HOME BUSINESS INSURANCE POLICY DECLARATIONS am,0335&A RIM Insurance Company
Renewal of Number 9025 North IJ ridbergh Drive Peoria,IL 61615 Form Applicable
Policy No. BOP1033564 HOME BUSINESS INSURANCE POLICY [:]Standard Special
DECLARATIONS
Named Insured and Mailing Address: Administrator Name and Mailing Address:
Dave Ryndes Bomba Insurance Agency
DBA Spheres By Blaise
20929 Lake Vienna Drive PO Box 429
Land 0 Lakes,FL 34638
Vista,CA 92085
Policy Period: Insureds Brokering Agent:
From 12110/17 to 12110/18 at 12-101 A.M."
Standard Time at your mailing address shown above.
`Exceptions:
12:00 noon in Michigan, Nailh Carolina,and Puerio Rico.
— in return for the payment of the Premium,and suoject to all the temis of this policy,we agree with you to provide the Msural`[Ce as stated in fts policy,
BUSINESS DESCRIPTION
Form of Business. Individual D Joint VenturelPartnership El LLC Organization (Any Other)
Business description-.. Clowns, 1a icians, Entertainers
DESCRIBED PREMISES ADDITIONAL INTEREST
20929 Lake Vienna Drive
Land 0 Lakes, FL 34638
PROPERTY
"PIREM,NO I BLDG NO EKA_NO.2 BLDG,NO. PREM,NO.31 BLDG NO,
Limits of Insurance for
—"--J—
Buildings $ NIA $NIA
*Actual Cash Value-Buildings Option(Y/Nl,
"Automatic increase-Business Personal Property Limit(%) 4% %
Business Personal Property T r Std
Deductible$_2LO Minimum Earned Premium $
Additonal/Optional Coverages–Applicable only if an'X" Limits g1jD52rance
is shown in the boxes below:
1, El Electronic Data Processing
2. Money and Securities(Special Form only) $ Inside the Premises
$ Outside the Premises
3 El
jeweiry and Watch Increased Theft Coverage
4. [Z Other(specify) Additional insured, Terrorism
LIABILITY AND MEDICAL PAYMENTS
Each paid—claim for the following coveracs reduces the amount of insurance we provide during the a—ppiicabte a'—finualperbd.
Please refer to Section 11–Liability e Businessowners, Coverage Form and any attached endorsements,
grrrit of Insurance
Liability and Medical Expenses
$1,000,000 per occurrence
Medical Expenses $5,000 per person
Damage to Premises Rented to You $ 5D,000 any one premises
Other Than ProductsXompleted Operations Aggregate $2,000,000
Products/Completed Operations Aggregate $2,000,000
FQRA+I Ahlf# ENIRBEI�'ENS Ferrrls and Endorsements rrrae_ rartf this perlicv at time of issue
Please see reverse side,
PREMIUM
Policy Florida Florida Total
Premium$342�00 HCF Surcharge$0.00 CPIC Surcharge$0.00 Annual Premium$342.00
*C=[age f.QE Ce
Countersigned: By
Authorized Representative
THESE DECLARATIONS,TOGETHER WITH THE COVERAGE FORMSS ,COMMON POLICY CONDITIONS AND FORMS
AND ENDORSEMENTS,IF ANY, ISSUED TO FORM A PART THERE , COMPLETE THE ABOVE NUMBERED POLICY
Includes copyrighted material of Insurance Services Office, Inc.,with its permission,Copyright,Insurance Services Office,Inc-, 1984, 1985
101261117 Somba Insurance Agency/[t1005 Bomba insurance Agency199999
BOP 0001 (05/13)FL