CERTIFICATE OF INSURANCE (022)
INC.
AFFORDING COVERAGES
ROGER BOUCHARD INSURANCE,
POBOX 6090
CLEARWATER, FLORIDA 33518
A
B u. S. FIRE INSURANCE COMPANY
C
COMI"',' 0
LEn Lf<
COMPANY E
LETTER FOR THE POL ICY PER 10 D . IN D I CAT E
This is to certify that policies of insurance listed below have been issued to the insured named above ~V~Dl'CY1li ~i'ft\rny. 'Notwithstanding any requirement, term or condition
of any contract or other document with respect to which this certificate may be issued or may per1Ml%~ ~,ft)rli'n'2e"arfoflj&l by the policies described herein is subject to all the
terms, exclusions and conditions of such policies.
ANDAD[JRESS 0, INSUREI
SUNCOAST PAVING,
ROUTE #1 BOX 222
ANCLOTE ROAD
TARPON SPRINGS,
COMPANY
l.ETHP
TYf)[ Of~ INSUf\ANC'f
GENERAL LIABILITY
A []] CUf;1PREHENSIVC FORM
[]] F'REMISES ()I)ER~TION:';
D EXPl.OSION ,\NU C(lITiIPSE
IIAZ/\RD
D UNDEflGPOUND HAZI";,'
[X] PRODUCTS/COMPI.ETCD
OPERATIONS IIAZAWJ
[ZI CONTRACTlIAL INSUllANCT
D BROAD FOI,M PROPERT';
DAMAG[
[j) ,fNDEPENDENT CONTI1N. rOIlS
[xl PEflSONAL. INJURY
AUTOMOBILE LIABILITY
A [Xl COMPREHENSIVE EOFlM
[Xl OWNED
00 ," Rm
00 NON.OWNED
EXCESS LIABILITY
B [Xl UMfJRfLLA IORM
D OTHEliTHM,lIMI,qElI:,
FORM
C
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS,VEHICLES
IOWA NATIONAL MUTUAL INSURANCE
INC.
FLORIDA CONSTRUCTION, COMMERCE
& INDUSTRY SELF INSURERS FUND
FLORIDA 33589
POl.WY NIIMElfR
Dp'[)j'L~ __(jn>;~I;'~.c~f~~~'_.dl~f~'-
cJUD!l.r INJUI.'Y" "
04/02184-'
04/02/85
CCC 80179050
I'ROPE RTY lIA.MAGE
$ 100,
$ 100,
[~(J[}ll_Y INJURY I\NC
1',,',n1 .:,ny DAMAGE I' $
,IMHINED
.- f'~~)UNAI iNJUh'!,
cee
80179050
04/02/84-
04/02/85
$ 500,
$ 500,
[3UDIL Y INJURY
(EACH ACCiDENT)
Pf,'CH-'t,RTY [}t\MAGE
[IUDI! Y INJ!JRY AND
PFmF'EIHY DAMAGE
_~~M8INF-'L-_
130DIl Y IN.JLJP'y t.,Nn
523 321992
04/02/84-
04/02/85
I C\Vf<,:,'\.H:: I
[JROflU--iT\ :". rl.,\Cf
7-18-1934
$1 00,
Cancellation: Should any of the above described poliCies be cancelled before the eXplrlt10n date thereof. the iSSUing corr,
pany Will endeavor to mall ~ days written notice to the below named certificate holder, but failure to
mall such notice shall Impose no obligation or liability of any kind upon the company.
.-...........--.....-..----.---. --,
N}\ME AND ADDF\[~;~~ OF CFRT!FICA 1 [HO~ ~')f fi
: :.1 [ Ie "!JET_ _______.______Jl..6LD.6_L8!Ln_
CITY OF CLEARWATER
POBOX 4748
CLEARWATER FL 33518
~OI"'m """",0,"'''"'
ROGER O. BOUCHARD/JA