HOME BUSINESS INSURANCE POLICY DECLARATIONS (2) aQP-1M1U__' II Insurance Cornpan.v
PQoruaJL6116l5
Renewal of Numbpr Forimi Appficable
Pollicy No. OP10115993 HOME BL)SINESS INSURANCE POLICY OStandard Speciall
II)EC."LARATIONS
Narned Insured and Mailing Address: Adi-ninilstrator Narne and Mading Address:
Richard Sarnlin, Rick Martin FAIIA Member Services,ins;.
DBA The Tricky Do.4t,Show I
1648 San Charles D ve PO Box 16579
Dunedin,FL 34698 Tell lah assee,F L 32317 ......
Policy Period, Insured's Brokering ABeni:
From 05,(0111f,'
,I, to 05M 1117 at 12.011 kk* Phoenix insurance Services
StandardTirne at your rl'iaifing address shown above,
*Exceptions.,
12DO noon in Mich4an,Nw1hGaroUna, and I'luolo Rica
in return for the payinent cA the prerniurn,w!KI sut)jert to all ffie terms of tNs policy,we aqree�with ycw to provide the insuraroe as stated in Ns poficy,
BUSINESS DESCRIIPTION
......... T-TL 7ic 6�r�ar'li"7atjorii (Any Otheir)
Form of Business: El Indf0duai Ell )oot venhire/Partnership
Business a escripflow C Owrjs, M M mm 'E.tas, Entertainers
DESCRIBED PREMISES
ADDITIONAL INTEREST
1648 San Charles Drive
Dunedin, Ft.34698
PROPERTY
PI I I ll NI IHLimits of Insurance for E
BuildIIngs fiil /A isNl
'ArtuW Cash Value-Buildings Option(WN)
'Automatic Increase-Business Personal Property Limit % %
Business Personal—Pror)lff—ty-
duictible $ 250 Minimum Earned I PrernIIum
Additonal/Optional Coverages--Applicable only if an 'X" Lj n
Ul_
is shown in the boxes belaw:
I. 0 Electronic Data Processing $
2. 0 Money and Securities(Special Forni only) $ inside the Premises
1:1 $ Outside the Premises
1 El Jewelry and Watch Increased Theft Coverage
4. 0 Other(SPe6fy) Additional ItISUred,Terrorism
.............
ILITY AND MEDICAL PAYMENTS
��ach—pWiF the ainount of,insurance we provide during the applicable annual period.
Piease refer to Section!III–Liability In the Businessowners,Coverage Forrn and any attached endorsements,
Lon Lsof-Insa—ura–rum
Liability and Medical Expenses $1,000,000 per OCCUrrence
Medical Expenses $5,000 per person
Damage to Prernises,Plented to'You $150,000 any one premises
Other,Than ProductsICornpleted Operafic)ns Aggregate $2,0001,000
PiuduUls/1Cc')mpieied Operafiuns Aqqreu.)ate $2,000,000
"F6-RiiAND ENDORSEMENTS Forms and Endorsements mad at firne of isslje�
e_p§L�j j
Please see reverse side, j?1Lt1j-s.
—–-------------
PREMIUM
Policy Florida Florida Total
Prernium$64100 HC F Surcharge$0,00� GF11C Surcharge$0,00 Annual Prennium$643.00
By Q
COLHIlersigned:
Aulliwized Representafive
THESE DECLARATIONS,TOGETHER Wffil THE CC.VEP.AGE FORM S (","OMMON P01I CONDrnONS AND FORMS,
AND, ENDORSEMENTS, IF ANY, ISSUED TO,FORM A PART THERIE&I,COMPLETE THE ABOVE NUMBERED POLICY.
fficludes ropynghted matenal ot Insurarice Servwos()ffice,tnc,,with its pennmswn Copyright, Insurance ServloesOffire, inc, '1984, f985
03g 15/16 F:AIA Mernber Serviceas,lnc,/1 1007 Phowilx lnsuranut SerOces/65019
SOP 0004, (05/13) FL