premium Factor
All terms and conditions of the policy remain unchanged
except as amended by this endorsement.
DATE DUE
PREMIUM
INSTALLMENT
CHARGE
TOTAL
STATE
SURCHARGES
1
2
3
4
5
6
7
8
9
10
11
12
o If this box is X'ed, the installments
(other than the first installment) are
to be equal amounts.
GEN.1179 Ed. 10/83
Policy Number
Named Insured
(.-.
COMPREHENSIVE INSURANCE POLICY
SECTION IA
PROPERTY
SCHEDULE OF LOCATIONS
Location 1
715 S. Gulfview Blvd.
Clearwater Beach, Fl.
Location
Location
'.
Coverage applies only where a Limit of Liability is shown.
Unless otherwise shown beneath the applicable limit of liability:
(1) Perils insured against for all locations shall be as provided in (:1 1106 for coverages ABC E
as provided in for coverages
(2) Valuation clause applicable for all locations shall be Number -----I..- for Buildings, Number ----L- for
Personal Property.
''''-. _.~'"
Location Number, Building Number 1 - 1
Occupancy Hotel and
Restaurant
Deductible I (applicable to coverage A&B See Endt. 2
per location, per occurrence) Section IA
Protective Safeguard Clause(s) Applicable
Co. Automatic
COVERAGE Increase in LIMITS OF LIABILITY
Insurance Insurance
A. Building See
CFl2l0 2% 15.506]00
B. Personal Property
o Excludes property See
of others CFl2l0 2% Incl.
o Excludes stock
o Reporting
Stock
o Reporting
C. Additional Expenses
5 000
Contribution
D. Loss of Rents
E. Gross Earnings See
~ Excludes ordinary CFl2l0
payroll
U Limited ordinary 3.108.062
payroll "
Each
30
F. Loss of Earnings Days
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Aggregate
CI.1103 Ed, 1/84
CI.1103A Ed, 1/84 (single)
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POLICY NUMBER
EFFECTIVE, DATE
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NAMED INSURED
COMPREHENSIVE INSURANCE POLICY
ENDORSEMENT NO. SECTION
Named insured to read:
Lane Clearwater Limited Partnership
DBA Clearwater Beach Hilton Inn
Lane Properties, Inc. as General
Lane Industries, Inc. which owns
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CI-0008 Ed. 2/81
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partner of Lane Clearwater Limited Partnership;
Lane Hotels, Inc.
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For the purpose of determining the limit of the Company's liability, all personal injury and property damage arising out of
continuous or repeated exposure to substantially the same general conditions shall be considered as arising out of one occurrence. }
Subject to the above provision respecting "each occurrence", the total liability of the Company for all damages because of all
personal injury and property damage to which this coverage applies and described in any of the numbered subparagraphs below
shall not exceed the limit of personal injury and property damage stated above as "aggregate":
(a) all personal injury arising out of any offense in Groups A, Band C, defined in part (2) of thlldeflnition of personal injury;
(b) all property damage arising out of any premises or operations rated on a remuneration basis Of contractor's equipment rated
on a receipts basis, including property damage for which liability is assumed under any contract relating to such premises or
operations, but excluding property damage included in subparagraph (c) below;
(c) all property damage arising out of and occurring in the course of operations performed for the Named Insured by
independent contractors and general supervision thereof by the Named Insured including any such property damage for
which liability is assumed under any contract relating to such operations, but this subparagraph (c) does not include property
damage arising out of the maintenance or repairs at premises owned by or rented to the Named Insured or structural
alterations at such premises which do not involve changing the size of or moving buildings or other structures;
(d) all property damage included within the products hazard and all property damage included within the completed operations
hazard.
Such aggregate limit shall apply separately to the property damage described in subparagraphs (b), (c) and (d) above, and under
subparagraphs (b) and (c), separately with respect to each project away from premises owned by or rented to the Named Insured.
Note: If this endorsement applies to CI 2006, Intermediate Form, (d) above does not apply and the prior paragraph is amended to
read:
Such aggregate limit shall apply separately to the property damage described in subparagraphs (b) and (c) above, and under
subparagraphs (b) and (c), separately with respect to each project away from premises owned by or rented to the Named ".)
Insured.
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POLICY NO.
EFFECTIVE DATE
NAMED INSURED
I
COMPREHENSIVE INSURANCE POLICY
SECTION II
COMPREHENSIVE GENERAL LIABILITY
SCHEDULE
Description of Hazards
Premises - Operations
Hotel - not apartment - with
swimming pool or bathing
beaches.
Ten Pak
Restaurants - with sale of
alcoholic beverages that are
less than 75% of the total
annual receipts of the
restaurant - with dance floor
Building or premises office
PREMIUM BASIS:
Premises - Operations
Escalators (Number at Premises)
,..~-,'
Independent Contractors
Products
Completed Operations
CI.2315 Ed. 2/81
GENERAL LIABILITY HAZARDS
Code
No.
Premium Bases
Rates \
8.1. P.O.
70112 209 vrs.
70122 c)1,400,00 vrs.
99998
vrs.
vrs.
58260 d)8ll,000 vrs.
vrs.
65121 c)1,400 vrs.
1.1 Area ISq, Ft,l
(bl Front_
Cel Remuneretion
ldl Receipt>
(e. Units
(f) Admiaionl
Number insured
Cost
101 Sal..
(bl Receipts
vrs.
1.1 Per 100 Sq, Ft, of Area
(bl Per Linear Foot
(e) Per $100 of Aemunerltion
Idl ~r $100 of Racaopts
(e) Per UnIt
(1) Per 100 AdmiSSions
Per Landing
Par $ 1 00 or Cost
t.1 Pe, $1.000 of Sala.
lbl Per $1.000 of Raceipts
Advance Premiums
Bodily Injury Property Damage
Incl.
Inc1.
Incl.
Incl.
Inc1.
Incl.
incl.
Incl.
Incl.
Inc 1.
POLICY NUMBER
NAMED INSURED
COMPREHENSIVE INSURANCE POLICY
SECTION IA
Location # Name Address
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SCHEDULE OF MORTGAGEE(S)
Location # I Name Address De~',gnated Property
1 Ameritech 149 w. Central Telep;;one System
Credit Corporation Schaumburg, Ill. 60193 i
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1 Comtel Communications 170 Montauk Hwy. Drawer E Telephone System
Corporation Speonk, New york 11972
1 Associate Business 11 James Street Telephone System
Telephone Systems Corp. Mt. Ephraim, N.J. ;
08059
AttN. Pete Karahalios
SCHEDULE OF LOSS PA YEE(S)
CI.1117 Ed. 6/81
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CONTINGENT LIABILITY FROM OPERATION OF
BUILDING LAWS ENDORSEMENT
(For use with ,Property Damage Building Items Only)
1, In consideration of the additional premium for this coverage and subject to stipulations, limitations and conditions herein and in the policy to whic
this endorsement is attached, including endorsements thereon, this Company under this policy and this endorsement shall, in the case of loss to
buJlding(s) covered by this endorsement by fire or other peril insured against. be liable also for the loss occasioned by the enforcement of any state I
municipal law or ordinance regulating the construction or repairof bUildings and in force at the time such loss occurs, which necessitates the demolitic
of any portion of the insured bUllding(s) not damaged by the penl(s) insured agamst, subject to the following limits of liability.
2. limits of liability: This Company shall not be liable under this policy and this endorsement for:
A. Any cost of demolishing or clearing the site of undamaged portions of the ,buildinA(s) unless such liability is otherwise speCifically assumed t
endorsement hereon and an amount of insurance specified therefor. '
B, Any greater cost of repair, construction or reconstruction due to the enforcement of any 'State or muniCipal law or ordinance unless such liability
otherwise speCifically assumed by endorsement hereon and an amount of insurance speCified therefor.
e, More than the amount insured under the poliCY to which this endorsement is attached,
D. More than the actual cash value at the time of the loss of the building(s), or any part thereof, damaged by perils insured against or demolished due I
the enforcement of any state or municipal law or ordinance.
E. Any greater proportion of any loss than the amount insured under this policy on said building(s) bears to the total insurance on such building(s
whether all such insurance contains this endorsement or not.
CF 04 0
@,057
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3. If this policy is divided into two or more items, the foregoing shall apply separately to each item to which this endorsement applies,
This Endorsement must be attached to Change Endorsement when issued after the Policy is written.
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DEMOLITION COST ENDORSEMENT
(For use only with Contingent liability from Operation of
BUilding Laws Endorsement)
CF 04 06
@j, 0577)
I COM"NY
POLICY NO.
: AGENCY
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,. In consideration of an additional premium of 5 Tnt'l . the amount of insurance under this policy is increased by not exceeding
$ 1.000.000 applicable only te the cost ef:~molishlng anv uncamaged oortlon of the building(s) covered under this poliCY and this endorsement
including the cost of cieaflng tne site trereot. ca~seo oy 'ass from ary oerll,nsured against under'tnlS poilcy and resulting from enforcement of any state
or municipal law or ordinance regulating tne construction or repalf oi buildings and In force at the time of lOSS which necessitates such demOlition
2. This Company shall not be liable under thiS endorsement for:
A. Any greater proportion of any I'JSS t'1an :ne amount insured "nder this endorsement for demolition anO clearing site bears to the total insurance
covering expense of demOlition and Clearing Site,
B, More than the amount speCified acove.
This Endorsement must be attached to Change Endorsement when issued after the Policy is written.
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CF 04 06 (Ed 05 77)
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INCREASED COST OF CONSTRUCTION
(Excess of Replacement Cost)
CF 04 15
@ 05 77)
I COM""
I POLICY NO.
[ AGENCY
f
This endorsement applies only to Building Item(s) No{s) .of this Policy
'.
1. In consideration of an additional premium of $ Inc 1 , the amount of insurance under this policy is increased by not exceeding
$, 500 .000 provided, however. that the amount of such increase shall apply only to the In'creased cost of repair, rebuilding or construction of the
building(sJ. on the same premises, of like height. floor area, and style and for like occupancy. caused by loss from any peril insured against under this
policy and resulting from the enforcement of and limited to the minimum requirements of any state or municipal law or ordinance regulating the
construction or repair of damaged building(s),
2. Limits of liability under this endorsement.
This Company shall not be liable for;
A, cost of the demolition of any portion of the building(s),
B, any loss unless and until the damaged or destroyed building{s) is actually rebuilt or replaced on the same premises with due diligence and dispatch,
and, In no event. unless repair or replacement is completed Within two (2) years after the destruction or damage. or Within such further time as the
Company may allow. In Writing, during the two years.
C, more than the amount actually and necessarily expended to repair or replace as above provided. in excess of the amount recoverable under this policy
had thiS endorsement not been attached thereto,
0, more than the amount Insured under this endorsement In excess of the replacement cost of the building(s) without deduction for depreciation however
caused,
E. any greater proportion of any loss than the amount covered under this endorsement bears to
% of the difference between the
:80% ort\ll1hef!
replacement value of the building(s) at the time of loss. without deduction for depreciation and the cost of erecting the building(s) on the same premises
of like height. floor area. and style and for like occupancy and Within the minimum requirements of said state or municipal law or ordinance reguiatlng
the construction or repair of damaged bUllding(s) at the time the loss occurs. nor for more than the proportion which thiS insurance bears to the totai
insurance covering increased cost of repair, rebuilding or construction of the building(s),
3. If this poliCY is diVided into two or more items. the foregOing shall apply separately to each item to which this endorsement applies,
This Endorsement must be attached to Change Endorsement when issued after the Policy is written,
CF 04 15 (Ed, 05 77)
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L1CY NUMBER
NAMED INSURED
COMPREHENSIVE INSURANCE POLICY
ENDORSEMENT NO. SECTION IA
The following are added as additional Insureds
Ameritech Credit Corp.
'.
Comtel Communications Corp.
Associate Business Telephone Systems Corp.
CI-0008 Ed. 2/81
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COMPREHENSIVE INSURANCE POLICY
ENDORSEMENT NO.2 SECTION
IA
In consideration of the reduced rate at which this policy is written,
Loss Settlement Provisions for Coverages A and B is amended as follows:
\
The sum of $1,000 shall be deducted from the amount of each loss occurring
at the same time and at the same location for all perils except Windstorm,
the sum of 1,000,000 shall be deducted for the peril of Windstorm.
90-6501
Oberdorfer Ins.
Atlanta, GA
CI-0008 Ed. 2/81
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POLICY NUMBER
1
EFFECTIVE DATE
,
NAMED INSURED
COMPREHENSIVE INSURANCE POLICY
ENDORSEMENT NO. SECTION
SPECIAL THIRTY (30) DAYS NOTICE CLAUSE
It is hereby understood and agreed that the insurer will give the Investment
Administration, State Mutual Life Assurance Company of Am~rica, 440 Lincoln
Street, Worcester, Massachusetts 01605, at least thirty (300 days prior
written notice of cancellation or major modification, by any party.
CI-0008 Ed. 2/81
. ill '4.90 62 G~
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Renewal 01
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EXCESS-UMBR,:, \..LA POLICY
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Reliance I
1 RELIANCE INSURANCE COMPANY
F\!llladelphla, Pennsylvania
6 UNITED PACIFIC INSURANCE COMPANY
Federal Way, Washington
2 PLANET INSURANCE COMPANY
Home Office-Sun Prairie, Wisconsin
Administrative Offices-Philadelphia. Pennsylvania
8 RELIANCE INSURANCE COMPANY OF ILLINOIS
Home Office-Roiling Meadows. illinois
Administrative Offlces-Phlladelllhla, Pennsylvania
Agency Code, Name ,and Address
. SQ-6501
Cherc10rfer J.nsurance A..SeJ.1CY
Atlanta, G\ 30328
\"",i,~ .. CoveraQe,. ',5 prOVIded .., lhe Compony deSlQnated by
','. 1 Number, Each is a S10ck In.UfIIQ Company. he..",
.' called ~ Company,
.,Dee ~a 10DSi~,
f'ltell:I.:-Naed Insured and Address: (No., Street, Town, County, State, Zip)
. '< ",.';\\>1 Lan' 'Cl' Limi.' 1 P 1 .
':,:~!~~i' e- ~vater tea .arb.lerslup
~~~,;.,~~;DBA Clem:waterBeach Fi1tan Tl1l1
7ls South G1.1lview Blvd,
'.Cl~~, Pinc1las, FL 33515
Itell,2., Policy ,From:' 5/29/86 To: 5/29/87
'\;fPeri~::J,.12:01 A.M. Standard Time at the Address of the H.ed laured as stated herein.
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Item 3. Sc~edule of Underlying Insurances;
CARRIER
P.e1:i.mlce Ins, Co,
COVERAGE
~ Comprehensive Generalliabi lity
La including Products--Completed Operations
o excluding Products--Completed Operations
LIMITS
$ 1,OGO,000/1,000,000
$
BI
PO
Reliance IriS, Co .
:El Automobile Uability
~ Covering Any Auto
o Other
o Employers' Liability
$ 1,000,000/1,000,000
$
BI
PO
$
H.
P.e1iance Ins. Co .
w p.:r
$ 1,000,000/1,000,000
1t.1I 4. Amount of ultimate net loss to be borne by the Named Insured in respect of Each Occurrence not covered by Underlying Insurances:
$ 10,000
Item 5. limits of liability:
a. $ 5,000,000
Each Occurrence
b. $ 5,000,000
Aggregate for Each Annual Period where applicable
C1.. -$32,243
P~:I - (; 1 /~20
/\l1to-:-: 162-
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Item 6. Premium:
$ 33,825
I'''m 7 Minimum Premium' $ zooe f h A I P'OO t b' t h
"'. ' . ,'. or eac nnua en ,no su Ject os ort rate a'lustment.
c rCi. t.,7 Cen 1179
.
Countersigned 19_. at
By
CP1SP~H9 Ed. 9/80 Rev. 11-1-76
{)&fl J7 J~ILf/d,
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Company Numbers.
, = RIIIillflC6lnsufIfICI Company
2 = Planet InsunlllCf Company
6 = United Pacific InsunlllCf
Company
8 =RlllilJ/lCt InsuflllCf Co. of
Illinois
IIth;S endorsem~nt is ilUed concurrenlly with the polic-;'the A\laching Clause need not be mpleted
Issued by Co. No. Insured
End\. No.
Policy No,
Unearned Premium Factor
All tenns and conditions of the policy remain unchanged
except as amended by this endorsement.
Return Premium
Premium subject
o to audit
Effective Date
Policy Period
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EXCLUSION OF REAL PROPERTY IN CARE, CUSTODY OR CONTROL
In consideration of the premium charged. it is understood and agreed that
this policy shall not apply to real property rented to occupied or used by or
in the care, custody or control of the Insured.
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L-3739 Ed. 12-75
Company Numbe~s
1, '" Reliance Insurance Company
2 '" Planet Insurance Company
6 s United Pac,fic Insurance Company
8 '" Reliance Insurance Co, of 1/lmols
illhlS endor;em I 15 Issued concurrently with the poilcy, the Anachlng Clause need nol e completed
Issued by Co, ,0, 'Insured
End\. No.
Policy No,
EHective Date
Policy Penod
Return Premium
$
Unearned Premium Factor
All terms and conditions 01 the pohcy
remain unet'langed except as amende<:! by
this endorsement,
EXCLUSION OF PERSONAL PROPERTY IN THE CARE, CUSTODY OR CONTROL
In consideration of the premium charged, it is understood and agreed that this policy shall
110t apply to personal property rented, to, used by or in the care, custody or control of
the Insured, or as to which the Insured is for any purpose exercising physical control.
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L-3740 Ed. 12-75
Premium
o sUb"",t
10 audit
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Gl 21 33
(Ed, 2-85)
This endorsement forms a part of the policy to which atta:hed, effective en the i:1ception date of the policy unless otherwise stated herein,
(Tl)e following information is required only when this endorsement is iss'ued subse'quent to preparation of policy.)
Endorsement effective Policy No. Endorsement No.
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(Authorized Representative)
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This endorsement modifies such insurance as IS afforded by thE provIsions of the policy relating to the fOllowing:
, COMPREHENSIVE GENERAL LIABILITY INSURANCE
CONTRACTUAL LIABILITY INSURANCE
MANUFACTURERS AND CONTRACTORS LIABILITY INSURANCE
OWNERS AND CONTRACTORS PROTECTIVE LIABILITY INSURANCE
OWNERS, LANDLORDS AND TENANTS LIABILITY INSURANCE
SMP LIABILITY INSURANCE
STOREKEEPERS INSURANCE
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POLLUTION EXCLUSION
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:If.:, \ It is agreed that the exclusion relating to the discharge, dispersal, release or escape of smoke, vapors, soot.
..!~? fumes. acids. alkalis. toxic chemicals. liquids or gases, waste materials or other irritants. contaminarlts or pollu-
;:~~;\t~nts;s replaced by the following:
~t.,' \ (1) to bodily injury or property damage arising out of the actual, alleged or threatened discharge. dispe'rsal.
N..!l",l': release or escape of pollutants:
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t-:'/ (a) at or from premises owned, rented or occupied by the named insured;
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1i"I" ," (b).at or from any site or location used by or for the named insured or others for the handling, storage,
J~:,,;J;!;~:'i"'" disposal. processing or treatment of waste; .
!:t< . (c) which are at any time transported, handled, stored. treated. disposed of, or processed as waste by or:
." ,. for the named insured or any person or organization for whom the named insured may be iegally
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'ii: responsible; or
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:',1;:; (d) at or from any site or location on which the named insured or any contractors or subcontractors
.~ working directly or indirectly on behalf of the named insured are performing operations:
(i) if the pollutants are brought on or to the site or location in connection with such operations; or
(ii) if the operations are to test for, monitor, clean up, remove. contain. treat. detoxify or neutralize
the pollutants. '
(2) to any loss. cost or expense arising out of any governmental direction or request that the named insured
test for', mor.itor, clean up. remove. contain. treat. detoxify or neutralize pollutants.
~.':;~Pollutants means any solid. liquid. gaseous or thermal irritant or contaminant. including smoke, vapor. soot. ' '
:tl-", "fumes. acids', alkalis, chemicals and waste. Waste includes materials to be recycled. reconditioned or reclaimed.
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GL 21 33 02 85
Copyright. Insurance ~ervices Office, Inc,. 1984
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, POW1l'I~ EXC:t.U;I~ GL2133
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This pollC'J c:a\t:&ina an ~t not pJ:8YiOUllly a\ your pollcy that
m:xiifJM tM pollut.ica acl~. Pleue rea4 thia ~t carefully.
It excl\.IiM 1xx1i.ly injuxy ar prcprty ~ ariainq ~ of the actual,
al~ or thna~~, diaperNl, releue or .....~~ of pollutants
.. ,.11 .. lc:Iu, CXlII1: OJ:' u;a'IM arisinq out of any ~tal di.rec:ti.on
or: ~ that yw ~t tar, m:::I1itcr, clean up, ~, a:mtain, treat,
detaxify or nuutral.iza pollutants.
Pollutants axa c1efilwd in tha ~t.
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Company Numbers
r . Reliance Insurance Company
2 . Planer fnsurance Company
6 . Umled Pacll,c Insurance Company
8 .' RIII/llnelllnsurance Co, of /l/mo.s
IIlhlS endorsemenl'S Issued concullenlly ",'Ih the pOliCy, the A"~cnmQ CI~use need not be COmoleled
Issued by Co. No. Insured
Endl. No
Polley No,
EHeCI,ve Date POhCy Penol2
Uneamed PremIum facto,
AII1.""S anO condlhons 0' The DOlley
'e"'~,n unCh~nged eleepl U ~mended by
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LIQUOR LIABILITY
Relurn PremIUm
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It is agreed that this policy does not apply to personal injury or property damage
for which ,the insured or his indemnitee maybe held liable
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1) As' a person or organization engaged in the business of
manufacturing, diStributing, selling or serving alcoholic
beverages, by reason of the selling, serv,ing or givingol
,any alcoholic beverage (a) inviolcition of any' statute, orcli-
nance or regulation, (b) to a minor, (c) to a person under
the influence of alcohol, or (d) which causes or contributes
to the intoxication of any person; or
2) If not so engaged, as an owner or lessor of premises used
for such purposes, by reason of the selling, serving or giving
. of any alcoholic beverage in violation of any statute, orcli-
nance or regulation. .
Unless such liability is covered by valid and collectible underlying insurance as.
described in the Schedule of Underlying Insurance, and then only for such hazards
fo~\vhich coverage" is afforded under said underlying insurance.
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Use when Host Liquor Liability is not covered by the underlying liability policy
and Reliance does 'not want the coverage on th.e Umbrella, even subject to the
, retention.
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~ GEN 47-19
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Issued by Co, No
,Ellectlve Date
!r"lsured
End!. No,
Cl:lmp~.fY ~wmbe,s
,1" Reliance Insurance Company.
~ '''!' Pfanet Insurance Company
,6 '.'f" United Pacific Insurance Company
8''''' Reliance Insurance 'Co, of l/Imols
W'lhls endor'"Jrne IS Issued concutrently With the pohcy, the Attaching Clause need n
Additional Premium
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Plemium
subject
to audit
Allached 10 and lormlng .: "t 01 PoliCY No
Countersigned by (Authollled Representative)
Return Premium
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All terms and conditions of the pohcy remain unchanqed excepl as amended by this endorsement, UMarned Premium Factor.
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l1li.",.. Additional Insureds
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~;> City of1Clearwa.ter
ii~~",;a~~7~.. FL 33518
~~:;::'iF;:'Hilton . Hotel Corporation & Hilton Inns, Inc.
~" . 'c,;':; 9880l-Jilshire Blvd.
~W1",'~'P 0 Box5567
~c~~~? " "~ly Hills, CA 90210
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THE PREMI:.JM FOR THIS ENDORSEMENT IF ON INS'ALLMENTS IS PAYABLE AS FOLLOWS:
ADDITIONAL
RETURN
REVISED ANNIVERSARY PREMIUM
(NOT APPLICABLE)
AT DATE OF ENDORSEMENT
$
$
$
s
FIRST ANNIVERSARY
S
$
$
$
SECOND ANNIVERSARY
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.tG~H1,!:J:O. 4174 (Sets.
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PRINTED IN U.S.A.
ORIGINt..: SOpy
GEN47A ED. 4/741~e.j
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INSTALfMENT OR TOKEN BILL ENDORSEMtNT'
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Company Numbers
1 = Reliance Insurance Compan,v
, 2= Planet Insurance Company
. 6=Ufllted Pacific Insurance
".' Company
8= Reliance Insurance Co. of
tnlnols
If this endorsement is issued concurrently with the policy, tr;e Attaching Clause need not be completed
Issued by Co. No. Insured
Endt. No.
Policy No.
Ell&ctive Date
Policy Period
Return Premium
Premium subject
o to audit
Unearn9d Premium Factor . All terms and conditions Of the policy remain unchanged
except as amended by this endorsement.
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DATE DUE PREMIUM INSTALLMENT STATE TOTAL
, CHARGE SURCHARGES
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1 5/29/86 8454
2 6/29/86 2819
3 7/29/86 2819
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4 8/29/86 2819
5 9/29/86 2819
10/29/85 2819
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7. 11/29/86 2819
a 12/29/86 2819
9 01/29/87 2819
1002/29/87 2819
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o If this box is X'ed, the installments
(other than the first installment) are
to be equal amounts.
GEN.1179 Ed. 10/83