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American Safety Indemnity Company
<br /> 185/ 100 Gaferia Parkway SE, Atlanta GA 30339
<br /> 800 - 388 -3647 FAX 770 -955 -8339
<br /> EIS Fax Number (770) 955 -6163
<br /> AmERicarabwrrhystouwa
<br /> ALL PREMISES YOU OWN, RENT OR OCCUPY
<br /> LOCATION NUMBER: ADDRESS OF ALL PREMISES YOU OWN, RENT OR OCCUPY
<br /> 1 360 BLANCA AVE
<br /> Tampa FL, 33606
<br /> As on file with application dated: a ..
<br /> CLASSIFICATION AND PREMIUM
<br /> LOCATION CLASSIFICATION CODE PREMIUM RATE PREMIUM
<br /> NUMBER NO BASE Prom Prod/Com Prom Prod/Com
<br /> Ops Ops Ops Ops
<br /> 1 Contracrors- Executive supervisors or executive 91580+ $33.400 28.13 Included $940.00 Included
<br /> superintendents
<br /> 1 I withtractong subcontracted recontruclien, repair or 91583 I $200.000 1.91 7.46 5382,00 I S1,492.00
<br /> erection - one or two family dwellings I
<br /> PREMIUM SHOWN IS PAYABLE: STATE TAX OR OTHER (if applicable) $173.79
<br /> POLICY FEE (if applicable) $35.00
<br /> TOTAL PREMIUM (SUBJECT TO AUDIT) $2,814.00
<br /> AT INCEPTION 100%
<br /> AT EACH ANNIVERSARY
<br /> IF POLICY PERIOD IS MORE THAN ONE YEAR AND PREMIUM
<br /> IS PAID IN ANNUAL INSTALLMENTS
<br /> AUDIT PERIOD (if applicable) J 19 ANNUALLY 1 ❑SEM- ANNUALLY 1 ['QUARTERLY 1 ❑MONTHLY
<br /> ENDORSEMENTS
<br /> ENDORSEMENTS ATTACHED TO THIS POLICY:
<br /> ASI CLAIMS, ASI SIGNATURE PAGE, OCCURRENCE DECLARATIONS PAGE, ASI 0001 0906, IL00
<br /> 03 09 07, ASI 3000 09 06, ASI 3001 09 06, AS1 3002 09 06, AS1 30x3 09 06, ASI 3004 09 06, ASI 3005
<br /> 09 06, ASI 3006 09 06 ASI 3024 09 06, ASI 3026 09 06, ASI 3027 09 06, ASI 3028 09 06, ASI 3029 09
<br /> 06, AS1 3030 09 06, ASI 3031 09 06, ASI 3032 09 06, ASI 3033 09 36, ASI 3034 09 06, ASI 3035 09 06,
<br /> ASI 3036 09 06, ASI 3038 04 08. ASI 3040 05 08, CG 03 00 01 96, CG 21 6712 04, CG 21 46 07 98,
<br /> CG 21 47 07 98, CG 21 55 09 99, CG 21 96 03 05, CG 22 24 07 98, CO 21 86 12 04, CG 22 31 07 98,
<br /> CG 22 34 07 98. CG 22 43 07 98, CG 22 79 07 98, CG 21 90 01 06, IL 0017 11 98, IL 00 21 05 04, CG
<br /> 00 67 03 05 , CG 02 2012 07, COL 17 07 07 02, ASI 3063. ASI 3064 06 10, ASI 3084 07 10, ASI 3081
<br /> 07 10, ASI 3082 0710, ASI 3083 0710, ASI 3087 07 10, ASI 3080 07 10, ASI 3086 0710, ASI 3085 07
<br /> 10
<br /> IN CONSIDERATION OF THE PAYMENT OF THE PREMIUMS, AND SUBJECT TO ALL THE TERMS, CONDITIONS AND
<br /> EXCLUSIONS OF THIS POLICY, WE AGREE TO PROVIDE THE INSURED WITH THE INSURANCE AS STATED IN THIS POLICY.
<br /> THESE DECLARATIONS TOGETHOR WITH THE COMMON POLICY CONDITIONS, COVERAGE FORMS) AND ENDORSEMENTS
<br /> ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE REFERENCED POLICY.
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