AMENDED DECLARATIONSf?J'FOREMOST
AMENDED
iiusuRaNCr= COMPANY DECLARATIONS
Admin1wralivo Office
P.O. Box 2450
Grand Rapids, Michigan 49501
AMENDED DECLARATIONS EFFECTIVE 0$/15/2009
SUPERSEDES ANY PREVIOUS DECLARATIONS BEARING
THE SAME POLICY NUMBER FOR THIS POLICY PERIOD.
REASON FOR CHANGE: POLICY INFORMATION.
IARA CATHARINA WALSH
1720 DUNBAR LN
CLEARWATER FL 33756-1315 INSURANCE COUNSELORS INC
1 GEICO BLVD
FREDERICKSBURG VA 22412-9000
Vehicle Insurance $ 235.33
Additional Prem um esu t ng From This Change
$. --- 0.00
Operator Name License Number State Birth Date
#1 IARA CATHARINA WALSH W420403566060 FL 03/26/1956
::.......... .:
OTHER AMOUNTS THAT APPLY TO YOUR POLICY INSURANCE
FHCF SURCHARGE ..$ 2.33
$ 2.33
VEHICLE INSURANCE COVERAGES LIMITS OF LIABILITY PREMIUM
PART A - LIABILITY
BODILY INJURY $100,000 EA PERS/ $300,000 EA ACCIDENT $ 12.00
PASSENGER LIABILITY INCLUDED
PROPERTY DAMAGE $100,000 EA ACCIDENT $ 5.00
PART B - MEDICAL PAYMENTS
276-0072144223 -001 ADDITIONAL INSURED Form 081000 06/94 PAGE 1
MEDICAL PAYMENT
PART C - UNINSURED MOTORIST
UNINSURED MOTORIST BI
PART D-DAMAGE TO YOUR VEHICLE
COLLISION
OTHER THAN COLLISION
... ADDITIONAL INSURED
CITY OF CLEARWATER
PO BOX 4748
CLEARWATER FL 33758-4748
$1,000 EACH PERSON $ 5.00
$100,000 EA PERS/ $300,000 EA ACCIDENT $ 32.00
ACV NOT TO EXCEED $18,000 $ 77.00
LESS $250 DEDUCTIBLE
ACV NOT TO EXCEED $18,000 $ 102.00
LESS $250 DEDUCTIBLE
Annual Premium By Vehicle $ 233.00
VENICLE INSL RAND $ 235 33
NUAL PREM ? .... .
!' ANI ;ENDORSEMENTS
PROCESSED: August 17, 2009
276-0072144223
-001 ADDITIONAL INSURED
Form 081000 06/94 PAGE 2
I
FOREMOST
INSURANCE COMPANY GRAND RAPIDS, MICHIGAN
EN 721530
276-0072144223
INSURANCE COUNSELORS INC
1 GEICO BLVD
FREDERICKSBURG VA 22412-9000
CITY OF CLEARWATER
PO 80X 4748
CLEARWATER FL 33758-4748
CITY OF CLEARWATER :
We provide insurance coverage for:
IARA CATHARINA WALSH
1720 DUNBAR LN
CLEARWATER FL 33756-1315
Loan Number:
Policy Period: 08/15/09 to 08/15/10
Policy Number: 276-0072144223 01
If you have questions about this policy, please contact:
1-888-395-1200
INSURANCE COUNSELORS INC
1 GEICO BLVD
FREDERICKSBURG VA 22412-9000
To report a claim, call toll-free, 1-800-527-3907.
Form 738879 10/05
661 276'0072144229
ADDITIONAL INSURED
338702/01
PART A - Liability Coverage
B.3. includes, for "your covered off-road vehicle", the
person or organization named in the Declarations as
additional insured but only with respect to legal
responsibility for acts or omissions of a person for whom
coverage is afforded under this Part.
1. If we terminate this policy, notice will also be
mailed to the additional insured.
2. The additional insured is not responsible for
payment of premiums.
3. The designation of the person or organization as
an additional insured shall not operate to Increase
our limits of liability.
All other provisions of your policy apply.
Includes copyrighted material of Insurance Services Office, Inc., with its permission.
338702/01 Copyright, Insurance Services Office, Inc., 1986, 1992