Laserfiche WebLink
COMMON POLICY DECLARATIONS <br /> o... <br /> This Declaration Page is attached to and forms a part of certificate provisions (Form SLC-3 USA). <br /> Certificate No. GIG001741M <br /> Previous No. New <br /> Authority Ref.No. #60621 F33080913,#60621 F33066213 <br /> 1 oma?Name and address State File No 4 <br /> SIL Agent&Lich: Loma S Wirtz E060450 <br /> of the Assured <br /> Agents Address: 635 93rd Ave. N., St. Petersburg FL 33702 <br /> Greene Investment Partnership, Ltd Producing Agent: Delos Lee Carroll <br /> 51 SW Flagier Avenue Prod Agent Addr. Deakins-Carroll insurance Agy. <br /> Stuart Florida 34994 5600 South Federal Highway <br /> Stuart, Florida 34997 <br /> 2 Effective from 1/30/2014 to 113012015 <br /> both days at 12:07 a.m. standard time <br /> 3 Insurance is effective with certain Percentage 100% <br /> UNDERWRITERS AT LLOYD'S, LONDON. <br /> 4 THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED. THIS PREMIUM MAY BE SUBJECT <br /> TO ADJUSTMENT. <br /> PREMUM <br /> Commercial Propem-Coverage Part $11,796.00 <br /> Commercial General Liabilin Coverage Part $2,560.00 <br /> Commercial Business Auto Coverage Part <br /> Commercial Garage Coverage Part <br /> Commercial Inland Marine Coverage Part <br /> Liquor Liability Coverage Part <br /> Other Coverage Pan <br /> Total Premium $14,356.00 <br /> Admin. Fee $35.00 <br /> Inspec. Fee $150.00 <br /> State Tax $727.05 <br /> Citizens Fee $145.41 <br /> FHCF Fee $189.03 <br /> Service Fee $29.08 <br /> EMPA Fund $4.00 <br /> Total Charged $15,635.57 <br /> 5 Special Conditions <br /> Minimum 25% fully earned premium in the event of cancellation by the insured. <br /> Form(s) and Endorsement(s) made a part of this policy at time of issue`: SLC-3(USA), <br /> J13-600 (04/13) JH 900 05 10, <br /> 221/12/00'7,, LSWTMIL I135b)(07/004),LSW MEP(11/2002), IL 00 17 11098,NMA29 5NLMA 50A. 18 (0905),IGLDEC(09/9)! <br /> PROPDEC(9/97) <br /> -Omits applicable forms and endorsements if shown in specific Coverage Part/Coverage Form Declarations. <br /> 6 Service of Suit may be made upon: Mendes &Mount <br /> 50 Seventh Avenue, New York, NY 10019-6829 <br /> 7 In the event of a claim, please notify the following: <br /> John Handel&Associates.Inc. <br /> P.O.Box 21377 <br /> St.Petersburg.Florida 33742 <br /> 1.727-576-1536 <br /> This insurance is issued pursuant to the Florida Surplus Lines Laws.Persons insured M Surplus Lines Carriers do not have the protection <br /> of the Florida Insurance Guarani` Act to the extent of any right of recover for the obligation of an insolvent unlicensed insurer. <br /> fhese Declarations together with the Common Polic-, Conditions.Coverage Part Declarations.Coverage Part Form(s) <br /> and Forms and Endorsements. if am'. issued to form a part thereof.complete the above numbered olicv <br /> J0 an el & As tes, Inc* <br /> Countersignature Date 2/3/2014 b` <br /> S:236286 1:95524 A:2665 D:2/3/2014 10:12:55 AM Ori incl Correspondent <br /> 80 <br />