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 -