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COMMON POLICY DECLARATIONS <br /> Ccft" y Insura C o m p a n 0 a °O4 <br /> POLICY UMBER <br /> 8720 Stony Point Parkway, Suite 300 y FA x8 0 y S6 1193y GL 3679 82 -1 <br /> Richmond, VA 23235 RENEWA OF <br /> Underwritten By Colony Management Services, Inc. PDQ CO 82 - <br /> PDQ CO � <br /> 91F <br /> 1. NAMED INSURED and MAILING ADDRESS: - PRODUCER: 09002 <br /> FIRE PREVENTION SYSTEMS - —•,,\ Amelia Underwriters, Inc. <br /> DWIGHT R. TEATER, JR. DBA 'N 2384 Sadler Road <br /> 413 BROWARD TERRACE Fernandina Beach, <br /> WINTER HAVEN FL 33884 FL 32034 3127 <br /> • <br /> 2. POLICY PERIOD: From 01 /08/ 010 to 01/08/2011 12:01 A.M. Standard Time at your M. ling Address above. <br /> IN RETURN FOR THE PAYMEN OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF HIS POLICY, WE <br /> AGREE WITH YOU TO PROVID \THE INSURANCE AS STATE() IN THIS POLICY. <br /> 3 . THIS POLICY CONSISTS OF THE' OLLOWING COVERAGE PATS FOR WHICH A PREMIUM IS I DICATED. THIS <br /> PREMIUM MAY BE SUBJECT TO ADJUSTMENT. <br /> COV'ERAGE PARTS PREMIUM <br /> Commercial General Liability <br /> Liquor Liability $ 1,174.00 <br /> Commercial Property $ OT COVERED <br /> Commercial Crime $ OT COVERED <br /> Commercial Inland Marine $ OT COVERED <br /> Commercial Farm and Ranch $ OT COVERED <br /> Owners And Contractors Protective $ OT COVERED <br /> $ OT COVERED <br /> Coverage for Certified Acts of Terrorism Rejected; Exclusion Attached. $ OT COVERED <br /> (Per Policyholder Disclosure TRIA2002Notice attached.) <br /> Florida Hurricane CAT Fund Assessment TOTAL $ 1,174.00 <br /> $ 13.34 <br /> POLICY FEE $ 35.00 <br /> INSPECTION FEE $ 125.00 <br /> FLSO FEE $ 1.33 <br /> FLSL TAX $ 66.70 <br /> $ <br /> $ <br /> $ <br /> $ <br /> Premium shown is payable at inception. <br /> -rota olicy Premium: $ 1,415.37 <br /> 4. FORMAPPLICABLE TO ALL COVERAGE PARTS: <br /> See Schedule of Forms and Endorsements - 001 <br /> 5. BUSINESS DESCRIPTION: KITCHEN HOOD & EXHAUST CLEANING <br /> HIS INSURANCE IS ISSUED PURSUANT TO THE FLORIDA SURPLUS UNE. LAW. PERSONS INS RED BY SURPLUS <br /> NE$ CARRIERS DO NOT HAVE THE PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT • THE EXTENT 0 <br /> NY RIGHT OF RECOVERY FOR THE OBLIGATION OF ANY INSOLVENT UNLICENSED INSURER. <br /> Countersigned: 01/26/10 <br /> Date <br /> By: <br /> A uth rized Representative <br /> X16550 (07/05) Copyright, copyrighted material of Insurance Services Once, Inc. with its permission. <br /> Copyright, insurance Services Office, Inc., 1984 <br /> Insured <br />