CERTIFICATE OF INSURANCE FOR ENTRANCE MONUMENTS IN RIGHT-OF-WAY 2005
.Auto-Owners
Page
1 55039 (11-87)
Issued 04-01-2004
TAILORED PROTECTION POLICY DECLARATIONS
INSURANCE COMPANY
6101 ANACAPRI BLVD., LANSING, MI 48917-3999
Renewal Effective 05-15-2004
AGENCY CARLISLE FIELDS & CO INC
12-0025-00 MKT TERR 068 (727) 797-0441
INSURED MORNINGSIDE MEADOWS HOMEOWNERS
CIVIC ASSOC
POLICY NUMBER 952312-20517816-04
ADDRESS PO BOX 5182
Agency
Bill
POLICY TERM
12:01 a.m. 12:01 a.m.
05-15-2004to 05-15-2005
CLEARWATER, FL 33758-5182
In consideration of payment of the premium shown below, this policy is renewed. Please attach this
Declarations and attachments to your policy. If yoU have any questions, please consult with your agent.
COMMON POLICY INFORMATION
BUSINESS DESCRIPTION: Homeowners Assoc
ENTITY: Homeowners Assoc
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PART(S).
THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
COMMERCIAL GENERAL LIABILITY COVERAGE
PREMIUM
$362.00
TOTAL
$362.00
FORMS THAT APPLY TO ALL COVERAGE PART SHOWN ABOVE (EXCEPT GARAGE LIABILITY, DEALER'S
BLANKET, COMMERCIAL AUTOMOBILE, IF APPLICABLE)
55000 (01-87>
Countersigned By:
tAuto-Owners
Page
1 55040 (11/87)
Issued 04-01-2004
TAILORED PROTECTION POLICY DECLARATIONS
INSURANCE COMPANY
6101 ANACAPRI BLVD., LANSING, MI 48917-3999
Renewal Effective 05-15-2004
~~cv CARLISLE FIELDS S CO INC
12-0025-00 MKT TERR 068 (727) 797-0441
INSURED MORNINGSIDE MEADOWS HOMEOWNERS
CIVIC ASSOC
POLICY NUMBER 952312-20517816-04
ADDRESS PO BOX 5182
Agency
Bill
POLICY TERM
12:01 a.m. 12:01 a.m.
05-15-2004to 05-15-2005
CLEARWATER, FL 33758-5182
In consideration of paYDBnt of the premiu. shown below, this policy is renewed. Please attach this
Declarations and attachments to your policy. If you have any questions, please consult with your agent.
COMMERCIAL GENERAL LIABILITY COVERAGE
LIMITS OF INSURANCE
General Aggregate Limit
(Other Than Products-Completed Operations)
Products-Completed Operations Aggregate Limit
Personal And Advertising Injury Limit
Each Occurrence Limit
Fire Damage Limit
Medical Expense Limit
$500,000
500,000
500,000
500,000
50,000 Any One Fire
5,000 Any One Person
"General Aggregate Limit" shown above, is reinstated once per policy period at no
additional charge, in accordance with form 55050.
AUDIT TYPE: Non-Audited
FORMS THAT APPLY TO LIABILITV:
IL002l (11-85) 55081 (08-88)
IL0017 (11-85) 55050 (07-87)
CG2l47 (09-89) 55137 (06-92)
55181 (11-95) 59246 (05-00)
55084
55029
55064
55146
55145
Ul-95)
( 07-87)
( 07-87)
(07-96)
U2-01>
59351) (02-03)
CGOOOl (11-88)
C1175 (02-86)
55160 (11-95)
55229 (01-02)
55118 (08-91>
CG0220 (07-92)
55069 (01-88)
55163 (11-95)
LOCATION OF PREMISES YOU OWN. RENT OR OCCUPY
LOC 001 SLOG 001 2296 Habersham Drive
Clearwater, FL 33764
TERRITORY: 004
COUNTY: Pinellas
Classification Subline
CODE 41670
Homeowners S/Or Mobile Homeowners Prem/Op
Associations - No Buildings Or
Premises Owned Or Leased Except For
Office Purposes. Including Products
And/Or Completed Operations.
(Not-For Profit)
PremiLID
Basis
Rates
Premium
Prem/Op Prem
350
Each 1
1.024
$358.
CODE 49950
Additional Interests
Designated Per/Organizqtion L Prem/Op If Any
City Of Clearwater
$0.
FOREIGN TERRORISM - CERTIFIED ACTS SEE FORM 59350
$4.00
LOCATION 001 PREMIUM
$362.00
Agency Code 12-0025-00
Policy Number 952312-20517816
55163 (11-95
COMMERCIAL GENERAL L1ABILlT't
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - CONTROLLING INTEREST
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART,
SCHEDULE
;"""'~;;
Name of Person or Orghnization:
CITY OF CLEARWATER
(if no entry appears above, information required to complete this endorsement will be shown in the Declarations a
applicable to this endorsement.)
1.
WHO IS AN INSURED (Section II) is amended to in- 3.
elude as an insured the person(s) or organization(s)
shown in the Schedule, but only with respect to their
liability arising out of
a. Their financial control of you; or
b. Premises they own, maintain or control while
you lease or occupy these premises.
This insurance does not apply to structural alter-
ations, new construction and demolition operations
performed by or for that person or organization.
2.
The following is added to LIMITS OF INSURANCE
(Section III):
8. The limits of liability for the additional insured
are those specified in the written contract or
agreement between the Insured and the con-
trolling interest, not to exceed the limits pro-
vided in this policy, These limits are inclusive
of and not in addition to the limits of insurance
shown in the Declarations,
Includes copyrighted material of Insurance Services Office, Inc., with its permission
, Copyright, Insurance Services Office, Inc., 1984
Agency Code 12-0025-00
Policy Number 952312-20517816
55181 (11-95)
COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - DESIGNATED PERSON OR
ORGANIZA TION
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
1. WHO IS AN INSURED (Section II) is amended to include as an insured the person or organization shown in the
Schedule as an insured but only with respect to liability arising out of your operations or premises owned by or
rented to you,
2, The following is added to LIMITS OF INSURANCE (Section III):
8. The limits of liability for the additional insured are those specified in the written contract or agreement be-
tween the Insured and the designated person or organization, not to exceed the limits provided in this policy,
These limits are inclusive of and not in addition to the limits of insurance shown in the Declarations.
Includes copyrighted material of Insurance Services Office, Inc" with its permission
Copyright, Insurance Services Office, Inc., 1984