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COMMON POLICY DECLARATIONS <br /> `I/410# 9 <br /> C turfy Insurance Company <br /> POLICY UMBER <br /> 8720 Stony Point Parkway, Suite 300 GL 367 182 1 <br /> Richmond, VA 23235 RENEW L OF <br /> GL367. 182 -0 <br /> Underwritten By Colony Management Services, Inc. PDQ CO • E <br /> 91F <br /> 1. NAMED INSURED and MAILING ADDRESS: PRODUCER: 09002 <br /> FIRE PREVENTION SYSTEMS Amelia Underwriters, Inc. <br /> DWIGHT R. TEATER, JR. DBA 2384 Sadler Road <br /> 413 BROWARD TERRACE Fernandina Beach, FL 32034 3127 <br /> WINTER HAVEN FL 33884 <br /> From 01/08/2010 to 01/08/2011 12:0 • Standard Time at your M : iling Address above. <br /> k • : • • YMENT OF • : - BJECT TO ALL THE TERMS OF HIS POLICY, WE <br /> AG' 11 • ' se • • _ • • • " • - ANCE AS STATED IN THIS POLICY. <br /> 3. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS NDICATED. THIS <br /> PREMIUM MAY BE SUBJECT TO ADJUSTMENT. <br /> COVERAGE PARTS PREMIUM <br /> Commercial General Liability 1,174.00 <br /> Liquor Liability NOT COVERED <br /> Commercial Property NOT COVERED <br /> Commercial Crime NOT COVERED <br /> Commercial Inland Marine NOT COVERED <br /> Commercial Farm and Ranch NOT COVERED <br /> Owners And Contractors Protective I NOT COVERED <br /> Coverage for Certified Acts of Terrorism Rejected; Exclusion Attached. NOT COVERED <br /> (Per Policyholder Disclosure TRIA2002Notice attached.) <br /> TOTAL 1,174.00 <br /> Florida Hurricane CAT Fund Assessment 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 /> Premium shown is payable at inception. Total Policy Premium: $ 1,415.37 <br /> 4 - • • LICABLE • • VERAGE PARTS: <br /> S - Schedule of Forms and Endorsements - U001 <br /> 5. BUSINESS DESCRIPTION: KITC • N HOOD & EXHAUST CLEANING <br /> ► t, • PURSUANT TO THE FLORIDA SURPLUS LINES LAW. PERSONS INS RED BY SURPLUS <br /> NE •1 - - •'• NOT HAVE THE PROTECTION OF THE FLORIDA INSURANCE GUARANTY ACT 0 THE EXTENT OF <br /> NY RIGHT OF RECOVERY FOR THE OBUGATION OF ANY INSOLVENT UNUCENSED INSURER. <br /> Countersigned: 01/26/10 B W A"" <br /> Date Auth rized Representative <br /> Includes copyrighted material of Insurance services Office, Inc. with its permission. <br /> DCJ6550 (07/05) Copyright, Insurance services Office, Inc., 1984 <br /> Insured <br />