COMMERCIAL GENERAL & LIQUOR LIABILITY INSURANCE COVERAGE� '� FOUNDERS INSURANCE COMPANY
dba Prosure Insurance Company in Florida
1G45 EAST BIRCHWOOD AVENUE DES PLAINES, IL 60018 UNI - PAK
(800) 972-8778 / Fax (847) 795-0080 NeW Business Declaratian
AGENCY ACCT EFFECT�VE Og/O1/09
POLICY NUM6ER FROM pOLICY PERIOP TO
CPF'L000449 0�/O1/09 04/01/10 12:01 AM STANDARD TIME 2885
NAMEDINSURED AND AppR�SS PROpUCER
THOMAS & PATRICIA WOLKOWSKY ATLANTIC SPECIALTY LINES OF
DBA THE MARINA RESTAURANT AND FLORIDA, INC.
25 CAUSEWAY BLVD. 1595� BAY VISTA DRIVE STE 250
CLEARWATER BEACH FL 33767 CLEARWATER FL 33760
(727) 540-9100
COVERAGES
THIS FOLICY CONSTSTS OF THE FOLLOWING COVERAGE PARTS/POLICIES FOR WHICH A
PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
COVERAGE PART/POLICY ATTACHED PREMIUM
COMMERCIAL GENER.AL LIASTLITY COVERAGE ...................... $1,992.00
COMMERCIAL L�QUOR LIABILITY COVERAGE ....................... $325.00
FULLY EARNED COMPANY FOLICY F'EE ........................ $75.00
M�NIMUM AND DEPOSIT PREMIUM ................................ $2,392.00
FORMS THAT APPLY TO APFLICABLE C�VERAGE PA.RTS
ENDORSEMENT NO EDITION DATE DESCRIPTION
*CG 00 O1 10-0� Cammercial General Liability Coverage Form
*CG 00 62 12-02 War Liability Exclusion
*CG 21 01 11-85 Athletic or Sparts Participants Exclusion
*CG 21 39 10-93 Contractual Liaba�lity Limita�.ion
*CG 21 44 07-98 Limitation of Cov ta Designa�ed Premises
*CG 21 46 Q7-98 Abuse or Molestation Exclusion
*CG 21 47 07-98 Emp�.oymen�-Related Fractices Exclusion
*CG 21 49 09-99 Total Pollution Exclusion
*CG 21 66 12-04 Exclus�.on - Volunteer Workers
*CG 21 67 12-Q4 Fungi or Bacteria Exclusion
*CG 24 07 O1-9G Products/Completed Operations Hazard Redefine
*FL-CGL01 09-07 Florida CGL Mandatory Endorsement Addl Exc1
*FL-CSL 04-07 Florida Liquor Liability Coverage Part
*IL 00 21 07-02 Nuclear Energy Liability �xclusion Endo�semen
ADDITIONAL INSIIRED(S)
AI# INTEREST NAME AND ADDRESS
1 LANDLORD CITY OF CLEARWATER
MARINE & AVIAT�ON DEPARTMENT
25 CAUSEWAY BLVD.
CLEARWATER BEACH FL 33767
Special Interest
. - FOUNDERS INSURANCE CUMPANY
dba Prosurc lnsurance Company in Florida
]6a5 EAST B1RCHwOOD AVENUE DES PLAINES,IL 60018 General Liabili�y
(800) 972-8778 / Fax (847) 795-0080 New BuSineSS Declaration
AGENCY ACCT EFFECTIVE 04/01/09
PpLICY NUMBER FROM POLICY PERIOD Tp
CPFLOpp449 0�/01/09 04/01/10 12:01 AM STANDARD TIME 2885
NAM�D INSURED AND AD�RESS PRODUCER
THQMAS & PATRxCIA WOLKOWSKY ATLANTIC SPECIALTY LINES OF
DBA THE MARINA RESTAURANT AND FLORIDA, INC.
25 CAUSEWAY BLVD. 15950 SAY VISTA DRIVE STE 250
CLEARWATER BEACH FL 33767 CLEARWATER FL 33760
(727) 540-9100
'�,> . '\�
LOCATiON ADDRESS(ES)
LOCATION 1
THOMAS & PATRICIA WOLKOWSKY
DBA THE MARINA RESTAIIRANT AND
25 CAUSEWAY BLVD.
CLEARWATER BEACH FL 33767
COVERAGES
ITEM LOC TERR CLASS BASIS TYPE DED AMT EXPOSURE
001 1 006 1161 /OCC 325000
COVERAGE PER PERSON DCCURRENCE AGGREGATE PREMIUM
General Aggregate Limit 2,ODQ,000 INCLUDED
Each Occurrence Limit 1,Op0,000 INCLUDED
Medi.cal Expense Limit 5,Q00 INCLUDED
Personal and Advertising I 1,000,000 INCLUDED
Damage ta Premises Rented 50,000 TNCLUDED
Products-Completed Operati 1,000,000 INCLUDED
A.DDITIONAL FORMS AND ENDORSEMENTS APPLYCABLE TO THIS COVERAGE PART ONLY
NUMBER DATE LOC ITEM LIMIT PREMIUM
*CG 20 26 07-04 Addl Insrd Design Persan 1 1 $100.00
*CG 21 73 01-08 Exclusion - Terrorism 1 1
*FL-CGL02 09-07 Assault/Battery Exclusi�n 1 1
MINIMiJM AND DEPOSTT PREMIIJM--•--••-•-•--• ...................... $1,992.00
Special Interest
FOUNDERS INSURANCE COMPANY � • •
dba Prosure Insurance Coinpany in Florida
1645 EAST BIRCHWOpp AVENUE DES PLAINES,IL G0018
($00) 972-8778 / Fax (847) 795-0080 Liquar L�ability
New Business D�claration
AGENCY ACCT EFFECTIVE 04/p1./09
POLICY NUMBER FROM POLICY PERIOU TO
CPFL000449 �4/01/09 04/01/1� 12:Q1 AM STANDARD TIME 2885
NAMED INSURED AND ADDRESS PRODl10ER
THOMAS & PATRICIA WOLKOWSKY ATLANT�C SP�CIALTY LINES OF
DBA THE MARINA RESTAURANT AND FLORIDA, INC.
25 CAUSEWAY BLVD. 15950 BAY VISTA DRIVE STE 250
CLEARWATER BEACH FL 33767 CLEARWATER FL 33760
(727) 540-9100
.;.�. ��.
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LOCATION A,DDRESS ( ES )
LOCATION 1
THOMAS & PATRICIA WOLKOWSKY
DBA THE MARINA RESTAURANT AND
25 CAUSEWAY BLVD.
CLEARWATER BEACH FL 33767
COVERAGES
ITEM LOC TERR CLASS BASTS TYPE DED AMT EXPOSURE
001 1 001 1161 25000
COVERAGE PER PERSON OCCURRENCE AGGREGATE PREMxUM
Combined Single Limit 1,000,000 1,OOQ,000 $225.00
Fully Earned PQ1icy Fee $75.00
A.DDITIONAL FQRMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE PART ONLY
NUMBER DATE LOC ITEM LIMIT PREMIUM
*CG 21 73 01-Q8 Exclusion - Terrorism � �
*FL 20 26 07-04 Addl Insd Designate Pers 1 1 $100.�0
MINIM[TM AND DEPOSIT PREMIUM .................................. $400.00
S pecial Interest