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COMMERCIAL INSURANCE APPLICATIONI r,: raga ? Y of 11 2008-07-14 18:24?04 (Tah1T) 17276839047 F-o.Tg %Jana.75Lran2sau COMMERCIAL INSURANCE APPLICATION L1AT'IMTdfDDVYYI') APPLICANT IN MAT)ON 9ECTiow 0&904006 AWMCV CAWER I?tIt cPDE_ _ -...-{ tiPW+WYM ?wDFRL+mwgh 9F F. All UHam Insuronco OMbP inc allou"aAa NLawranGa CorppAnY I 130 6 M1ssoun Ave ?-,..,_- .... ?- - - ---- - )_...:.?.- ' I PPU:CIES OR INMt?oAPM RE4JldT[C T ' Ckowalor FL 3VA6 POP.ICY NUNBBR I 48 6731 WIMGRT! 6E 16Ye MTACIR'0 ,....L`_. iGUOwftl l'"A ER I , GARAO2?AWD MALSF_ . . _ ..-.__ _ °ROPErilY i amao I ' c'.-Ass sSICN - c'.-Ass ? iNi-AU,AThOV hLb"s yAk EI,E_^TkQh0 WA 'W-. ' _ verr0i EDU c L' 60f RR ti MACI,INF'R: ? ol/N7S REC°_ VA&C . I dAW 141 PAPER! :11WWR'CIAL x VJpI1tQ r? t"EI La'IbN -.?__. . i - ..... ... _.. __..,? ._-_ '? CAWELVADMI-ARrous CRJi19 euw.."abs:: L LMABtt!T? ?? .? r . . MSRE D49B2 _ , _ :-- - _ ?.HOTormyc CAROD . 14 Fa1SIMFas AU!, ! 'rRUC"ftWVOTOR CAN R t.IIt LI .LA • OVOTE' J( !ISSUE "-ICY % ! RSNRW I ENre?THla I+FgiNATPDKYVIBJ COWO! CATE6 AND TERMG AFD v r0 9E\ !RAL LMMIf,. pq cpp UCpNpltwe voltC EB. -... _ W')40 n?r?a:e a•e:?r Aneri. Ca?OY> PW>Pa6W WR IDA*.' P11Grosr?OP DArF M41.RY0 Pdv -'--_^-PAT'YGMT PLAN ... I . ICHAN7E MTa I TIME '}hr? ???.. _.__....-•.`...._____._._- ---_I 1. ,........_._.,,.._...,.....__-_._?-_,.,..,t.;_, AUDIT J I 0612812004 66P2A120A8? AoENCY sL1: j -"? CARC'•L I ?---' iar I DiREC'r 91,.1 NAMN(PN.t4ai InVVrB"aren.rfthT"!.o..wt OBB fSKATt 9NOP B -?wii4NO+onRissH1CLYtbaIornxN.n,.tt'I.,W.eP -- alp' • wtJNE LEARWATER FL 3R 3740 G 61" uk Mar Phu MM.mw InMwMi.. T WIC. (M:. Krtcl' - _ t.Nt?VIDUAL 1 ?( GOR°:>RA110N •.....",?...... gUl1L`h/dATER '9" . L-(: -.. ????._ OR BU NUMBER MREl1U I ID i -MATE BUS ?? piPORA'L?N N STARTED °I rnr?.DF ?qury>iRt A f NA W-NERSH P CWT vdR'VRE ! NCT FOR PROFIT ORG -._. _....:_- ... ...._-_1-.- '---• OMBPEC7104 0047ACT: j ACLQJwnN6 RECORI1111 GOMITACT JAY 4QG•R.' aLDNI ' iTRiGT,CYfY,COUNri;bYA7gJJPM C(rTSUMIY4 ? IM7Titii6T h WILT I iNPL.CYGls. '. tRS3itNY[A I 91.G000hEC r 14366M4PninLuNwr"JrAve 06*rW91er 11 i PINRLLAS ft 33766 ~j( OJT9'DE X t;wWT ..-,,....,.-.,....-,.,??.......,..,?.., ., !?'dr.SIDE, r_ ? a/rNEa !..•...-._...._ -T..-,,.... _,,..,.1.. ,. .^? O?Ynwe WWT i Ef.P4SU:.V.L "Irii" fRLBPONGGB 'rsp I RIO GKeLAdI 41 `171h• RssMoMGaR ' ! rRt . Np 1ti ID'HE APFUGMM-sP,DDBPCIAAY OF .1Np p?NTliv -? C D1)RWCT4ELAE7fWV EARa(TEN IN RI;, HAS AWr APPLeFINT BE EMI - -Mfr--^? ND1c'ED FOR OR CONNCtsq CF ANY DEGREE OF -NE CR1M[ QF tHYALD. t I NIGGRY AP-SON OR aw grHfiR ARSOH-RELA7EO Chmi61N tpI+RGC?CN l 1 aA L T E ANPT 6 " ' Y x , w_ f_ H .1 Aw +R 1 b O 7E9 SVO#K G9 VR I.N 2 19 A FORMAL BAFETY PROGRAM IN C12PAT10Nr '__...^-T w,^ +• j ATM NhdI m qL- M/ -t eP be ? se.oROPrRTti7 by kt. * nw Rru.t o" L Wb01RY iwyn.+aV (' ENK' ji ArQIVK01r RAIrleT00 bNYr0!L cVYk`1t? WY IlerrRl #6, ryNild9!NMnM M ?t6rablG A Mtn' E11P08UaE TO FLAMwA.>I.FA. EY.h08N69. CPEMRItBi' ) X' wj*n 61 up m "A yWr q bhANrc.mKt: p .. . , , 4 ANV0f,7iA8TROPIie EY,YO8UR6? I ,S.ANYUPCORRECTiDRRECOWgvrq,Arg;,W x -,--,-.r ...................?,....,...-,..-..?,..w.,,.- ,..,._.??.,?..__. - ___-t_,...,-. y, ANY OTNER INRURANCE"IrcH TMIBCOMPAHY OR BEIRC BUBHrTTECi ! ti Lnr Rrw lwr xa TAtx?yyTFyrya x W rr JT rv a.+R:)yr': 6. ANY POJCY COVERAGE f DECUNBD.GA FS1i7JN OR I x -v4"1, _ NON•RENE E UR11 W?D D'URINC'rN5 RR1ORfYRAP AAap!.-+, wlr.ln? ?_-.' I vw. I1 ArY t.'. ?? ti hatr?f?Wl.irN Oh,:L'J..' 8:>19 ?RBU7Li: JC ? ANY PAST _Ma1pR CLAMS RELATING TO BEXIAl ABUSE OR 7 I x! ?`'rPUC•;,;TB.XAJtD8Ta4.-CC .r?t;w:aww•e:Sa?,r1'ES Sln+ ? } MOI,C9TR7.OhK::0A7RjIM8, pE!SRILHMATIDIM OR NfGI::>rb7rT HIRING? kANAMLb?Rt14.llSIMO.Ra4TalCT101i6 (M18e4 Add Iww Mrb N "Wo 1"ot N. MA;utw1) ANY PER WNW-, WYNWGLY AND'AITH )IuT'EkI YO CEFRa'JD ANY tv9UMAIN CL! C;CMPANY OR AWCTHE3 PERSON R L E S AN APPUCATICM FAR !4EWRANCI OR 3TAIEMEN-OI-CLAIM CONTAININGANf V?TE4iAL,YFALSEINFORMATION,OltCONCEAl9?ORTHEPURFQSki OF'MISLEADO.4. WFORMA'r1ON TERIAL THERETO O<i1RILT3 AF RALOU_ENT INILIRANCE ACT, w WCH 13 A CRIME AND WSIE :T9 rFE FER3:1N TO CR MRVAL ANt.> CCPNCERN'NG ANY Fa KA ; Nv' S 1?STANT!A?! Cltnl P6p?rIES. 'Np; sPP:kAAI, n CO. ,,NE. OK 09. 150 r 0in. DC, 1A., NI;. TN And VA inbutw+v Go,Ntdo to 46. t. d.:.qd! N '. HL: UNDERSIGNED ti AN AJ IHORILED REPF TA11V'E.L* . HE A'•R+:1.:Ah' A.NU CL:H I !MILS I KAI RLASONAOLE ENQUIRY .wAS 86LN Mr.U8 IQ 09 MN !He. ANEVVFH8IQ L2'A4I*L1W6.UN!HIj1AF+ .. He:nH_ EF',n-ILVMA11FtANOVI&KdAft KJk.CrCRR=:IANUGLIMNLF.11_'IU'HE yty1Lt.H-1H=k KNO4MI)CGL. Awimcmwrm mmmmATL1e j T>: . PT1AoNCSIrs sKwmTL we NATIONAL. PhobuGM NL4*d* I ACORD 723 ( 2001x116)/ 0 PL'Z"W6 WMVLM 1 C nCYCKOM OWr w. rR..unu WIRrumrtvyYPr T V9a-suw 0nuan, 1.3. 2003 - y -