CERTIFICATE OF INSURANCE
I Certificate of Insurance r
This is to certify that Hardware Mutual Casualty Company / Hardware Dealers Mutual Fire Insurance Company has issued to the
insured named herein such and so many of the kinds of insurance as are indicated herein by specific limits of liability and policy
number, and that such insurance is in force to the end of the term shown on this certificate.
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o Policy No.(s) ..'..,..,..,...............,..,..,....,..,..,'.........,....",'..,,'....
This certificate replaces the certificate previously issued.
Insured
and
Address
r WILLIAM H. HEINEMANN, INC.
3621 49TH STREET NORTH
ST. PETERSBURG, FLORIDA
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Kind of
Insurance
Workmen's Compensation
Policy No.
Term
From:
To:
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Limits
of
Liability
As provided by the Workmen's Com.
pensation Law Which Applies to the
Employees.
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has been canceled and rewritten.
Issued at ,..ST......PE.TE.RSBURG"....F.LORI.DA
Date ,., DE C EMBE.R." .1..0.,.....1.968,..,.,...".,...".
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General Lia.bility
Policy No. 09 025404 01
From:
To:
10-1-68
10-1-69
Automobile
Policy No.
From:
To:
o Owned Autos Described Below
o Non-Owned Autos
o Hired Autos
Bodily Injury
Each Person
Each Occurrence
Property Damage
Each Occurrence
Bodily Injury & Property Damage
(Combined Limit)
Each Occurrence
If any Additional Interest, check here a and show Additional Interest on reverse side. 0 Same as shown below.
Types of Coverage Provided:
[] Premises-Operations [] Elevator
o Completed Operations & Products
o Contractual*
IZJ Owners & Contractors Protective
Bodily Injury
Each Person $ 2 00 , 000
Each Occurrence $500 ,000
Aggregate Completed Operations
and Products
Property Damage
Each Occurrence $ 25 , 000
Aggregate - All Coverages Provided
Except Elevator
Bodily Injury & Property Damage
(Combined Limit)
Each Occurrence
Aggregate
Model Yr. Trade Name and Model Type of Body Ident. or Serial No. Motor No.
Desc~1tion
Automobile(s)
Insured
*Coverage is provided for liability assumed by the named insured for the contract between the named insured
and dated
in accordance with the Contractual Liability Insurance Part of the policy and for other contracts as defined in the
policy,
If cancelation or change occurs during the term or terms of such policy or policies, and after the date of this Certificate, in such
manner as to affect this Certificate, 10 DA YS written notice of such cancelation or change will be given to the firm or person
named below, in accordance with whose requirements this Certificate is issued. Notice by regular mail addressed shall be sufficient
compliance with this provision. HARDWARE MUTUAl. CASUALTY COMPANY
Name
and
Address
'CITY OF CLEARWATER
P. O. BOX 4748
CLEARWATER, FLORIDA
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F8Q-E701 Jl00M6"67
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HARDWARE DEALERS MUTUAL FIRE INSURANCE COMPANY
Secretary
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11 Certif icate of Insurance"
This is to certify that Hardware Mutual Casualt'y Company / Hardware Dealers Mutual Fire Insurance Company has issued to the
insured named herein such and so many of the kinds of insurance as are indicated herein by specific limits of liability and policy
number, and that such insurance IS in force to the end of the term shown on this certificate.
.,
,.
o Policy No.(s) .."..,.""........,....",....,...,....,..,.."..,.....",..".,..
This certificate replaces the certificate previously issued.
........,....,.......... has been canceled and rewritten.
Insured
and
Address
I
WILLIAM H. HEINEMANN, INC.
815 COURT STREET
CLEARWATER, FLORIDA
Issued at ..,S.T...P,ETERS.BU.RG..",ELOR1D,A
Date "",.. .,Mt\.~, P-l.. ,,? ~..I" ..1,9..9,~, ",...,...,.,.',..".,
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Kind of
Insurance
Workmen's Compensation
Policy No.
General Liability
Policy No. 09-025404-01
Automobile
From:
To:
, '"
Policy No.
From: "
To:
,
Term
From:
To:
10167
10 1 68
Types of Coverage Provided:
~. Premises-Operations [2g Elevator
o Completed Operations & Products
o Contractual*
~ Owners & Contractors Protective
Bodily Injury
Each Person 200, 000
Each Occurrence 500 , 000
Aggregate Completed Operations
and Products
Property Damage
Each Occurrence 10,000
Aggregate - All Coverages Provided
Except Elevator
Bodily Injury & Property Damage
(Combined Limit)
Each Occurrence
Aggregate
o Owned Autos Described Below
D Non-Owned Autos
D Hired Autos
Bodily Injury
Each Person
Each Occurrence
Limits
of
Liability
As provided by the Workmen's Com-
pensation Law Which Applies to the
Employees.
Property Damage
Each Occurrence
Bodily Injury & Property Damage
(Combined Limit)
Each Occurrence
If any Additional Interest, chick here [2{J and show Additional Interest on reverse side.
Model Yr. Trade Name and Model Type of Body Ident. or Serial No.
Desc~ttion
Automobile(s)
Insured
Motor No.
*Coverage is provided for liability assumed by the named insured for the contract between the named insured
and dated
in accordance with the Contractual Liability Insurance Part of the policy and for other contracts as defined in the
policy,
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If cancelation or change occurs durin..g the term or terms of such policy or policies, and after the date of this Certificate, in such
manner as to affect this Certificate, TEN DA YS written notice of such cancelation or change will be given to the firm or person
named below, in accordance with whose requirements this Certificate is issued. Notice by regular mail addressed shall be sufficient
compliance with this provision. HARDWARE MUTUAL CASUALTY COMPANY
Name
and
Address
l''f ';- - ;-:) P I
I MR. WILLIAM Me KENZIE
227 S GARDEN AVENUE
CLEARWATER, FLORIDA
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Secretary
HARDWARE DEALERS MUTUAL FIRE INSURANCE COMPANY
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15-66 F80-F701
Secretary
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ADDITIONAL INSURED
(State or Political Subdivisions - Permits)
, (GIIOl
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RECEIVEO'
, APR12 -1968 -
Effective Date~f This Endorsement 3/25/68
Issued to Willi AM H. HE I HE HAHN I NC
Address 3621 Z.gTH STREET NORTH
No. Street
For Attachment to Policy No.
~TIS~QffU81
TOW~!r Pfs~J~~SBURG
County
F L~tate
Policy Period: From 11/28/67 to 11/28/68
THIS ENDORSEMENT MODIFIES SUCH INSURANCE AS IS AFFORDED BY THE PROVISIONS OF THE POLICY RelATING
TO COMPREHENSIVE GENERAL LIABILITY INSURANCE, MANUFACTURERS' AND CONTRACTORS' LIABILITY INSURANCE,
OWNERS', LANDLORDS' AND TENANTS' LIABILITY INSURANCE
It is agreed that the "Persons Insured" provision includes as an insured any state or political subdivision thereof desig-
nated in the schedule below, subject to the following additional provisions:
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1. The insurance applies only with respect to operations performed by or on behalf of the namecl insured for
which the state or political subdivision has issued a permit.
2. The insurance does not apply to bodily injury or property damage
(a) arising out of operations performed for the state or municipality~ or
(b) included within the completed operations hazard.
3. If the Property Damage liability Coverage is not otherwise afforded, such insurance shall nevertheless apply
with respect to operations performed by or on behalf of the named insured for which such permit has been
issued subject to the limits of liability stated herein.
SCHEDULE
Designation of State or Political Subdivision: CITY OF CLEARWATER. FLA.. I NC . ,
A FLA. MUNICI'ALITY. CLEARWATER, FLA.
Limits of Property Damage Liability .
$ 2r. 000 each occurrence
ii, .
$ aggregate
Premium $
HARDWARE DEALERS MUTUAL FIRE INSURANCE COMPANY
HARDWARE MUTUAL CASUALTY COMPANY
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Secretary
Secretary
CG.71
MC.73
OL.72
SPII.71 JSM4.66
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ADDITIONAL INSURED
eState or Political Subdivisions - Permits)
(GIIO)
I
'RECEIVED
Effective Date of This Endorsement "/29/68
Issued to WILLIAM H. HEINEMANN INC
Address 3621No~9TH STRE~tTeetNORTH
For Attachment to Policy No.
MAY' 1 1968
09 R'l..cW"~
STow~~JWAURG
County
FLA
State
Policy Period: From 11/28/67
to 11/28/61
THIS ENDORSEMENT MODIFIES SUCH INSURANCE AS IS AFFORDED BY THE PROVISIONS OF THE POLICY RELATING
TO COMPREHENSIVE GENERAL LIABILITY INSURANCE, MANUFACTURERS' AND CONTRACTORS' LIABILITY INSURANCE,
OWNERS', LANDLORDS' AND TENANTS' LIABILITY INSURANCE
It is agreed that the "Persons Insured" provision includes as an insured any state or political subdivision thereof desig-
___~___~_nated in the schedule below, subject to the following ad~itional_ provisions:
1. The insurance applies only with respect to operations performed by or on behalf of the named insured for
which the state or political subdivision has issued a permit.
2. The insurance does not apply to bodily injury or property damage
ea) arising out of operations performed for the state or municipality, or
(b) included within the completed operations hazard.
3. If the Property Damage liability Coverage is not otherwise afforded, such insurance shall nevertheless apply
with respect to operations performed by or on behalf of the named insured for which such permit has been
issued subject to the limits of liability stated herein.
SCHEDULE
Designation of State or Political Subdivision: CITY OF CLEARWATER, CIO CITY CLERK'S
OF~ICE, CLEARWATER, ~LA.
Limits of Property Damage Liability
$ 25,000.
$
each occurrence
_...~-
aggregate
Premium
$ 2... 00 MIN.
HARDWARE DEALERS MUTUAL FIRE INSURANCE COMPANY
HARDWARE MUTUAL CASUALTY COMPANY
~
Secretary
~
Secretary
CG.71
MC.73
OL.72
SPII.71 J5M4.66
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April 19, 1968
Hardware Mutual Casualty 00.
771 Pasadena Ave. S
St. Petersburg, ~la.
Gentlemen:
.3 Y 7 - z H-3
HE: Policy No. 09-025_0"-01
Reoently you supp11ed Mr. William MaoKenzie a certificate
of insurance for the above noted policy number with the
in8u~~d be1ng William H. Heinemann Inc., with the City
of Olearwater being an additional insured.
We assume that as tbe City i8 an additional insured that
we will be notified ot any cancellations or changes
oocurring regarding this polioy, but we would appreciate
youmarklng your recorda for such notice to be glven,to
the City, ln oare ot The Clty Clerk's Orflce, and at the
tlme of renewal, pleue forward to this orflce the cer-
tiflcates showlng such renewal.
Thank you tor your ooope:r.tlon and attentlon to this
matter.
Very truly yours,
R. G. Whitehead
City Clerk
RGW:er