CERTIFICATE OF INSURANCE (109)
~. NATIONWIDE
'lI t~~w~~t~~~U~I~1
CERTIFICATE OF INSURAN~ (COI)
~E OFFIC;E: ONE NATLO~IDE PLAZ--\.: COLUMBUS. CJ.HIO 43211
The NatlonWloe Mutuai ns. Co. or the Nationwide Mutual Fire Ins. Co.
certifies that the insurance afforded by the policy or policies numbered and
described below is in force as of the effective date of this certificate and
that this COI does not amend, extend or otherwise alter the terms and
conditions of insurance coverage contained in any policy or policies numbered
and described below. Date certificate issued: 11-25-86
Certificate Holder's Name and Address: Insured's Name and Address:
City of Clearwater Sign Craft, Inc., Sign Craft of the
P.O. Box 4748 Palm Beaches, Inc., B.H. Vaughn
Clearwater, FL 33518 & 1825 Church Street Realty, Inc.
1890 Church Street
West Palm Beach, FL 33401
DESCRIPTIVE SCHEDULE
POL I CY LIM ITS_, OF~~LJ:~A~ ILl TY
Pm:Tcr~II--~- ,_. l! FF~-DICfE EX!?:b A T jf- - IN' -T ifo U SANDS (000)
EACH AGGRE
OCCUR -GATE
'I' Y-PEO F-~I-N.sU-RA NeE
GENERAL LIABILITY
XComp. Form
XPremises-Operation
Explosion & Collapse
Hazard
-Underground Hazard
XProducts/Completed
Operations Hazard
-Contractual Ins.
-Broad Form Property
_Damage
Xlndepend. Contractor
XPersonal Injury
Broad Form Compo
XG.L. Endorsement
AUTOMOBILE LIABILITY
XComprehensive Form
XOwned
XHired
XNon-Owned
EXCESS LIABILITY
XUmbrella Form
WORKERS' COMP &
EMPLOYERS' LIABILITY
OTHER
77SM-504563-0001 12-01-86 12-01-87
Bodily
Injury
Property
Damage
Bodily
Injury &
P.D.
Combined
$500
$100
$
$500
$100
$
$500
$
$
$
$500
$1000
(Each
Ace)
Additional Information Descript on of Work: Sign Manufacture.
& Erection. . .
Location Of Work: Same & temp work. .
sites elsewhere in the state of FL. .
Insurance in force only for hazards indicated by X. Should any of the
above described policies be cancelled before the expiration date thereon, the
insurance company will endeavor to mail written notice to the above named
certitiJ~Clte l1()_.!d~r, , but" failure to mail such notice shall impose no
obligation or liabilityoT-anYkTnd UpoIl>th-ecompany.
This certificate is executed by Nationwide Mutual Ins. Co. if said company
has issued the policy to which this certificate is attached; it is executed
by Nationwide Mutual Fire Ins. Co. if said company has issued the policy to
which this COI is attached.
Countersigned at: Albertz Ins. Agency, Lake Worth, FL '688Ft
Personal
Injury
77BA-504563-0002 12-01-86 12-01-87
Bodily Injury
(Each Person)
Bodily Injury
(Each Ace.)
Prop. Damage
Bodily Injury
&P.D. Combined
Bodily Injury
& Prop.Damage
Combined
Statutory:
:$
77CU-504563-0004 12-01-86 12-01-87