COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL DECLARATIONS
Oct 17,07 OS:43p p.2
(-- , COMMON POLICY DECLARATIONS
RENEWAL OF )~ SCOTTSDALE INSURANCE COMPANY" Policy Number
CPS0807023 Home Office: CPS0887227
One Nationwide Plaza. Columbus, Ohio 43215
Administrative Office:
8877 North Gainey Center Drive. Scottsdale. Arizona 85258
1-800-423-7675
A STOCK COMPANY
ITEM 1. Named Insured and Mailing Address
MT. CARMEL COMMUNITY DEVELOPMENT
CORPORATION
1751 KINGS HIGHWAY
CLEARWATER, FL 33755
Agent Name and Address
Crump Insurance Services of Florida
1211 State Road 436
Suite 227 Agen~ No.: 09010 Program No.: MK
Casselberry, FL 32707
ITEM 2. Polley Period From: 09/26/2007 To: 09/26/2008 Term: 366 DAYS
12:01 A.M., Standard Time at your mailing address.
Business Description: ARTS ACADEMY
In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the
insurance as stated in this polley. This policy consists of the following coverage parts for which a premium is indicated.
Where no premium is shown, there is no coverage. This premium may be subject to adjustment.
Coverage Part(s)
Commercial General LIability Coverage Part
Commercial Property Coverage Part
Commercial Crime Coverage Part
Commercial Inland Marine Coverage Part
Commercial Auto (Business Auto or Truckers) Coverage Part
Commercial Garage Coverage Part
Professional Liability Coverage Part
SURPLUS LINES AGENT: Gary L. Sanborn,lIC. t#A230773
1211 Slale Road 436, Su~e 227
Casselberr!. Fl 31707
Premium
6,751
500
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
NOT COVERED
$
$
$
$
$
$
$
$
$
Total Policy Premium: $
policy Fee $
Inspection Fee $
Surplus Lines Tax $
Service Fee $
FL EMPA FEE $
FL CAT FUND $
PRODt.r;7 ._Ranal n T.anca~ter
ADDRE: ~ .J :(] 0 !::. Myrt 1 eAve.
CITY _C.lea,rwa~er. FL
This j,13U..... , ~"1 pursuanl to the Florida Surplus Lines
Law. Pcr::~~ .::1 by Surplus Lines Carriers do nol have
the proleciion .: ti1~ Florida Insurance Guaranty Ad. to lhe
extent of any of right of recowry for the obligation of any
insolvent unli CIlnsed insurer.
7,251.00
35.00
100.00
369.30
7_39
4.00
73.86
Form(s) and Endorsement(s) made a part of this polley at time of Issue:
SEE SCHEDULE OF FORMS AND ENDORSEMENTS
casselberry, FL
10/04/2007
TT/TJ
&~ r~o-.u,(
THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH .......-
THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY,
COMPLETE THE ABOVE NUt$EfERED POLICY. S ERMITIED
INSURED NO FLAT C~NCElLA110N P opsdli . fap
OPS-D-1 (12-00)
Oct 17 07 06:44p
p.3
)l SCOTTSDAL;E: INSURANCE COMPANY~
\t;.l>
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SUPPLEMENTAL DECLARATIONS
Policy No.
CPSOBB7227
Effective Date
09/26/2007
12:01 A.M.. Standard Time
Named Insured MT. CARMEL COMMUNITY DEVELOPMENT
Agent No.
09010
Item 1. Limits of Insurance
Coverage Limit of Liabllitv
Aggregate Limits of Liability Products/Completed
$ EXCLUDED Operations Aggregate
General Aggregate (other than
$ 2,000,000 Products/Completed Operations)
Coverage A - Bodily Injury and anyone occurrence subject
Property Damage Liability to the Products/Completed
Operations and General
$ 1,000,000 Aggregate limits of Liability
anyone premises subject to the
Coverage A occurrence and
the General Aggregate Limits
Damage to Premises Rented to You Limit $ 100,000 of Liability
Coverage B- Personal and anyone person or organization
Advertising Injury liability subject to the General Aggregate
$ 1,000,000 Limits of Liability
Coverage C - Medical Payments anyone person subject to the
Coverage A occurrence and
$ 5,000 the General Aggregate Limits
Item 2. Description of Business
Form of Business:
0 Individual 0 Partnership o Joint Venture o Trust 0 Limited Liability Company
rn Organization including a corporation (other than Partnership, Joint Venture or Limited Liabllil'/ Company)
Location of All Premises You Own, Rent or Occupy:
1) 1751 KINGS HIGHWAY, CLEARWATER, FL 33755
2) 908 PALM BLUFF STREET, CLEARWATER, FL 33755
Item 3. Forms and Endorsements
Form(s) and Endorsement(s) made a part of this policy at time of issue:
See Schedule of Forms and Endorsements
Item 4. Premiums
Coverage Part Premium: $ 6,751
Other Premium: $
Total Premium: $ 6,751
THESE DECLARATIONS ARE PART OF THE POLlCY DECLARATIONS CONTAINING THE NAME OF THE INSURED AND
THE POLICY PERIOD.
CLS.SO-1L (8-01)
INSURED
C15sd~le.fap
Oct 17,07 06:44p
p.4
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COMMERCIAL GENERAL LIABILITY
CG 20 12 07 98
CPS0887227
THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY.
ADDITIONAL INSURED -
STATE OR POLITICAL SUBDIVISIONS - PERMITS
This endorsement modifies insurance provided under the following:
COMMERCIAL GENERAL LIABILITY COVERAGE PART
SCHEDULE
State Or Political Subdivision:
CITY OF CLEARWATER
100 SOUTH MYRTLE AVENUE
CLEARWATER, FL 33756
(If no entry appears above, information required to complete this endorsement will be shown In the Declarations as
applicable to this endorsement.)
Section II - Who Is An Insured is amended to
include as an insured any state or political subdivision
shown in the Schedule, subject to the following
provisions:
1. This insurance applies only with respect to oper-
ations performed by you or on your behalf for
which the state or political subdivision has Issued a
permit.
2. This Insurance does not apply to:
a. "Bodily injury,' .property damage" or "personal
and advertising injury" arising out of operations
performed for the state or municipality; or
b. "Bodily injury" or "property damage" Included
within the "products-comPleted operations
hazard".
CG 20 12 07 98
Copyright. Insurance Services Office. Inc., 1997
INSURED
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