CERTIFICATE OF INSURANCE (030)
MI NATIONWIDE I
'!JI t~o~~~~~U~i~
I
CERTIFICATE OF INSURANCE -(COI)
RECEIVED
EXCESS LIABILITY
.XUmbrel1a Form
HOME OFFICE: ONE NATIONWIDE PLAZA. COLUMBUS, OHIO .3216 I.J I... \,., ~ J984
The Nationwide Mutual Ins. Co. or the Nationwide Mutual Fire Ins. Co.
certifies that the insurance afforded by the policy or policie(:~~t9~~~
described below is in force as of the effective date of this certi(ica~e ana'
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: 11-29-84
Certificate Holder's Name and Address: Insured's Name and Address:
Clty 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
DESCRIPTIVE SCHEDULE West Palm Beach, FL 33401
POLICY LIMITS OF LIABILITY
POLICY # EFF.DATEIEXP.DATE IN THOUSANDS (000)
I .... .. . ..! . .... .... .. I .. .1 lEACH ! AGGRE
t77SM"';504563-000T f 12"';01-84 r 12-0 1-8S1 I OCCUR r'::GA TE
! I I !Bodily! I
! I I I Injury I $500 1$500
I I I !Property! I
I I 1 lDamage 1$100 1$100
I ! 1 ! Bodily! !
I I l IInjury &! !
, I I I P D 1$ 1$
I I I I .. I I
! I 1 !Combined: I
, I I 1 I
I I I ( I
: !:: Personal !$500
I I I I Injury :
I I I I I
I [I I I
I I I I I
I I (I I
I ! I !Bodily Injury I
! 77BA-504563 -0002 ! 12-01-84112-01-85 : (Each Person) l $
I I!: Bodily Injury :
! ! I l(Each Ace.) 1$
I I I I P D 1 $
I I ( { rop. amage I
! I! !Bodily Injury :
I I I l&P.D. Combinedl$500
I I: !Bodily Injury !
:TICH,...50.4563...0004...l12",.D 1-84112-01-85 ! &P-rop~Damage l$5000
I !! I Combined
I I! IStatutory!
I I I I 1$
I I I I I
I 'I
I I I
I I I
I I I
Additional Information: lDescription of Work: Sign Manufacture.
I. & Erection. . .
ILocation Of Work: Same & temp work. .
!sites elsewhere in the state of FL. .
Insurance in force only for hazards indicated by X. Nationwide agrees to
mail the Cert. Holder named hereon at this indicated address (a) at least 10
days' prior notice of cancellation of the policy or policies and/or this
cert.; except that this cert. 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
has issued the policy to which this certificate is
by Nationwide Mutual Fire Ins. Co. if said company
which this COI is attached.
Countersigned at: Albertz Ins. Agency, Lake Worth, FL #688FL
WORKERS' COMP &
EMPLOYERS' LIABILITY
OTHER
(Each
Ace)
TYPE OF INSURANCE
GENERAL LIABILITY
- . XGomp. Fa rm-
XPremises-Operation
Explosion & Collapse
Hazard
-Underground Hazard
XProducts/Completed
Operations Hazard
-Contractual Ins.
-Broad Form Property
Damage
Xlndepend. Contractor
XPersonal Injury
Broad Form Compo
G.L. Endorsement
AUTOMOBILE LIABILITY
XComprehensive Form
XOwned
XHired
XNon-Owned
Ins. Co. if said company
attached; it is executed
has iS~H~d the polic~ to
33