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CERTIFICATE OF LIABILITY INSURANCE (6)�� R 1����R.Yr.f"A A G � r �IM. �F' � I 1 I�� I Y��� IS�tl�R l'Y'�.:.I� � I. �ATE 1011M/Dd1YYY'Y) 12J19/�(�'G 9 T�IIIS CEF:TNFICA'TE IS �SSIPE[7 14S ,4 �IA.�4�'EFt fi� INF�lA�WIA�ON {�FNLY ,4Nd GU'�IFERS CYt7 RIfaHTS C�IPDIN TEIE CER'�"7FYCAi'E r-IdLDE42. T4i1S CERT6FACATE QOES NCSi nqFF1'�MATRV�LY pR I�EGATI'VEL,Y APJIEND, EX7�N'D (}R 6iLTER THE GQM/ER�4C�E AFF�Rt7Ea BY THE F't3LICIES BE,LO'li'YF. 1fHIS CEF2TI�'ICATE C?F II�SUFtAIVGE �OES Nmi C�N'STE"�UTE A�C�.l{�TI�,AC7 �SET�NNEEM1I Tk�E �SSIPINfi� 11�5URER(��: AllTHdlRlZE� REPFtESE�TATIVE �R PFtQ�UGLR, e4R1b THE C�RTIFICr4TE Hi?LQER. 11iAPORTA'NT: If the certificate haMder is an A13QITI0�AL INSURED, the pa9icy(ies� must have C�[�D�TIA#JAL uNSUREC� prmvisions or be en�lors�d. �f SUBROG�ATIi)N �S WAIVED, subj��ct ta tMe terrros and condit�ons of ahe palicy, cert�in �r�licies re�ay require a�n erudorsement. A stiatement on this c�mkiiic�ke dnes ato't confier rn hts to tlue certifca#e hcrlder irr li+eu �f suc� �enslorsement(s). wRoo�c�R ca�oura�cr 4Nend VVilson w,ann�: Y �'�������� o�c� �nart�n ir�SUrar,C� ���r��y i�,�. �HON� 72�-aa�-as�� _...__...�..� F� �z��-aa5-�ra��...�... AfC No E k ��. A(C Na� = �fl�26 US H'�vy 19 N �aoR��ss qJVendy.�Ison.N�GQJ cr Statefarxra.cora� .._.__ .___.._._._.._ _.—_ __ ��__. ", Paln'r �arbcsr F� 34684 in�s�er�R�sl a��a�nNN� cav��n��: MAIC # inrsuR��z q: State F�em hlEutual AutomabiBe Insurance �ompany 25178 9Na^tPRE6 BAT�S, EDWARD AI DBA KINN�YS KA�'CHEN '654�1 CL�B C�R TARPC7�J SPRINC'aS FL 346&9-7D27 Ira'SURER B : �wsu���x c r INSUREFt d :'�. C411"�Ft/.'k�f"'aES GEFi1"IFI�CA,TE !hlUM�ER: R�VISIQN NtVlUIF3EM2� TH�S IS TO CERTIFY T9iAT TI�E P[3LIGIES t7� IR9SURA6VC� LIS"�ED BELt7W 'HAVE BEEN ISSUED TC5 THE INSUREL� N,4hdIED ABOVE FOR THE PQLIGY PEFCIp� 1NDICATED. Nd7W9Tti5TRf��I'NG ANY V��QUIhE&vtEN4,i, 'T�RM C]R CO�1CfITION a� AEVY Cl3NTf�,4CT 4R r3TH'ER CrOCfJMENT Wi!ITH RESPECT TO 9NHICH 7HIS CERTIF�Ct�7E MAY BE ISSUED QR i�P;Y' pER7ACN, �H� P�S�JRA�CE ,4FFO�d�C9 Bl✓ THE, Fd�ICIES DESCFi6BED HE�F2Ethli IS SiJ�.IECT Ti7 A1..L 7HE T�f�MS, EYCLUSiONS AN� CC9N131�"1f3NS OF SU'CH P�LICIES. LaMiT� SHJYIVN MAY FiAiME BEEN REL1lJCEb BY'�Ald CIAI�S. ��. ICJSR 7yP� OF IWSIJf'u4NCE ���� �U�� � PJLICY EFF POLICY E3C� ury�ITS�. 3R PdE.kG'�Y NUMBER. MMfp .1l'"dYY� MM! �. IYYYY .. COMMERCf�H� GE'NERJI�L LIAF31L9TX IF-�S.CH CJCC+J�R12EiNGE- $. ...... .. .. � CLAI�S-N+A�E [...� 4GCU@2 �A�S E ccu�nce . _$__..._.....__.. �7E� ExP (Arry ar�e persan} $ IPERSONAL & fi��I INJURY $ GEM'L AGGi2EGATE LIYVflIT� APPLIES PER: ,�"`,ENEIRNL AGGft'�GATE $ PCILkGX. � P�6- � �,4G IPRfl�UCTS-C(3Yu1PJC}PAGG.. $. . _ _ JE�T iITHER: $ T ---,����..� AIJT4Pt7Q91i�E L9A81LI�Y� '+p' CC}M�INECY S16VY'a�E LI'N11T .. . $ Ea accide�tti JwNY AU7(? '�Cial�Y INJURY (Per persan)� $ �j ,�(}�p(),pQ(j �uvM�o sGHEcru�Ec� E92431fl-E12fJ-A 1912tiJ2fl19 0412(7/2Q2Q � ,�uTos o�v�'r autos �c�oi�v eN�uav `pQ� ��;d�nr7 g 1,QOQ,t7(70 a�aR��r rvaor�-awhr�d iP�zop��rv oa�.�G� � 1„OfPd,000 AUTc]S C7NLY AUTbS ad�'�Y . per a�cciUec�¢ ,._.d._�.._._ .. . . . . . .... . . . . $ �� UMBRELLE4. LIAB� ....C1CCU...R ..,., .' EACFV OCC�}RRE6�t�GE. . . i . �XCE�S�IAB _. GLAlMS-MADE ' AGGREGATE $ —�_ _ �._.. ' � � i�Ep R�7�h171[�YV S $ YIUO�.KERS CO�VIF��NSATIDN PER ' C}TH- �42J17 EMAPLCyY�(2S" LIAF3IClTY N! N STFaTUTE � ER � ANY PROPRIETORIPAR�'hlERdEX�CUTIV� ❑ � +A �.L. �,ACH ACG[dEN7 $ d�FFICERIM��...FMBER EXGLU���? {ManrPatory in NHp E.L. CSISEASE - EA EMPLOYEE $ . �f yes, deser�be� urvder ......�........_.__,_w_w._.�__._._.__... �_____. ��$CF2IPTI�PJ (7F qPERkTI�NS below E.L. C1ISEASE - P'ClLICY LIMIIF� $ � CaESGRIPTIi?PA QF OPERR.I'EQN�S! L4CA4TFQN5 J"If�HIICL�S� �AGpRD 1 Q1, AcWiCionel Remarks S�h�dule, m2y be al3aehed��. Si more spac�e is requured) �fl08 DC3D�E ff2A�a1 150�} PICKUP VIN: 1 �7�1A1828�56�}8303 �EI�7I�ICAT� HQI.[�ER Cl�y 4f CIeaNV3tEr P(} Box 4748 Gle�rwater, F� 3�759-4748 d1,GORm 2s (2D1G�03) CANCEL4�T�'+dN� SHOl1Li7 ANl! OF THE ABO'NJE OESGI&18EEb PdLiGEES F3E' GAWGE'�LED BEF�R£ TNE EXPIRATFp6�1 D/�TE 7HEiiEC7F ICE WYfILt, E3E Cf��lr/E,REG IC+�f ACCORd�ANCIE WITH TEtE P�LICY P VISIO 5. A4DTH41�ZE0 REP�tESENTATRVE C� 1988-2�15 Th� ACRaRm nara�e and lac�c� are regisfiered marks nf A� a r ��a �C)CtPG16iA710N. ,All riahts reserved. 1�a01486 132649.1'.2 03-iFi-204�8