LIQUOR LIABILITY - NEW BUSINESS DECLARATIONN x
FOUNDERS INSURANCE COMPANY
dba Prosure Insurance Company in Florida
1645 East Birchwood Avenue Des Plaines, IL 60018
(800) 972-8778 / Fax (847) 795-0080
W W W.FOUNDERSINSURANCE.COM
Following Policy Set For:
CITY OF CLEARWATER, FL
112 S OSCEOLA AVE.
CLEARWATER FL 33755
0- El?
n. 4 2009
t
LEA ,cTX
Reason for Policy Set Copy:
Additional Insured
LLFLOOD354
FOUNDERS INSURANCE COMPANY
dba Prosure Insurance Company in Florida
1645 EAST BIRCHWOOD AVENUE DES PLAINES, IL 60018 Liquor Liability
(800) 972-8778 / Fax (847) 795-0080 New Business Declaration
AGENCY ACCT EFFECTIVE 09/02/09
POLICY NUMBER OM POLICY PERIOD ro
LLFL000354 09/02/09 09/06/091 12:01 AM STANDARD TIME 2980 -0001
NAMED INSURED AND ADDRESS PRODUCER
CLEARWATER DESIGNER CO-OP ALL RISKS, LTD
411 CLEVELAND ST. #114 ALL RISK'S, LTD OF FLORIDA
CLEARWATER FL 33755 640 BROOKER CREEK BLVD STE 405
OLDSMAR FL 34677
(866) 363-1295
COVERAGES
THIS POLICY CONSISTS 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 LIQUOR LIABILITY COVERAGE ....................... $912.00
MINIMUM AND DEPOSIT PREMIUM ................................ $912.00;
FORMS THAT APPLY TO APPLICABLE COVERAGE PARTS
ENDORSEMENT NO EDITION DATE DESCRIPTION
..-FL-CSL -- 04-07 Florida Liquor Liability Coverage Part
ADDITIONAL --INSURED (S) _._... __....
AI# INTEREST NAME AND ADDRESS
?
1 ADDITIONAL INSURED 628 E CLEVELAND ST-CLE
LLC C/O ISTAR FINANCI - =
.
3480 PRESTON RIDGE RD. 5
.
, J
- ---- ---- -----
ALPHARETTA '='----- _
9
2 ADDITIONAL INSURED CITY OF CLEARWATER, FL (="
112 S OSCEOLA AVE. 1.PT
CLEARWATER FL 33755
3 ADDITIONAL INSURED PARAMOUNT POWER
7855 126TH AVE. N
LARGO FL 33773
IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THE
COVERAGE PARTS/POLICIES ATTACHED, WE AGREE WITH YOU TO PROVIDE THE INSURANCE
DESCRIBED THEREIN.
Surplus lines insurers' policy rates and forms are not approved by any
Florida Regulatory Agency.
Special Interest WWW.FOUNDERSINSURANCE.COM DATE 08/31/09
FOUNDERS INSURANCE COMPANY
dba Prosure Insurance Company in Florida
1645 EAST BIRCHWOOD AVENUE DES PLAINES, IL 60018
(800) 972-8778 / Fax (847) 795-0080 Liquor Liability
New Business Declaration
AGENCY ACCT EFFECTIVE 09/02/09
POLICY NUMBER FROM POLICY PERIOD T
LLFL000354 09/02/09 09/06;09 12:01 AM STANDARD TIME 2980 -0001
NAMED INSURED AND ADDRESS PRODUCER
CLEARWATER DESIGNER CO-OP ALL RISKS, LTD
411 CLEVELAND ST. #114 ALL RISKS, LTD OF FLORIDA
CLEARWATER FL 33755 640 BROOKER CREEK BLVD STE 405
OLDSMAR FL 34677
(866) 363-1295
LOCATION ADDRESS(ES)
LOCATION 01
628 CLEVELAND ST.
CLEARWATER FL 33755
COVERAGES
ITEM LOC TERR CLASS BASIS TYPE DED AMT EXPOSURE
001 1 001 3112 300
COVERAGE PER PERSON OCCURRENCE AGGREGATE PREMIUM
Combined Single Limit 1,000,000 2,000,000 $612.00
ADDITIONAL FORMS AND ENDORSEMENTS APPLICABLE TO THIS COVERAGE PART ONLY
NUMBER DATE LOC ITEM LIMIT PREMIUM
*CG 21 73 01-08 Exclusion - Terrorism 1 1
*FL 20 26 07-04 Addl Insd Designate Pers 1 1 $300.00
MINIMUM AND DEPOSIT PREMIUM ............ ....................... $912.00
Special Interest