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ll ; nol �nn5 11 : Gb 1rLIlbllvn HLRLIrHUL na <br /> X91 : 0Gl1 s'ia 1i : 04 1 / 1 [ 4b ! Ybd- UMp HEAL.1HY S74Rr PAGE. 0 <br /> COMMON POLICY DECLARATIONS <br /> _�OkYIN*URANCECOMPANY 9elten b Meoclatrs <br /> 7101 FOREST HILL AVENUEBox <br /> 2911 Cardinal Ortva POLICY NUMBER <br /> RICHMOND, VA 23233 Pero Sesch4api., 32964- 7498 AP509497 -- <br /> RENEWALOF <br /> NEW <br /> UnderwH ten by Colony MaxI#gemenr Services, Inc, PROGRAM CODE : — -� <br /> 1 . NAMED INSURED AND MAILING ADDRESS., PRODUCER: 09012 y <br /> KIDS CONNECTED BY DESIGN, INC. ROEHRIG & MACDUI: F (ST PETE) <br /> 117 ATLANTIC AVENUE AVE NE <br /> 1 2k <br /> 110 <br /> FORT PIERCE, FL 34950 11 1TE O A <br /> SAINT PETERSBURG , FL 33701 <br /> 2, POLICY PRIRIOp: From 7 <br /> _ `, ✓ a t0 PTn512W 12:01 A . M Standard Time al Your Mailing Address above. <br /> IN RETtsW POR THC PAYMENT t1F THE PRE1411M, AAD SUalECT TOALL 07 TME TERNS OF THIS ' LICv, WE AGREE WITH YOUO T <br /> PROVp)E Tr1E INeUNANC$ A9 aTATFD IN THIS POLICY. <br /> 3. THIS POLICY CONetSTS OF THE FOLLOWING COVERAGE PARTS FOR WH)gB Aa!ApjUM IS blpiCATEO . <br /> THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT, "�"` " "" <br /> -- <br /> 111 EY. AYEt&* i4E Y irlE fip <br /> -� — COVERAGE PARTa <br /> PREMIUM <br /> COM1iERCIAL GEl\ERAi LIAFi2LI " Y C.tivERaGE' PJ <br /> PP.R1 SG . b66 . UO <br /> E1tn+a rf. u,a q (E Ms , <br /> udvv <br /> U4' <br /> �6PFLfM. !NJIRt +.,c oviartK e i r4E I <br /> .n- <br /> h <br /> N�(.YeM-�7.QIEM$�71N4.liic:4 <br /> Premitlm Charge for coverage of certified (tete of terrorism : i s <br /> (Per Policyholder Disclosure TRIA2002Notios- 1202 attached.) <br /> er <br /> Coverage fpr certified aCIa of terrorism has been rejected ; exclusion attached . <br /> (Per PORCyholder Diaciosure TRIA2002Notice- 1202 attached ) <br /> _ ISSUED 38 / 1) e12066 SG <br /> `_ Prwnlum ahowe 4 payabM at inception`-" Teta) Pottoy Pro"Oum: S 6 . 666 . 00 <br /> 4. FORMS APPLICABLE TO ALL COVERAOES: InapaCtion Fea: �rV! $126.00 - <br /> feauS160 . 00 <br /> Sae Form U001 - Sc9ladu4e Of Forma anp Endorsements Tause 0354 , 95 <br /> TOTAL '17 . 180 . 95 <br /> S. BUSUNE935ESCRIPTION: SOCIAL ,SERVICrq— CASE MANACEN.EN_T <br /> CounteMpned. <br /> AV fspen[nVtllrt <br /> Wue+a«a„lyaa wa4w of huwo frvva Mrw 4<. vn « to-wrVn <br /> DCJ6660 107102) cap-�n. n.....wi sr.: ., a.a� :n . .a►. <br /> nsa. .. .. . .. <br />