CERTIFICATE OF LIABILITY INSURANCE (104)
NOTICE OF CANCELLATION
LiAbilit:'
(KIND OF POLICY)
.
,
!\I LED:
I ISSUED TH~OUGH AGENCY OR Ol"'FICE AT FOR CANCELLATION
F9~p'" A W9[..:l9Aolii,..FLORIDA RoD-P.,....t:
IS CANCELL
5/20
1~4 -
..-overa of Plori4a,
a Ucftaniel 4ba
o 41th Ave. 110.
PetarUur:9', PL 3370lTY CLERK
MAY 8
..
CCI ..L. Jtadpn ,
I P.o. Box "00
Clearwa~, PL
d..~y of 8t:. Pe
175 5~ St. 110
S~. ..~
RECEIVED
....J
:)tified that inaCoord~Aj;;~1~~l:Ij '1:~,:rll1sandconditionscpftbe al;lpve~J1ti9ned'policy. yourinsura
~date mentioned abov~..I"" ...... ......
, , " :-.- ',' _ ",_':',:', ,:':...:::: _'>/- ," ,,' _: _ ,;' ",::,:,,"}\,:_,>,:-;:iYj.::,'
lsheen paid, premium adjUs~l'l'l~~~c~Jllbe madeass90rya.spracti~bleaftercl2ncellation becomes ef
).tbeen paid, abUI for the premiu!'l;le~~~gi~o,J~.~jmeof cancellation)ll/i11 be. forwarded in due COU
i.:,
i'"
Gr_t:lIoubv...
(COMPANY)
HULL & COMPANY,
City of c:leuwa1:er
P.o. IIox 47.'
Clearwater" PI. 33511
St. .~ Jr. CDl1eqa
P.o. Box 13..9
ft. PetanbarCJ, PI. 33733
AUTHORIZED REPRESEN-
CERTIFICATIO
I hereby certify that I personally ma
Office at the place and time stamped he
cellation, an exact carbon copy of whic
at said time received from the U.S. Pc
(Form 3817) hereto attached.
Signed this
day of
Signature
EXTRA COPY