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, '~ib'~LA "nn. ti . QLA 3....46 21 ~NEWAl OF NUMBER 522 85 i;f AMERICAN SOUTHERN INSURANCE CO. ATLANTA. GEORGIA GENERAL L1ABllITY.AUTOMOBILE ~ '100.00 MINIMUM RETAtNaD PRBNIUM DECLARATIONS 1t11ll1. NI"" Jns.,,' and Address: (No" street, Town or City, County, Stlh) RUfl'MAN, CARLTL! '.0. BOX 251-RADM,U PLACK CRYSTAL 'POS, PASCO, n. 33524 It,.. 2. Policy Period: (Mo. D.y Yr ,) From 10-09-'0 to' 10-09-'1 ]2:0] A,M.. standard time at the address of the nlmed InsDred as stated herein, The Ill"" Ins.,,' Is: []Clndlvldual D Partnership Builness of Ihe n....d Insured is: [RNT... ..LOW) aLP.CTRICIAN o Corporation D Joint Venture D Other: Audit pe'r'iod: Annual, unless otherwise stated, (...n.. ..LOW) It.m 3, The insurance afforded is only with respect to the Coverage Part(s) indicated below by specific premium charge(s) and allached to and forming a part of this policy, ~ AdYlnce Ctymae Cover'le P.rtls) Adv.nce Cmr'ae Coverall Partls) Premiums Part Ntis). Premiums Part Nols), S Automobile Medical Payments Insurance $ Hospital Professional liability Insurance $ Automobile Physical Damage Insurance $ Manufacturers' and Contractors' liability (Dealers) 291.00 [,6<<10 Insurance $ Automobile Physica' Damage Insurance $ Owner's and Contractor's Protective liability (Fleet Automalic) Insurance $ Automobile Phrical Damage Insurance S - Owners', Landlords' and Tenants' liability (Non,Fleet Insurance $ Basic Automobile liability Insurance $ Personal Injury liability Insurance $ Completed Operations and Products liability $ Physicians', Surgeons' and Dentists' Professional Insurance liability Insurance $ Comprehensive Automobile liability Insurance S Premises Medical Payments Insurance S Comprehensive General liability Insurance S Spec ial Protect ive and H ighw3yliability Insurance S Comprehensive Personal Insurance New York Department of Transportation $ Conlractualliabilily Insurance S Storekeeper's Insurance $ Druggists' Liability Insurance $ Uninsured Motorists Insurance S Elevltor Collision IMurlnce S $ Farm Employers'liabilily and Farm Ef1lllloym' Medi,cal Payments Insurance S $ Farmer's Comprehensive Personal Insurance $ Farmer's Medical Payments Insurance S $ Garage Insurance t,..611)-A $100.00 DEDUCTIBLe ml P.o. au 271 6/85 Form numbers 01 endorsements, other than thos. entered on $ Cover'le Pulls), .llach.d .t issue S 291 .. I) OTolI1 Advanco Premium f.r this polley, I AS 304 U/89 ) 10/90 ~ .",,.': "" , · II the Policy Period Is more than one year and the premium is to be paid in installments, premium is payable on: Effective Date 1st Anniversary 2nd Anniversary' $ $ $ Item 4, During the past three years no insurer has cancelled insurance, issued to the named Insured, similar to that afforded hereunder, unless otherwise stated herein: lSIUID POle 090S!-e IN!UlANe! ~L\RT-Z~pnRYRtLLS Count.Fllillldl 10/0l/DO ~~rHY'Rl{t ~L$ INot 'Plllluble'n Tem CDL8300(O)X-G (1-1-73' By IDGA, INC. .4199 ,J Ptd, 'n U,S,A, Authorized Represenlalive /' ~ -~.- _ ....-. _.. ___._ _.......~ _h"._ .,__" _..._ ____ _....__ _""""_ _~." n... _.