CERTIFICATE OF INSURANCE (042)
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Certificate of Insurance
NW 01 98
(Ed. 12-83
The Nationwide Mutua/Insurance Company or the Nationwide Mutual Fire Insurance Company certifies that the insurancdtttltl~:.;htP.Y.Qr Q2)icies
numbered and described below is in force as of the effective date of this certificate and that this Certificate of Insurance does not amencf;'el'teM'otItUNise
alter the terms and conditions of insurance coverage contained in any policy or policies numbered and described below.
Certificate Holder's Name and Address:
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City of Clearwater
PO Box 4748
Clearwater, FL 33518
L -.J DESCRIPTIVE SCHEDULE CITY CLERK.
This is to certify that policies of insurance listed below have been issued to the insured named below and are in force at this time.
POLICY POLICY LIMITS OF LIABILITY IN THOUSANDS 000)
EFFECTIVE EXPIRATION EACH
DATE DATE OCCURRENCE AGGREGATE
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FEe 4 1985
TYPE OF INSURANCE
GENERAL LIABILITY
~ Comprehensive Form
~-Premises~Ope~atiQ/'ls --..
o Explosion and Collapse Hazard
o Underground Hazard
~ Products/Completed Operations
Hazard
~ Contractual Insurance
I!] Broad Form Property Damage
I!] Independent Contractors
I!] Personal Injury
I!] Broad Form Comprehensive G.L.
Endorsement
AUTOMOBILE LIABILITY
~ Comprehensive Form
~ Owned
~ Hired
I!] Non-Owned
POLICY NUMBER
77-SM-504-563-0001 12-01-8 12-01-8 Bodily Injury $ 500 $ 500
--_.._,------ -----,- fJroperly.Damage $ 100 $ 100
Bodily Injury and
Property Damage $ $
Combined
Persona/Injury
$
77-BA-504-563-0002
12-01-8
*
Bodily Injury
(Each Person)
Bodily Injury
(Each Accident) $
Property Damage $
Bodily Injury and
Property Damage $
Combined
Bodily Injury and
Property Damage
Combined
Statu1()fL__
$
500
EXCESS LIABILITY
~ Umbrella Form
77-CU-504-563-0004
12-01-8
12-01-8
$ 5,000
WORKERS'COMP~NSATION
AND
EMPLOYERS' LIABILITY
OTHER
Additional Information:
Description of Work. . S.i.gn. Mfg... .&. Erec.tion . . . . . . .
Location of Work. . . . Same. .and. .tem.porary. w.ork. . . .
. . 5.i tes. . elsewhere. .in. .the. .sta.te. of . FL . . . .
Insurance in force only for hazards indicated by X. *Continuous Until Cancelled
Nationwide agrees to mail the Certificate Holder named hereon at this indicated address (a) at least 10 days' prior notice of cancellation of the policy or policies and/or this certificate; except that this certificate
shall expire on the expiration date if it is shown above; and (b) notice of any other material change in the policy or policies.
This certificate is executed by Nationwide Mutual Insurance Company if said company has issued Date Certificate Issued
the policy to which this certificate is attached; it is executed by Nationwide Mutual Fire Insurance
Company if said company has issued the policy to which this certificate is attached.
Insured's Name and Address:
Sign Craft, Inc. Sign Craft of the
Palm Beaches, Inc. B. H. Vaughn &
1825 Church St. Realty, Inc.
1890 Church St.
West Palm Beach, FL 33401
Auto 5737-C
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01-25-85
NATIONWIDE MUTUAL INSURANCE COMPANY
NATIONWIDE MUTUAL FIRE INSURANCE COMPANY
Columbus, Ohio V2e
(}ff. ~~ (241:(
Countersigned at: Gainesville, FL Authorized Representative
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688 FL sh
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