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Aug. 17.2009 01:21 PM SIMMONS *OVEN *CLEANING 6783778552 PAGE. 1/ 2 <br /> • COMMON POLICY DECLARATIONS <br /> CLS1503822 ik SCOTTSDALE INSURANCE COMPANY' /� Policy <br /> Renewal of Number Home Office; CPS0986576 <br /> One Nationwide Plaza Columbus, Ohio 43215 <br /> Administrative Office: <br /> 8877 North Gainey Center Drive Scottsdale, Arizona 85258 <br /> 1- 800 -423 -7675 <br /> A STOCK COMPANY ADVANCED INSURANCE SERVICES <br /> ITEM 1. NAMED INSURED AND MAIUNG ADDRESS 200 MARKET PLACE, STE 220 <br /> S= 'IMONEI OVEN CLEANING, INC. 14 r <br /> ROSWELL. GA 30075 <br /> 35O ARBOR HTI,r. COURT <br /> ::AWHH ;NC:EVILLE, GA 3004, If property coverage is afforded <br /> AGENT NAME AND ADDRESS by this policy, the POLICY IS A <br /> - - - — - CO- INSURANCE CONTRACT. <br /> Tapco Underwriter, <br /> PC) BOX 286 <br /> BURLINGTON, NC 272,i6 Agent No. 32 001 Program No,: <br /> ITEM 2. POLICY PERIOD From June la , 2009 To June 18, 2010 Tern 365 DAYS <br /> 12:01 A.M. Standard Time at your mailing address. <br /> BUSINESS DESCRIPTION OVRN CLEANING <br /> In return for the payment of the premium, and subject to all the terms of this policy, we agree with you to provide the <br /> Insurance as stated In this policy. This pollcy consists of the following coverage parts for which a premium Is Indicated. <br /> Where no premium Is shown, there is no coverage. This premium may be subject to adjustment. <br /> COVERAGE PART(S) PREMIUM <br /> Commercial General LiabIllty Coverage Part $ 600.0 <br /> Commercial Property Coverage Part $ No- s. cnvxFn,.. <br /> Commercial Crime Coverage Part $ NO'1 COVERED _ <br /> Commercial Inland Marine Coverage Part GEORGIA SURPLUS LINES BROKER <br /> William P, Pinson Jr. $ NOT COVERED <br /> Commercial Auto (Business Auto or Truckers) Coverage Part $ NOT COVERED <br /> Commercial Garage Coverage Part $ NOT COVERED <br /> Professional Liability Coverage Part -- - -- -- -- <br /> . , , X w+ , . : µw 7 N <br /> «r� NOT COVERED <br /> `°" ' '� Total Polley Premium: $ . coo, o0 <br /> Total Taxes, Surcharges or Fees: $ 128.00 <br /> ., /;Siin,:::1 „ays.v ,••` -w. ``:: w.�;'. ;ail'd7Y_?.<i`'x,w ?"..• <br /> w« °r °tom &.'^`"`s •> S <br /> a < s . Grand Total Policy Premium $ •728.00_ <br /> > With Fees and Taxes : <br /> ... >;�,. EMPA Fee $ <br /> orm(s) and Endorsement(s) made a pert of this policy at time of issue • -- - ---- <br /> See Schedule of Forms and Endorsements <br /> Countersigned: BURLINGTON, NC - 07/06 /2009 KKH <br /> (Dste) GA By ... <br /> ( or z Re <br /> epresents <br /> THIS COMMON POLICY DECLARATION AND THE SUPPLEMENTAL DECLARATION(S), TOGETHER WITH <br /> THE COMMON POLICY CONDITIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, <br /> OPS - - (12 - 00) COMPLETE THE ABOVE NUMBERED POLICY, <br /> ORIGINAL opsdlg.lap <br />