POLICY CHANGE (4)LexisNexis is not the Insurance
Company.
For any and all policy changes you
must contact the Insurance Company,
the Carrier or the Producer listed in
the detail below.
If you are not the intended recipient,
please return this card.
IMPORTANT: INSURANCE COVERAGE NOTIFICATION(S)
LexisNexis is not the Insurance Company.
763833 - 8924184 -1 -A
LexisNexis /FIRSt
Mail Drop B1/290 -W
1000 Alderman Dr
Alpharetta, GA 30005
Place
Stamp
Here
-For any and all policy changes you must contact the Insurance Company, Carrier, or Producer listed in the detail below.
-For all cancellation, non - renewal, expiration, and lapse notices - all coverage will cease at 12:01AM local time at the premises, unless
otherwise shown in the item detail provided.
-If you want to receive future notifications electronically, email firstsupport@lexisnexis.com.
-This Insurance notice is sent to you as the Loss Payee /Mortgagee /Additional Interested Party on behalf of the carrier listed.
Policy:B1G7586H REASON: Policy Change Created: 09/23/2013 Eff. Dte: 09/13/2013
Carrier: OLD DOMINION INSURANCE COMPANY Pol. From: 05/25/2013 Pol. To: 05/25/2014
Loss Pay: CITY OF CLEARWATER -100 SOUTH MYRTLE AVENUE 2ND FLOOR - CLEARWATER -FL -34616
Insured: PREMIER FIRE SPRINKLERS INC -PO BOX 976 - RIVERVIEW -FL -33568
Insurance: MSA Group -P 0 Box 2004 - Keene -NH -03431
Producer: BUHL INSURANCE AGENCY INC -PO BOX 152698- TAMPA -FL -33684 813.876.0057
Deducts: Comp: 999,999 Coll: 999,999 Leased Vehicle: N State Reg: FL Eff. until cncld: N
PropDmg: 0 CSL 1,000,000
Add. Ins.: CITY OF CLEARWATER Vehicle: 2013 NOT ASSIGNED POLICY LEVEL INTEREST
Notes: PCNMTHE FOLLOWING ADDITIONAL INTEREST (ADDITIONAL INSURED - POLICY) HAS BEEN ADDED TO THE POLICY:
TRIAS CONSTRUCTION LLC 24710 STATE ROAD 54 LUTZ FL 33559- 6226THE INSURED NAME HAS BEEN CH FIRSt Id:
40231-/178-8920913-234545243