Certificate of Insurance11►1C11DAA1nr 11l!21w1nrn
Binder NO.
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT
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• • • TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
NAME AND ADDRESS OF AGENCY
COMPANY KF711F''F l't } {J j (jill.iLli"'
PAI..IL. L. ANDRE:
Effective 1.2' : 01. i:1m Aw4i.ti G '.::i 19 82
2650 ,S) W 27 fiVi:7
Expires 12:01 am Au4u it 25 19 133
Fi AP11 FL. 331.33
This binder is issued to extend coverage in the above named
company per expiring policy # (e%s Pas���bj3 3 J ri
NAME AND MAILING ADDRESS OF INSURED
Description of Operation/Vehicles/Property
r ACK i-:fFiLY L_:CTY' COL.
iINBOW UNLINITE"D
MAIRATHON 171_A :33050
Type and Location of Property
Coverage/Perils/Forms
Amt of Insurance
Ded.
C%Ns
P
R
0
P
E
R
T
Y
Type of Insurance
Coverage/Forms
Limits of Liabili
Each Occurrence
Aggregate
L
AScheduled
Form I lComprehensive Form
Bodily Injury
$
$
XPremises/Operations
B
Property
I
Products/Completed Operations
Damage
$
$
L
Contractual
Bodily Injury &
1
Other (specify below)
Property Damage
T
Y
Med. Pay. $ Per $ Per
Person
Combined
300.000
$
Accident
Personal Injury
1 ry
nA
B [:]C
Personal Injury
$ .300,00
A
Limits of Liability
V
Liability Non -owned Hired
Bodily Injury (Each Person) $
T
Comprehensive -Deductible $
Bodily Injury (Each Accident) $
0
Collision -Deductible $
M
0
Medical Payments $
Property Damage $
g
Uninsured Motorist $
Bodily Injury & Property Damage
I
No Fault (specify):
L
Other (specify):
Combined $
E
WORKERS' COMPENSATION — Statutory Limits (specify states below) EMPLOYERS' LIABILITY — Limit $
SPECIAL CONDITIONS/OTHER COVERAGES
fiVE'Fi:L1iLa L'i� Yi L_0 .1 i 1' CLIi Fil "i'E:itri:tNraL.
BUILDING t111" MARATHON A1RF 0;--ZT
NAME
AND ADDRESS OF11MORTGAGEE LOSS PAYEE ADD'L INSURED
LOAN NUMBER
COURT 3117 �.i (Yl E. }4 47 t. A ) i•J Ld ��
MARATHON F"L.): R 1:I)ra 3;3050
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i t
...i 91 112L3.3
Signature of Authorized Representative Date
FORM 75 (11-77)