LIQUOR LIABILITY CANCELLED DECFOUNDERS INSURANCE COMPANY
dba Prosure Insurance Company in Florida
1111 East Touhy Avenue, Suite 300, Des Plaines, IL 60018
(800) 972 -8778 / Fax (847) 795 -0080
W W W.FOUNDERSINSURANCE.COM
Following Policy Set For:
CITY OF CLEARWATER
100 SMYRTLE AVE.
CLEARWATER FL 33756
Reason for Policy Set Copy:
Additional Insured
Policy Set
Mailer Sheet
3
ELFL100182
FOUNDERS INSURANCE COMPANY
dba Prosure Insurance Company in Florida
1111 EAST TOUHY AVENUE, SUITE 300, DES PLAINES, IL 60018 Liquor Liability
(800) 972 -8778 / Fax (847) 795 -0080 Cancelled Dec
AGENCY ACCT EFFECTIVE 06/28/13
POLICY NUMBER
FROM POLICY PERIOD TO
ELFL100182
06/28/131 06/29/13
12:01 AM STANDARD TIME
2592
NAMED INSURED AND ADDRESS
PRODUCER
RUTH ECKERD HALL, INC.
111 MCMALLEN BOOTH RD.
CLEARWATER FL 33759
HULL & COMPANY
HULL & COMPANY OF TAMPA
800 CARILLON PARKWAY STE 150
ST. PETERSBURG FL 33716
(727) 561 -4855
THE NAMED INSURED IS RUTH ECKERD HALL, INC.
COVERAGES
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS /POLICIES
PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT.
COVERAGE PART /POLICY ATTACHED
COMMERCIAL LIQUOR LIABILITY COVERAGE
MINIMUM AND DEPOSIT PREMIUM
FOR WHICH A
PREMIUM
$415.00
$415.00
THE CANCELLATION OF THIS POLICY HAS RESULTED IN A
RETURN PREMIUM OF $415.00 -
FORMS THAT APPLY TO APPLICABLE COVERAGE PARTS
ENDORSEMENT NO EDITION DATE DESCRIPTION
FL -CSL 01 -11 Florida Liquor Liability Coverage Part
ADDITIONAL INSUREDS)
ADDRESS
CLEARWATER
AVE.
FL 33756
AI# INTEREST NAME AND
1 PREMISES OWNER CITY OF
100 SMYRTLE
CLEARWATER
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.
R _ . ``
qp a3 F,,
E.A. .wLA:i 1'E., ,«. ,..
Surplus lines insurers' policy rates and forms are not approved by any
Florida Regulatory Agency.
Special Interest WWW.FOUNDERSINSURANCE.COM DATE 06/30/13
FOUNDERS INSURANCE COMPANY
dba Prosure Insurance Company in Florida
1111 EAST TOUHY AVENUE, SUITE 300, DES PLAINES, IL 60018 Liquor Liability
(800) 972 -8778 / Fax (847) 795 -0080
Cancelled Dec
AGENCY ACCT EFFECTIVE 06/28/13
POLICY NUMBER
FROM POLICY PERIOD TO
ELFL100182
06/28/131 06/29/13
12:01 AM STANDARD TIME
2592
NAMED INSURED AND ADDRESS
PRODUCER
RUTH ECKERD HALL, INC.
111 MCMALLEN BOOTH RD.
CLEARWATER FL 33759
HULL & COMPANY
HULL & COMPANY OF TAMPA
800 CARILLON PARKWAY STE 150
ST. PETERSBURG FL 33716
(727) 561 -4855
LOCATION ADDRESS(ES)
TYPE DED AMT EXPOSURE PREMIUM
400 $400
OCCURRENCE AGGREGATE
1,000,000 1,000,000
TO THIS COVERAGE PART ONLY
LOC ITEM LIMIT PREMIUM
1 1
Pers 1 1 $15.00
LOCATION 01
400 BLCK CLEVELAND
CLEARWATER
COVERAGES
ST.
FL 33756
Fairs or Festivals
CLASS BASIS
4484
PER PERSON
Limit
AND ENDORSEMENTS APPLICABLE
Exclusion - Terrorism
Addl Insd Designate
DESCRIPTION:
LOC ITEM TERR
1 1 001
COVERAGE
Combined Single
ADDITIONAL FORMS
NUMBER DATE
CG 21 73 01 -08
FL 20 26 07 -04
MINIMUM AND DEPOSIT PREMIUM $415.00
Special Interest