CERTIFICATE OF HOMEOWNERS INSURANCE
Homeowners
Renewal Declarations Page
DECLARATION EFFECTIVE:
DIRECT BILL
.._. UNM8SAl..... UN....I..V... E.......R...............S............A..................L..........IN........S...................U...................RANCE CO.....M......p. . ANY...
ofNoltb AiINItit:a
P.O. Box 45-9021
Sunrise, FL 33345-9021
Polie Number From
UITH0016491-1 04/18/06
NAMED INSURED AND ADDRESS:
Polie Period To
04/18/07 12:01 AM STANDARD TIME
AGENT: (727) 787-4338
RAYMOND BROZOVICH
RAY BROZOVICH AGENCY
1316ALT19N
PLAM HARBOR FL 34683
SANDRA LEWIN
708 NICHOLSON ST
CLEARWATER FL 33755
. Basic
Coverages
Premium
$1,251
PREMIUM SUMMARY
--Scheduled --
Property
Premium
$0
LOCA liON
YEAR USE NUM FAM OCCUP PROT CLASS TERRITORY
1994 Primary 1 Owner 3 81
FIRE POLICE PERSONAL PROPERTY
CODE CODE REPLACEMENT COST
251 251 N
Coverage is provided where premium and limit of liability is shown.
Flood coverage is not provided by the Company and is not part of this policy.
. Attached --
Endorsements
Premium
$-21
-Policyree---
and Surcharges
$27
FORM
HO-3
COUNTY
CODE
52
CONST
M
COVERAGES - SECTION I
Coverage A. Dwelling Liability
Coverage B. Other Structures
Coverage C. Personal Property
Coverage D. Loss of Use
LIMITS
$ 149,000
$ 14,900
$ 74,500
$ 29,800
Premium Charged For Hurricane Exposure: $] 96
Issued: 03/10/2006
04/18/2006
A ent Code
4614
TOTAt
Policy
Premium
$1,257
BCEG
99
PROOF OF
PRIOR INSURANCE
Y
PREMIUMS
1,221.00
INCL
INCL
INCL
SECTION I COVERAGES ARE SUBJECT TO A $1,000 NON-HURRICANE DEDUCTIBLE PER
LOSS, AND A 2% = $2,980 HURRICANE DEDUCTIBLE.
COVERAGES - SECTION II
Coverage E. Personal Liability
Coverage F. Medical Payments
LIMITS
$ 300,000
$5,000
LOCATION(S) OF PROPERTY INSURED
708 NICHOLSON ST CLEARWATER FL 33755
PREMIUMS
30.00
INCL
~Jfk
Countersignature
VIC DEC 07 05
Issued: 03/1 0/2006
Homeowners
Amended Declarations Page
DECLARATION EFFECTIVE:
DIRECT BILL
04/18/2005
_ UNIVERSALINSURANCECOJA'!~
P.O. Box 45-9021
Sunrise, FL 33345-9021
Claims: (888) 846-7647
Polic Number From
UITH0016491 04/18/05
NAMED INSURED AND ADDRESS:
SANDRA LEWIN
708 NICHOLSON ST
CLEARWATER FL 33755
Reason: AMENDED FIRST MORTGAGEE.
Polic Period To
04/18/06 12:01 AM STANDARD TIME
AGENT: (727) 787-4338
RAYMOND BROZOVICH
RAY BROZOVICH AGENCY
1316 AL T 19N
PLAM HARBOR FL 34683
A ent Code
4614
.. . Basic......-
Coverages
Premium
$1,073
$27
I
.~TOTAt. . ..-
Policy
Premium
$1,078
FORM
HO,...3
COUNTY
CODE
52
PREMIUM SUMMARY
....--Attached-..... _n ..Schedulecr..
Endorsements Property
Premium Premium
$-22 $0
LOCATION
YEAR USE NUM FAM OCCUP PROT CLASS TERRITORY
1994 Primary 1 Owner 3 81
FIRE POLICE PERSONAL PROPERTY
CODE CODE REPLACEMENT COST
251 251 N
. Coverage is provided where premium and limit of liability is shown.
Flood coverage is not provided by the Company and is not part of this policy.
POlicy Fee.
and Surcharges
CONST
M
BCEG
99
PROOF OF
PRIOR INSURANCE
Y
COVERAGES - SECTION I
Coverage A. Dwelling Liability
CoverageB. Other Structures
Coverage C. Personal Property
Coverage D. Loss of Use
LIMITS
$ 142,000
$ 14,200
$ 71,000
$ 28,400
PREMIUMS
1,043.00
INCL
INCL
INCL
Premium Charged For Hurricane Exposure: $ 409
Section I coverages are subject to $1,000 non-hurricane deductible per loss, and a $2,840 hurricane
deductible per loss.
COVERAGES - SECTION II
Coverage E. Personal Liability
Coverage F. Medical Payments
LIMITS
$ 300,000
$ 5,000
PREMIUMS
30.00
INCL
LOCATION(S) OF PROPERTY INSURED
708 NICHOLSON ST CLEARWATER FL 33755
Countersignature
IIw.slk
VIe AMD 0704