CERTIFICATE OF INSURANCE (021)
ROGER BOUCHARD INSURANCE,
P 0 SOX 6090
CLEARWATER, FLORIDA 33518
INC.
COMPANIES AFFORDING COVERAGES
COMPA.N' A
LE 11 [f'
CC)1\1f-'t\f\.Y B
LETTEF
CCJMl'ANl C
LE 11 [Ii
--~-~,--
COMI"Af.,. 0
UTIEP
COMPANy E
LETTER FOR THE .POLICY PERIOD INDICATE
This is to certify that policies of insurance listed below have been issued to the insured named above <y11i1r~O/AI'iV \IIi.,t" Notwithstanding any requirement, term or condition
of any contract or other document with respect to which this certificate may be issued or may pe~~, ~~ i~sOrll\1~!'M'bftj~ by the policies described herein is subject to all the
terms, exclusions and conditions of such policies.
TYP[ Of INSUPANU. I POLICY NUM8EP I
A ~ ::::::,,~::~~~yl CC:8~1 mso ~-- - 04120/84-
[]]1'1"MISESOPfR"I'" ' 04/02/85
[] EXPLOSION f,ND
H AZA PIl
D UN[)FPGPOUND HI'Z,"'"
[X] PPODUCTS/COMF'[fT!:l,
Of'ERATIONS HAZM",
[XJ CON11<ACTUAL INSIJH,~~C[
D flllOAD F0I1M PROPEfiTY
LJAMAGE
IJ.(j INDEPENDENT CON r PACTOf,S
[XJ f'FRSONAL INJURY
IOWA NATIONAL MUTUAL INSURANCE
U.
S.
FIRE
INSURANCE COMPANY
AND AODf~fSS or- IN'~UPE'
SUNCOAST PAVING,
ROUTE #1 BOX 222
ANCLOTE ROAD
TARPON SPRINGS,
INC.
FLORIDA CONSTRUCTION, COMMERCE
& INDUSTRY SELF INSURERS F~ND
FLORIDA 33589
i'i/LliY r==:IT~I~,of!iabi,!-tLl,,_ Thou~_nds (OOOL
.'",\iiitrll~~I..\r[. I ,I\LH ~fGAI[
_r~lj_~~_ __ ____ I ~~ ur~RI N( F I f\~~__
UOIJILYINIl F(Y I b 30o;-pOO,
I I
$ 100, $ 100,
PF<OPEfHY
;;~,;~;~: T --
!)MfJINIi' I
~._---~-----
Pl"RSONAl
INJURY
AUTOMOBILE LIABILITY
A [X] COMPREHENSIVE fORM
[X] OWNED
[X] HIRED
00 NON,OWN[[)
CCC80179050
04/02/84-
04/02/85
HI.I[ L Y IN.JLJF?Y
H F'~ f.?~;()N)
~ 500,
$ 500,
BODILY INJURY
: ,.AC', ACCIDENT)
f""'F'UHY DAMAGE
EXCESS LIABILITY
,<,,[I Y iNJURY AND
1:;"),>fJ[fiTY DAM^GE
__ __ __~.Q.MHINFr::.-~______
8 [Xl UMBRU,LA FOfW
D OTHEFnHAN lIMB'iFllj
WO:~;:S' COMPENSATI~
-( and- ,',.,
EMPLOYERS' LIABILITY
----~.._..
OTHER
523321992
04/02/84-
04/02/85
y rr'tll;p'( ,\~~ '
f !-~i p[f-n v !-I/,.\1/\(';[
(",-"MHiNf-r)
7-18-1934
I
i
12/31/53- n
12/31/84
----~
~ 1 00,
RECEIVEO'''''
DESCRIPTION OF OPFPATIONSLOCATIONSIVEHICLES
MA Y 30 '984
CITY CLERK
Cancellation: Should any of the above described policies be cancelled before ~he eXpiration date thereof, tile ISSUlrw corn
pany Will endeavor to mail ~ days written notice to the belcw named certificate holder, but failure to
mall such notice shall impose no obligation or liability of ,][1y KI[llj UDO[l the company,
Nf,M[ AND AIlDFiESS OE CERTIEICATF HOI DER
-I
::'[ !ssu[[J_~~I__~~~~!3~__,____
CITY OF CLEARWATER
POBOX 4748
CLEARWATER FL 33518
"__n_~~_"_n___,j
BOUCHARD
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