COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS �7 COMMERCIAL GENERAL LIABILITY COVERAGE
L PART DECLARATIONS
E]°X°IF SUPPLEMENTAL DECLARATIONS ATTACHED
e'
1.POLICY NO.: VBA256791 00 EFFECTIVE DATE: 9/7/2013
SUNSETS AT PIER 60 SOCIETY, INC.,
2.NAMED INSURED: C/0 CRAIG WEST-BANK OF TAMPA DBA
3.LIMITS OF INSURANCE
General Aggregate Limit(Other Than Products-Completed Operations) $ 2,000,000
Products-Completed Operations Aggregate Limit $ 2,000,000
Personal and Advertising Injury Limit $ 1,000,000
Each Occurrence Limit $ 1,000,000
Damage To Premises Rented To You Limit $ 100,000 Any One Premise
Medical Expense Limit _ $ 5,000 Any One Person
Coverage A of this insurance does not apply to injury caused by a wrongful act which was committed before the Retroactive Date, if any
shown here: Retroactive Date:Norte(Enter Date or"None'it no Retroactive Date)
LOCATIONS INCLUDING 21P CODE OF ALL PREMISES YOU OWN, RENT OR OCCUPY(Enter-same-it same location as your mailing address):
1. PIER 60, CLEARWATER,FL 33755
Your interest in such premises: ®Owner ❑Lessee ❑Tenant ❑Other
CODE I PREM PREMIUM EXPOSURE RATE ADVANCE PREMIUM
NO. NQ.
CLASSIFICATION BASIS AMOUNT PRfCO ALL OTHER PR/CO ALLOTHER
10132 Bazaars-operated by the Sales 151,000 Inc] 8238 Incl $1,244.00
insured-Not-For-Profit only
49950 Additional Insured Each 1 Inc] Incl Inc[ Incl
TOTAL ADVANCE PREMIUM FOR THIS PAGE $ .00 $ 1.244.00
7OTALADVANCE
PREMIUM FOR THIS $ 1,244.00
COVERAGE PART
4.FORMS AND ENDORSEMENTS APPLICABLE(other than applicable Forms and Endorsements shown elsewhere in this policy)
'Forms and Endorsements applying to this Coverage Part and made a part of this policy at time of issue:
SEE SCHEDULE OF FORMS AND ENDORSEMENTS—GBA90DO02
`Entry optional if shown on Common Policy Declarations
5. FORM OF BUSINESS:
❑ Individual ❑Joint Venture ❑Partnership ❑Limited Liability Company 23 Corporation ❑Other
THESE DECLARATIONS, WHEN COMBINED WITH THE COMMON POLICY DECLARATIONS, THE COMMON POLICY CONDITIONS,
COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE
CONTRACT OF INSURANCE.
Includes copyrighted material of Insurance services Office,Inc.,with its permission.
Copyright.Insurance services.Ina.,1964..
GBA 100001 0312 Page 1
POLICY NUMBER:VBA256791 00 COMMERCIAL GENERAL LIABILITY
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED - OWNERS OR OTHER INTERESTS
FROM WHOM LAND HAS BEEN LEASED
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART.
SCHEDULE
Designation of Premises(Part Leased to You):
PIER 60
CLEAR WATER,FL 33755
Name of Person or Organization:
CITY OF CLEARWATER
100 S MYRTLE AVE
CLEARWATER,FL 33756
(If no entry appears above, information required to complete this endorsement will be shown in the Declarations as
applicable to this endorsement.)
WHO IS AN INSURED (Section ll) is amended to This insurance does not apply to:
include as an insured the person or organization 1. Any "occurrence" which takes place after you
shown in the Schedule but only with respect to liability cease to lease that land;
arising out of the ownership, maintenance or use of
that part of the land leased to you and shown in the 2. Structural alterations, new construction or demoli-
Schedule and subject to the following additional ex- per operations performed or on behalf the
clusions: person or organization shown n in the Schedule..
CG 20 24 11 85 Copyright, Insurance Services Office, Inc., 1984 Page 1 of 1 0