CERTIFICATE OF INSURANCE (028)
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FLORIA CONSTRUCTION, COMMERCE and't\lDUSTRY
SElF INSURERS FUND
P.O. Box 1616
Sarasota, Florida 33578-1616
CITY OF CLEARWATt..R
TO: P.o. "O~ 474d
CLEARWATER
FL 33518
This islo certify that:
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11 /2! /84
DATE
CIT,'{ CLER
being subject to the provisions of the Florida Worker's Compensation Act,
has secured the payment of compensation by insuring tlleir risk witbttte
FLORIDA CONSTRUCTION, COMMERCE AND I~DUSTRY S~~H'~StJRERS FUND.
COVERAGE IS SliP-.JEeT TO CANCta'LLATION YITH:llP'.Q.-VS NOTICE TO (~SL)kFD
SERVICED BY: F.C.C.!. Claims Service ... ..
P. O. Box 25248
Sarasota, FL 34277-2248
AGENT: 00122 - 01
...... Respectfully submitted,
COVERAGE NUMBER: 01934 - u 1
EFFECTIVE DATE: 1/011R5
EXPIRATION DATE:12131/~S
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F .C.C.I. members last year, still with the Fund, will receive refunds of up to 59% of premium, based on GOOD SAF ETY EXPER I ENCE. 30