CERTIFICATE OF INSURANCE (3)
NORTHVlESTERN NATIONAL IN~CE GROUP
HOME OFFICI731 NORTH JACKSON STREET · MILW,'UKEE, WISCONSIN 53201
(1) NORTHWESTERN NATIONAL INSURANCE COMPANY OF MILWAUKEE, WISCONSIN
(2) NORTHWESTERN NATIONAL CASUALTY COMPANY (3) UNIVERSAL REINSURAN~E_H>'JiP~RATION
(4) OREGON AUTOMOBILE INSURANCE COMPANY REl.., ~'1......,
NOV 9 1977
CERTIFICATE OF INSURANCE
This is to Certify, that poHcies in the name of
~rrx {;LEftK.
I
NAMED
INSURED
and
ADDRESS
L
I
U. S. HOME CORPORATION AND ITS WHOLLY OWNED
SUBSIDIARIES
One COUlltryside Office Park
Clearwater, FL 33515 ~
THIS CERTIFICATE OF INSURANCE NEITHER
AFFIRMATIVELY NOR NEGATIVELY AMENDS,
EXTENDS OR ALTERS THE COVERAGE AF-
FORDED BY ANY POLICY DESCRIBED HEREIN.
are in force at the date hereof, subject to all of their provisions, terms and conditions, and have been issued by the company indicated, as follows:
eo ---- ~ --K IND-OF ---..-.- ---- .--POI.TCT ----.-.-,-- -._.. .POLlCY -_ow ~--[IM ITs-or -U ABII:I TY-- ~-- .
NO. INSURANCE NUMBER PERIOD BODIL Y INJURY PROPERTY DAMAGE
*
1 WORKMEN'S COMPENSATION WC 577387 Eft, 11-1-77 Provided by Workmen's NIL
AND Exp, 11-1-78 Compensation Law-State of
2 EMPLOYER'S LIABILITY WC 625193 All states except me nopolistic state
funds
$ 100,000 Employer's Liability
1 COMPREHENSIVE GENERAL CLA 783711 Eff. 11--1-77 $ ,000 Each Occurrence $ ,000 Each Occurrence
LIABILITY INCLUDING Exp. 11-1-78 $ ,000 Aggregate $ ,000 Aggregate
rJ Contractual Liability
19 Prod, and Comp, Operations a combined single I imit of $ 5,000 ,000 Each Occurrence
MANUFACTURER'S AND Eft, $ ,000 Each Occurrence I: ,000 Each Occurrence
CONTRACTOR'S LIABILITY Exp. ,000 Aggregate
a combined single I imit of $ ,000 Each Occurrence
OWNERS' LANDLORDS' Eft. $ ,000 Each Occurrence 1$ ,000 Each Occurrence
AND TENANTS' LIABILITY Exp.
a combined single limit of $ ,000 Each Occurrence
OWNERS' AND Eft $ ,000 Each Occurrence I: ,000 Each Occurrence
CONTRACTORS' PROTECTIVE Exp. ,000 Aggregate
a combined single limit of $ ,000 Each Occurrence
AUTOMOBILE LIABILITY
o Owned Automobiles Eft. $ ,000 Each person $ ,000 Each Occurrence
o Hired Automobiles Exp, $ ,000 Each Occurrence
..... [IN.on,OwnPM AlItomnhil"'5.. . ...-.... .... -. . - a_ combin.ed.slnglelimit of $ _ M_ ,OOOJ;a~h Occurrence
COMPREHENSIVE AUTO- Eft 11-1-77 $ ,000 Each person [J~ ,000 Each Occurrence
1 MOBILE LIABILITY CLA 783711 Exp. 11-1-78 $ ,ODD Each Occurrence I CLUDED ABOVE
a combined single limit of $ ,000 Each Occurrence
OTHER: Eft.
Exp,
*NOTE: Company Number refers to the Company designated at the top of the form.
Description, Location of Operations, Automobiles Covered or Remarks:
In the event of any material change in, or cancellation of, said policies, the company will
endeavor to give 30 days written notice to the party to whom this certificate is issued, but
failure to give such notice shall impose no obligation nor liability upon the company.
CERTIFICATE ISSUED TO: I).
I !".:,- -," V I
NAME City of Clearwater I October 26,
and , \.~ _ 19
ADDRESS 315 Haven Street \
-.
Clearwater, FL 33516 ~\r (-
L \\ '\ ~
l~
13021 (9-751 ORIGINAL