COMMERCIAL GENERAL LIABILITY COVERAGE AND COMMON POLICY DECLARATIONS
:'
l'
MAR-08-07 10:51 FROI.4-Accrdia Blnetits
New Hampshire Ins~ce Compan)-.../
Member oCthe American lnternational Group,lnc
Executive Offices: 70 Pine St.
New York, NY 10270
1-727-791-3063 T-955 P.002/00S F-073
o New '-v.".opsbire Insurance Company
5a 'GmnitC State ImWilIlce Company
o Ulinois 'National Insurance Company
o 'Other
COMMON POLICY DECLARATIONS
POLICY NUMBER 02-LX-2825977-7 01104/07 1M
POLICYTERM 1 Year
PRODUCiR NAMED INSURED
BOLLINGER INC. Js~ARWATER COUNTRY CLUB MANAGEMENT INC
101 JFKParkwllY; P.O. Box 390 BA CUAAWATER. COUNTtW CLUB
Short Hills, NJ 07078-0390 S2S NOR.m BEITY LANE
CLEARWATER,FL 33755
POLICY PERIOD: FROM 01101107 V' TO 01101/08/ ^ T 1~;o) Mf STAI'IDAI'W TIME AT YOUR Ml\1UNc; ADDRJ!SS SHOWN.
ADJUSTMENT DATE;
BUSINESS DESCRIPTION: COUN'1tY CLUB
IN RETURN fOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY,
WE AGREE WITH YOU TO PROVIDE THE ~SURANCE AS STATED IN THIS POLlCY.
-
THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS:
PBEMltJM
COMMERCIAL PROPERTY COVERAGE PART S NOT INCLUDED
COMMERCIAL INLAND MARINE COVERAGE PART S NOT INCLUDED
COMMERClAL CRIME COVERAGE PART $ I'ORM #79413 010S
I" ....COMMERCLl\L GENERAL LIABlLlTY COVERAGE PART $ INCLUDED
""" ...COMMERCIAL LIQUOR LIABILITY COVERAGE PART $ rNCLUDED
COMMERCIAL AUTOMOBn.E COVERAGE PART $ NOT INCLUDED
Total $ INCLUDED .--'---- ". - I
FORMS i\PPLICABLE TO ALL COVERAGE PARTS: ,~- -- I a-<{.n , ,{.OIl. \
"I . 1 1 4, ._.\ . ,,;...l.Ir'~
See Schedule ofFOJmS and Endorsements Att 1 0402 : :.17.: '.:~ I.~ ~::~: ,'.'." ~, iliJldl:. ".
j
i ;: .:'.:... I'~.'#': .::..:.. ~..... .. - .,.100"
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1 ------...-..--..-- _...._~-- . .
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I COUNTERSIGNED JanuarY 4. :2.0Q1
. 1lA. TE
· Iocludes Terrorism Cov. Premium of $19S
BY
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I
AtJ1lIORIZED ""'P~SENT ATIYE I
TOTALP~ $ INCLUDED.
THE POllCY MAY BE SUBJECT '"('0 ADroSTMENr
79545 (4/02)
Page 1 of!
MAR-OB-07 10:6\
FROM-Acordia Benefit;
1
'--./
1-727-791'.3063
T-955 P.003/006 F-073
-.'
Policy Number: 02-LX-2825977-7
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
SCHEDULE OF FORMS AND ENDORSEMENTS
The following forms and endorsements are attached to this policy effective at inception:
Form Number
19545
74825
78711
90231
91222
69644
IL0003
IL0017
IL0021
IL0255
0402
0201
0406
1205
0706
0705
0498
1198
0498
0300
CROS01
79413
CR0021
CR0206
0702
0105
0702
0702
79547
79262
CG0001
CG0057
CG2407
56332
76589
CG2024
CG2028
76164
C00220
0402
0402
1204
0999
0196
0793
0703
1185
1185
0600
0398
79549
79260
CG0033
0402
0402
1204
Att 1 0402
Fl'Um Title
COMMON POUCY FORMS AND ENDORSEMENTS
COMMON POLICY DECl..A:RA TIONS
FL ADDENDUM TO THE DECLARATiONS
ADDENDUM TO THE COMMON POLICY DEC.
FL NOTICE OF LOSS CONTROL SERVICES
POLICYHOLDER NOTICE
COVERAGE TERRITORY E:NDORSEMENT
CALCULATION OF PREMIIJM
COMMON POLICY CONDrrlONS
NUCLEAR ENERGY EXCLIJSION
FL CHANGES-CANCELLATION,NONRENEWAL
CRIME FORMS AND ENDORSEMENTS
CRIME COVERAGE DEC
COUNTRY CLUB CRIME EXTENSION ENDORSEMENT
COMMERCIAL CRIME COV {LOSS SUSTAINED FOR.M}
FLORIDA CHANGES
GENERAL L1ABIHTY FORMS AND ENDORSEMENTS
GENERAL LIABILITY DEC
GENERAL LIAS. EXTENSION ENDORSEMENT
COMMERCIAL GENERAL liABILITY
GENERAL LIABILITY AMENDATORY
PRODUCTS/COMPLETED OPERATION HAZARD
TOTAL LEAD EXCLUSION
FUNGUS EXCLUSION
ADDITIONAL INSURED--LAND LEASED
ADDITIONAL INS-LESSOR ILEASED EQUIP
EMPLOYMENT BENEFITS LIAB ENDT
FL CHANGES - CANCELLATION/NONRENEWAL
LIQUOR FORMS AND ENDORSEMENTS
LIQUOR DEe
CC LIQUOR ENDORSEMENT
L1aUOR LIABIUTY COVERAGE
Page 1 of 1
Includes copyrighted material of Insurance Services Offic'~, Inc. witl't its permission
Copyright, I nsurance Services Office, In,:., 1999
,
MAR-OS-OT 10:52 FROM-Acordla eenetits 1-72T-T91'-3063 T-965 P.004/005 F-073
T New tiampsmre lnSurancc !';Offipany I l'lc:w JiarnpSl'llfC lnsurance Lompany
Member of the American lntt.m~tional Croup, i~' ~ .'Granile Snlll~ Insul11nce Company
Executive Offices: 70 Pine St. 0 IlHnois National Insur.lJ\ce Company
New York. NY 10270. 0 Other
COMMERCIAL GENERAL LlABn,ITY
COVERAGE PART DECLARATIONS
NAMED INSURED EFFEC11VE DATE POUCY NUMBER
CLEARWATER COl,lNTRY CL.U.B MANAGEMENT INe OllOl/O7 02-LX-282S9n-7
DBA CLEARWATER COUNTRY Cl'l,'1l
FORM OF BUSINESS
D Individual o Joint Vcnt\lJ'e 53 Organi2arion (Oche!' man Partnership. Joint
D Limited Liability Company o Partnership Venture or Limited Liability Company)
--
ALL PREMISES YOU OWN. RENT OR OCCUPY. LOCAnON Of PREMISES:
1: 525 NORTH BE1TY LANE
CLEARWATER. FL 33755
TIIESE DECLARATIONS ARE COMPLETED ON THE ATIACHED COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCH:EDULE(S).
LIMITS OF INSURANCE
. ..... Oerteral Aggrl:gatc Limit I $ 3.000.000 /
" .....prod\lctS-CompIeted Operations' Aggregate Limit ,. 3.000.000 /
t' 1.000,000 .; ,
Personal Injury and Ad\'c:tti~ng Injury Limit S - Anyone pason or organii;lUion
Each Occurrc:nCC Limit $ /
1.900.000
Damase to Prmriscs Rented to You Limit $ 300.000 ./ - Any om: premises
M~CA1 Expense Limit . S 15.000 ,j Anyone person
RE'tROACTIVE DATE (For Claims Made CoveI'age Ooly)
This insurance docs nOt apply to any "bodily irlj\uy" or "property damage" which occurs. or an olbse committed, before the Retroactive
Date, if any, shown below:
Retroactive Date; N/A
(Enter (\ale or "NODe" ifno RetrQllCtive Date applies)
FORMS AND ENDORSEMENTS
FORMS A.'/IID ENDORSEMENTS ATI ACHED TO TJ-l.JS COVERAGE PART:
See Schedule or Forms aDd Endorsements Att 1 0401
.
PREMIUM
STATE TAX OR OT1iER.CHARGE (If Applicable): S
ADV ANCE PREMIUM FOR PREMISES/OPERATIONS $ 1NCLUDED
ADVANCE PREMImvt FOR PRODUCTS/COMPl.ETED OPERATIONS $ INCLUDED
TOTAL COVCRAGE PART PREMlUM $ INCLlJDED
'19547 (04/02)
Page 1 of2
,
MAR-OS-Or 10:53 FROM-Acordla Benefits l-r27-r91'.3063 1'-955 P.005/005 F-073 i
. C~J.vlMERCIAL GENERAL LIAlnL~ ~ y .
CQMl\1ERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE
:
NAMED INSURED EFFECTIVE DATE POLICY NUMBER I
CLEARWATER COUNTRY CLUB MA.~AGEMENT INe 01/01107 02-LX-282S977- 7
DBA CUAItW ATER COUNTRY CLUB
CLASS CODE pkEMnIM BASIS PREMISES/OPERATIONS
--...
11138 s ~l RAn~ PREMnlM
LOCATION EXPOSURE I.i':') INCLUDED INCLUDED
1 $2,340,493 ~ / t;tj"'
~ J- f>J ,-
CLASS DSSCRlPTION: PRODUCT/COMPLETED OPERATIONS
COUl'llRY CLUB RAnt PREMIUM
-
INCLUDED INCLTJDED
.
CLASS CODE PREMIli'M BASIS PREMISES/OPERATJONS
RAnt PREMIUM
LOCATION EXPOSURE
CLASS DESCRIPTION: PROI>UCT/COMPIEtEO OPeRATIONS
RAll! PREMIL'M
CLASS CODE PREMtuM BASIS PREMISES/OPERATIONS
RAn~ PREMITJM
LOCATION EXPOSt.1RE
CLASS DESCRJPTJON: PRODUCTICOMPLETED OPERATIONS
RATE PREMIUM
CLASS CODE PREMlUM BASIS Pru:MISESlOPERATIONS
RAn~ PREMIUM
LOCATION EXPOSURE .
CLASS DasCRlPTION; PRODUC1'/COMPLETED OPERATIONS
RATE PRErvlIUM
I
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79547 (04/02)
Page 2 of2
..
.Auto,."OwneT-
Page 1
AGENCY COPY
19020 <10-80)
Issued 11-15-2006
AUTOMOBILE POLICY DECLARATIONS
Renewal EffeetlVe01-01-2007
INSURANCE COMPANY
6101 ANACAPRI BLVD., LANSING, MI 48917-3999
AGENCV ACORDIA SOUTHEAST INC
12-0153-00 MKT TERR 052 (727) 796-6666
INSURED CLEARWATER COUNTRY CLUB MANAGEMENT
INC DBA CLEARWATER COUNTRY CLUB
POLICY NUMBER
95-624-060-00
CLEARWATER FL 33755-4709
Company Use 20-04-FL-9410
Company POLICY TERM
Bill 12:01 a.m. 12:01 a.m.
to
01-01-2007 01-01-2008
Yr_
AGE SyttBOL/COST TERRITORY CLASS/PG
004 SPL
Pinellas County, FL
ADDRESS 525 N BETTY LN
Policy change: Effective Date of Change "0_____ Dy_____
Cross out old infor.ation and write in changes.
DESCRIPTION OF ITEH INSURED
Comprehensive Liability
TOTAL
PREHIUM
$160.20
1.60
$161.80
COVERAGES
Combined Liability
FHCF Assessment
LIMITS
$lMi11ion occurrence
Additional Forms For This Item:
79547 (03- 06)
79539 (03-99)
79939 (03-05)
PREHIUM BASIS: Esti..ted cost of hire - liability $ If AnY
Florida Hurricane CatastroPhe Fund assess.ent applies.
(Subject to audit)
140
1. 1994 ISU PU
VIN: JAACL11L5T7208681
9
004
Pine11as County, FL
5CA
TOTAL
PREi'lIUH
$1,991.00
172.00
11. 00
54.00
65.00
151. 00
24.44
$2,468.44
COVERAGES
Combined Liability
Uninsured Motorist
Medical Payments
Personal Injury
Protection
Comprehensive
Collision
FHCF Assessment
LIMITS
$lMi11ion occurrence
$ 500,000 person/$ 500~000 occurrence
$ 2,000 person
$ 10,000
Actual Cash Value - $ 250 deductible
Actual Cash Value - $ 500 deductible
Interested Parties: None
Additional Forms For This Item:
79539 (03-99) 79939 (03-05)
79255 <12-01>
79308 (01-01>
79402 (07-94)
PREHIUM BASIS: Radius of operation - within a 100 .il. radius.
Florida Hurricane Catastrophe Fund assesSDent applies.
140
0010446
Page 2
AGENCY COPY
AUTO-OWNERS INS. CO.
AGENCY ACORDIA SOUTHEAST INC
12-0153-00 MKT TERR 052
INSURED CLEARWATER COUNTRY CLUB MANAGEMENT
19020 (10-80)
Issued 11-15-2006
Company POLICY NUMBER
Bill Company Use
95-624-060-00
20-04-FL-9410
2. 1990 TRLR 16FT UTLY
VIN: KMH080459
9
Term 01-01-2007 to 01-01-200E
5CA
004
Pine11as County, FL
COVERAGES
Combined Liability
Comprehensive
Collision
FHCF Assessment
LIMITS
$lMi11ion occurrence
Actual Cash Value - $ 250 deductible
Actual Cash Value - $ 500 deductible
TOTAL
Interested Parties: None
Additional Forms For This Item:
79539 (03-99)
79939 (03-05)
PREMIUM
$ Included
14.00
25.00
.39
$39.39
PREMIUM BASIS: Radius of operation - within a 100 .ile radius.
USE CLASS (00260): NOC Not Wholesale Or Retail Delivery.
Florida Hurricane Catastrophe Fund assessment applies.
This trailer has a load capacity of 2,000 pounds or less and/or is towed by an aut~ile with a load capacity
of 2,000 pounds or less.
140
0003000
3. 2004 TOYT TACOMA BASE/LTD/SR5
VIN: 5TENL42N24Z403304
4
5CA
004
Pinel1as County, FL
COVERAGES
Combined Liability
Uninsured Motorist
Medical Payments
Personal Injury
Protection
Comprehensive
Collision
FHCF Assessment
LIMITS
$lMi11ion occurrence
$ 500,000 person/$ 500,000 occurrence
$ 2,000 person
$ 10,000
Actual Cash Value - $ 250 deductible
Actual Cash Value - $ 250 deductible
TOTAL
Interested Parties: See Attached Schedule
Additional Forms For This Item:
79539 (03-99) 79939 (03-05)
79255 02-01>
79308 (01-01>
PREMIUM BASIS: Radius of operation - within a 100 .ile radius.
Florida Hurricane Catastrophe Fund assess.ent applies.
140
0011251
PREMIUM
$1,991.00
172.00
11.00
54.00
80.00
195.00
25.03
$2,528.03
79402 (07-94)
.Auto-wOwnet
Page 3
AGENCY COPY
19020 nO-80>
Issued 11-15-2006
AUTOMOBILE POLICY DECLARATIONS
Renewal Effective 01-01-2007
INSURANCE COMPANY
6101 ANACAPRI BLVD., LANSING, MI 48917-3999
AGENCY ACORDIA SOUTHEAST INC
12-0153-00 MKT TERR 052
(727) 796-6666
POLICY NUMBER
95-624-060-00
INSURED CLEARWATER COUNTRY CLUB MANAGEMENT
INC DBA CLEARWATER COUNTRY CLUB
ADDRESS 525 N BETTY LN
CLEARWATER FL 33755-4709
Co.pany Use 20~04-FL-9410
Company POLICY TERM
Bill 12:01 a.m. 12:01 a.m.
to
01-01-2007
01-01-2008
Policy change: Effective Date of Change "0_____ Dy_____ yr_____
Cross out old inforllation and write in changes.
DESCRIPTION OF ITE" INSURED
AGE
CLASS/PG
TOTAL POLICY PREMIUM
{
\"------
Forms That Apply To All Items:
79517 (01-00) 79524 (06-92)
79419 (03-99)
79001 (03- 99)
79540 (03-99)
79200 (06-92)
79550 (06-92)
79203 (06-92)
79706 (03-98)
You have elected Non-stacked Uninsured "otorist Coverage.
Policy Rate Code 0000
Billing Type: Company Bill - MONTHLY
Account 006662830
0900 514620 140
CLEAR-1
Countersigned By: ACORDIA SOUTHEAST INC
Page 4
AGENCY COPY
AUTO-OWNERS INS. CO.
AG~CY ACORDIA SOUTHEAST INC
12-0153-00 MKT TERR 052
INSURED CLEARWATER COUNTRY CLUB MANAGEMENT
19020 (10-80)
Issued 11-15-2006
Company POLICY NUMBER
Bill Company Use
95-624- 060 - 00
20-04-FL-94l0
SCHEDULE OF INTERESTED PARTIES
Term 01-01-2007 to Ol-01-200(
Applies to item(s): 0003
FORD MOTOR CREDIT
PO BOX 105704
ATLANTA GA 30348-5704
Interest: lienholder
SIP ID: GA024098
.Auto-Owner,
AGENCY COPY
19020 (10- 80)
Issued 11-15-2006
AUTOMOBILE POLICY DECLARATIONS
INSURANCE COMPANY
6101 ANACAPRI BLVD., LANSING, MI 48917-3999
AGENCY ACORDIA SOUTHEAST INC
12-0153-00 MKT TERR 052 (727) 796-6666
INSURED CLEARWATER COUNTRY CLUB MANAGEMENT
INC DBA CLEARWATER COUNTRY CLUB
Renewal Effective 01-01-2007
POLICY NUMBER
95-624-060-00
ADDRESS 525 N BETTY LN
Company Use 20-04-Fl-9410
Company POLICY TERM
Bill 12:01 a.m. 12:01 a.m.
to
CLEARWATER FL 33755-4709
.01-01-2007
01-01-2008
Policy change: Effective Date of Change Ko_____ Dy_____ yr_____
Cross out old information and write in changes.
SCheduled Drivers List
Listed below are drivers currently scheduled on this policy, Please compare the lis~ with
your current records and contact your agent with any changes that need to be made. We
will update the list accordingly for the next renewal.
Name:
Last
First
Date of Birth
Age MM-DD-CCYY State
43 02-09-1963 FL
26 07-31-1980 FL
44 01-12-1962 FL
63 03-14-1943 FL
39 12-30-1967 FL
26 06-26-1980 FL
47 08-04-1959 FL
2S 12-27-1981 FL
51 08-23-1955 FL
BURNS V
RONALD
-PEREZSAI.VADOR----e~r--
PETERSON ./
RICHARD
-HAlVERSTADI-______.~~~___
.SAND------------THOtlAS_
nCKSON -WILLIAtJ~
HERING ./
_WALKER
BYNUtl ,;'
KEITH
..--1'ODD.--
RICHARD
C(OJ-t
j (;> ~e.-f-"'"
I,/J ClJ~" "'.
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