COPY OV INSURANCE BINDER AND NOTICE OF CANCELLATION
SHELTON ~ CONNELLY, INC.
600 LAKEVIEW ROAD STE A
CLEARWATER , FL
33516
Effective "-' ;;J ,19
Expires rJ 12:01 am D Noon 02/05,1987
o This binder is issued to extend coverage in the above named
company per expiring policy #
(e~cept as noted below!
NAME AND MAILING ADDRESS OF INSURED
ROBERT J BURNSIDE &
ASSOCIATES, INC
319 S. GARDEN AVE
CLEAF~WA TEr~, FLA
Description of Operation/Vehicles/Property
FFICE
33516
Type and Location of Property
Coverage/Perils/ Forms
Amt of Insurance Oed.
Coins.
%
319 S GARDEN AVE
CLEA.RWATEf~1 FL..A -3351 ~ ....
BUILDING
CONTENTS
ALL RISK, REPLACE.COST
ALL, REPLACE COST
231,500
46,300
~50
150
D Scheduled Form
~ Premises/Operations
~ Products/Completed Operations
~ Contractual
D Other (specify below)
~ Med, Pay. $ 1000 Per
~ Person
e.J Personal Injury
Comprehensive Form
Bodily Injury
Limits of Liability
Each Occurrence Aggregate
$ $
Type of Insurance
Coverage/ Forms
EXTENDED
COVERAGES
Property Damage $ $
Bodily Injury &
Property Damage $ $
Combined 1000000 1000000
$ 10,000 Per
Accident
DAD B Dc
Personal Injury
Limits of Liability
Bodily Injury (Each Person) $
Bodily Injury (Each Accident) $
rJ Liability ~ Non.owned ~ Hired
D Comprehensive.Deductible $
o Collision-Deductible $
o Medical Payments $
D Uninsured Motorist $
o No Fault (specify):
D Other (specify):
Property Damage $
I Bodily Injury & Property Damage 1000000
Combined $
[] WORKERS' COMPENSATION - Statutory Limits (specify states below)
~ EMPLOYERS' LIABILITY - Limit
100,000
$
SPECIAL CONDITIONS/OTHER COVERAGES
H f t~'
ADDITIONAL INSURED CITY OF CLEARWATER
SIGN COVERAGE $500
ft.\;) 2.4: 19~
NAME AND ADDRESS OF 0 MORTGAGEE
D LOSS PAYEE
o ADD'L INSURED
LOAN NUMBER
,..",),"
~",rrV CLt,,~\.b.
G~l ....
~
! ~
Notice of Cancellation MORTGAGEE'S COpy
The below numbered policy (includlg any e tension of the Policy Period or Tel1), issued to the Named Insured by the
Company or Companies named h~in, is ancelled as of the Effective Date 11 Cancellation stated below.
Policy Number
21 SBA Ph1587
I Producer's Name and Address
Lancaster Ins Inc. 221485
I
Named Insured and Address
L Cert Holder
121 SBA PH15rJ~~ Name and Address
City of Clearwater
PO Box 4748
Clearwater, FL 33518
~
r21 SBA PH1587
Robert J Burnside CLU &
319 South Garden Ave
~learwater,Pinellas, FL
I
Associates Inc.
33516
~
"I
L
~
EFFECTIVE DATE OF CANCELLATION:
As Respects the Named Insured
----- Ten (10) days after receist of this notice
As Respects the rcxtuillgeB. Cert Hol er
Ten (10) days after receipt of this notice
Company(ies)
Hartford Ins Co of the Southeast
Any return premium due under this policy, if not tendered herewith, will be returned upon demand,
(KANSAS: The words "Upon demand" are to be deleted,)
R E C r-: 'J '1",,1 E I:Non Payment
:-I .'~'" p"
(12/25/87)
FEB 12 198"(
',. "'0:'''<,.7' ,,--.,. T FRT{
G.,s " ,~} ~"".1,....1,~J 1.-,.
Date O?/lO/P.7 prieR
A~ho"',d 5;g",,"" A.. ~I
~
".;;rJ.
THE HARTFORD
Form G-2298-5 LP Printed in U,S.A,