CERTIFICATE OF INSURANCE (049)
.-
~;. "',- .
CITY S.LEARWATER
INTER-OFFICE COMMUNICATION
DATE
3/27
, 18.JLS..
TO
City Clerk's Office
FROM
Claire - Engineering Dept.
SUBJECT
r.prti-Fir::ltp of Tn"'llr::Jnc:e... Sea Form
Systems Gulf Coast, Inc.
Here is an original that was sent to us with
the rest of our pre-qualification package.
I am sending on your original, and I have made
a copy for my file.
Thanks.
Claire
RECEIVED
MAR 28 19B!'
CITy: CLERK
[J PLEASE REPLY ON REVERSE SIDE
COMPANIES AFFORDING COVERAGES
A.J. Pi1et Insurance Agency,Inc.
p.O.Box 26068
New Or1ans, La. 70186
National Union Fire Insurance
COMPANY A
LETTER
COMPANY B
LETTER
COMPANY C
LETTER
COMPANY 0
LETTER
COMPANY E
LETTER
L10yds
Ii 1;
NAME AND ADDRESS OF INSURED
Sea Form Systems Gulf Coast , Inc.
365 South Van Ave.
Houma, La. 70360
MAR 28
TYPE OF INSURANCE
POLICY NUMBER
POLICY
EXPIRATION DATt
GENERAL LIABILITY
BODILY INJURY $
A
[1g COMPREHENSIVE FORM
[il PREMISES-OPERATIONS
o EXPLOSION AND COLLAPSE
H AZA RD
o UNDERGROUND HAZARD
Ga PRODUCTS/COMPLETED
OPERATIONS HAZARD
Ga CONTRACTUAL INSURANCE
Ga BROAD FORM PROPERTY
DAMAGE
Ga INDEPENDENT CONTRACTORS
Q PERSONAL INJURY
3/19/86
PROPERTY DAMAGE
Binder
(Renewal of S99 593 63)
BODIL Y INJURy AND
PROPERTY DAMAGE
COMBINED
$ 500
$ 500
PERSONAL INJURY
A
WORKERS' COMPENSATION
and
EMPLOYERS' LIABILITY
OTHER
3/19/86
AUTOMOBILE LIABILITY
o COMPREHENSIVE FORM
Ga OWNED
Ga HIRED
g NON-OWNED
BODILY INJURY
(EACH PERSON)
BODILY INJURY
(EACH ACCIDENT)
3/13/86
Binder
(Renewal of
BA9285493)
PROPERTY DAMAGE
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
$ 500
EXCESS LIABILITY
BODILY INJURY AND
PROPERTY DAMAGE
COMBINED
$ 1000
3/19/86
A
Q9 UMBRELLA FORM
o OTHER THAN UMBRELLA
FORM
Binder
(Renewal of
UM916 07 67)
Binder
(Renewal of
[EACH Ace DENT)
(Renewal of
10518)
On
400/400 of 100/100
Maritime
B
Excess Maritime
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES
Cancellation: Should any of the above described policies be cancelled before the expiration date thereof, the issuing com-
pany will endeavor to mail .lll....- days written notice to the below named certificate holder, but failure to
mail such notice shall impose no obligation or liability of any kind upon the company,
NAME AND ADDRESS OF CERTIFICATE HOLDER:
3/15/85
DATE ISSUED:
City of Clearwater
p.O.Box 4748
Clearwater, La. 33518-4748
ur-