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HOME BUSINESS INSURANCE POLICY DECLARATIONS (4) RL{Insurance Company 9025No�hLjndhc9hDh,n Yrn,�|L0)0)5 R�ne�a| o{Number Form Applicable &BK��8C )�NJSDI�l�SS 8�JSKJD�/�I��]� ]�K�]�D�� | Standard �� Special Policy No. 80�101��9� -- -- ' DECLARATIONS Named Insured and Mailing Address: Administrator Name and Mailing Address: Richard Samlin,Rick Martin FAIA Member Services,Inc. v=^ The Tricky � nwnoa^ooane��,^»v PO Box 16579 Vuneum.FLs4698 '''~ Tallahassee,pILnna17 Policy Period: |naurod'sBrokering From 0501/17 to 0501U8 at 12:01 A.K4.^ Phoenix Insurance Services Standard Time a1 your mailing address shown above. *Exceptions: /2:oo noon m Michigan, North Carolina,and Puerto Rico. In return for of the premium,and subject to all the of this policy, with you to provide the insurance as stated i this o BUSINESS DESCRIPTION Form of Business: 2 Individual El Joint Venture/Partnership D LLC El Organization (Any Other) Business description: Clowns, Magicians, Entertainers DESCRIBED PREMISES ADDITIONAL INTEREST 1648 San Charles Drive Dunedin, FL 34698 PROPERTY PREM.NO.1 BLDG,NO. PREM.NO.21 BLDG.NO. PREM.NO.31 BLDG.NO. Limits of Insurance for *Actual Cash Value-Buildings Option (Y/N) *Automatic Increase- Business Personal Property Limit 4% % % Business Personal Property 1$6,840 Is r$ Deductible$_250 Minimum Earned Premium $ Additonal/Optional Coverages—Applicable only if an"X" Limits of Insurance is shown in the boxes below: 1. 0 Electronic Data Processing $ 2. El Money and Securities (Special Form only) $ Inside the Premises F� $ Outside the Premises 1 El Jewelry and Watch Increased Theft Coverage 4. FX] Other(specify) Additional Insured, Terrorism LIABILITY AND MEDICAL PAYMENTS Each paid claim for the following coverages reduces the amount of insurance we provide during the applicable annual period. Please refer to Section 11—Liability in the Businessowners Coverage Form and any attached endorsements. Limits of Insurance Liability and Medical Expenses $1,000,000 per occurrence Medical Expenses $5,000 per person Damage to Premises Rented to You $50,000 any one premises Other Than Products/Completed Operations Aggregate $2,000,000 Products/Completed Operations Aggregate $2,000,000 FORMS AND ENDORSEMENTS Forms and Endorsements made part of this policy at time of issue: Please see reverse side. PREMIUM Policy Florida Florida Total Premium$654.00 HCF Surcharge$0.00 CPIC Surcharge$0.00 Annual Premium$654.00 *Coveracie for Certified Acts of Terrorism$1.00 Countersigned: By Authorized Representative THESE DECLARAT|ONSTOGETHER VV|THTHE ERAGEFORM�j COMMON POLICY CON0T|ON8AND FORMS AND ENDORGEMENTS '|F ANY, ISSUED TO FORM��PART THERE OF' COMPLETE THE ABOVE NUMBERED POL|C�. Includes uupyngmodmatena(ofmswnan*eSomicesOffice, |nc..with its p*mnioio�.Copyright, Insurance Services Office, Inc., 1984. 1985 03/17/17 pmA Member Services, mo/11OVr Phoenix Insurance Somioas/85U1S BOP 0001 (05/13) FL