CERTIFICATE OF INSURANCE (4)
INSURANCE FROM
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CERTIFICATE OF INSURANCE
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The Policy identified below by a policy number is in force on the date of Certificate Issuance. Insurance is afforded only with respect to those coverages for which a
specific limit of liability has been entered and is subject to all the terms of the Policy having reference thereto including for Umbrella Excess Third Party Liability
Insurance a provision requiring the maintenance of underlying insurance or self insurance. This Certificate of Insurance neither affirmatively nor negatively amends,
extends or alters the coverage afforded under any policy identified herein.
In the event of cancellation of the Policy the Company issuing said Policy will make all reasonable effort to send notice of cancellation to the Certificate Holder at the
address shown herein, but the Company assumes no responsibility for any mistake or for failure to give such notice.
NAME AND ADDRESS OF INSURED
William H. Heinemann, Inc.
3621 - 49th street, N.
st. PetersburQ FL 33710
NAME AND ADDRESS OF WdlFICATE HOLDER
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DATE OF CERTIFICATE ISSUANCE:
CITY OF CLEARWATER
P.O. Box 4748
Clearwater, FL 33518
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r 18 1978
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R. S. HAMMERSCHLAG & CO.
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L. Williams, ~ City Cleri<
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City of Clearwater, Florida is an additional insured as respects
the propertY at 815-25 Court street, Clearwater, Florida
TFOS CERTIFICATE IS ISSUED AS A MAnn OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE HOLDER
LIMITS OF LIABILITY
TYPE OF INSURANCE IS DESIGNATED BELOW COVERAGES
EACH PERSON EACH OCCURRENCE
I. o Comprehensive Automobile Liability Bodily Injury Liability $
o Basic Automobile Liability Property Damage Liability
Bodily Injury and Property
Damage Liability Combined
o Uninsured Motorists Uninsured Motorists
II. gj Comprehensive General liability Bodily Injury liability
o Owners', landlords' and Tenants' Liability Property Damage Liability
0
o Manufacturers' and Contractors' Liability Bodily Injury and Property
o Owner's and Contractor's Protective liability Damage Liability Combined
o Beauticians' Malpractice Liability Bodily I njury Liability $
Property Damage Liability
III. 0
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IV. 0 Workmen's Compensation
Employers' Liability
V. 0 Umbrella Excess Third Party Liability
A. Statutory Statutory locations:
B. Bodily Injury $ t
The Excess Insuror's limit of liability is (Complete one)
(a) $ in excess of a Retained limit
(b) Up to $ in excess of a Retained Limit
and in excess of various underlying Insuror's Limits of Liability
t each Accident
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Complete below, by designating company by number in the box and entering policy number and expiration date in the sections corresponding to the type of insurance
indicated above.
I. II. SP 429 13 21 111. Policy Number
0 IT] 6-15-79 0 Expiration Dote
IV. v. Policy Number
0 0 Expiration Dote
OJ Continental Casualty Company
OJ Transportation Insurance Company
m Notional Fire Insurance Company of Hartford
m Transcontinental Insurance Company
rn American Casualty Company of Reading, Po.
m Volley Forge Insurance Company
G-32343,J
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