HomeMy WebLinkAboutInsurance Coverage for Winter Spectacular 97 -1997 12 10
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MEMORANDUM
DATE:
December 10, 1997
TO:
RON MclEMORE, CITY MANAGER
VIA: BROOK SEAll, PARKS & RECREATION DIRECTOR
FROM: ~ T. HillERY, SPORTS COORDINATOR
SUBJECT: Winter Spectacular 97'
Attached are six Certificate of Insurance Policies with at least
$1,000,000.00 General Liability coverage which list the City of Winter
Springs as Additional Insured from the following companies.
Company Name Policy Number Expiration Date
Delle City Amusements, Inc 97MF5571 04/01/98
American Candy Corp. ESP3751180200 06/04/98
Jim's Oasis ESP3751180200 12/24/97
Fireworks By Santore, Inc F97/2697/000 08/04/98
Mountain View Productions, Inc 97222MEI 08/14/98
L J's Concession CP40341601 05/07/98
Should you have and questions please call me.
Thank you !!!
/RTH
WINT9703.DOC
CC: File
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ALLIED SPECIALTY INSURANCE. INC.
10451 GULF BOULEVARD, TREASURE ISLAND. FL. 33706
Toll Free 1-800-237-3355 National
1-800-282-6776 Florida
Cert.ificate Number: :30
CERTIFICATE OF INSURANCE
;his Ct:H'tl'Picatp nei.ther affil~matively nor negatively amends, extends 01"' altel'S
"he coverage afforded by the policy(ies) described hereon and is issued as a
""iltt.'r (I'r' lnform,:,d;ion and confers no 'right upon the holder.
-:' h. e P, (J 1. i. C I,J \. i p. S;. ide n t H~ i e d bel 0. UJ b yap 01 i c: y n u m b e r i s i nr 0 l' ceo nth E! d ate 0 f
~rtjficate issu~nce lnsu~aryce ~s.afford~d 90~Y with respect to those.
\overages for whIch a specIfiC llmlt of lIabIlIty has been entered and 15
".ubj€'~t t~0 all term'?,of~ the p1J1~c9 having referenc€' thereto. Nothing hef'ein
ontalr1eO shall modlt'lJ any prDvlslcm cd' saId poll.ey.
(n tlH! event nt~ canc.ellation o{: the policy, the company issuing said palic\J
will make all reasonable effort to send Notice of Cancellation to the
Lertificate holder at the address shown herein, but the Company assumes no
esponsibilitles fOT any mistake Dr failure to give such notice.
An.y ins.urancp m~.~de a partof.th.e POli.Cy includes. ,as a person insured with
espect to an occurrence taklnq place at a CarnIvals sIte, (1) the
r a iT' Q rex h i bIt J ~'n ass 0 cia t i. 0 n ; s p (m ~i 0 r in g 0 r 9 ani z a t ion 0 reo mm i. t tee ( 2 ) the
owner or lessee ~here of (3) a munICIpalIty grantIng the Named Insured
permission to operate a(n) Carnivals. but only as respects bodily
fnjuryoT propertudamage c~use~ by Dr contributed to by ~he negligence of the
'Jamed Insured whIle actIng In tne course and scope of theIr employment.
NA~~ & ~DDRESS OF INSUR~D:
DE,\Jle C:d:!J t~mu";E\ment~", J.nc
338 North"PaPk Avenue
t-Jintff:T' P",ll'li
F'L .]~~~ .?f.i'7
ADDITIONA~ ~NSURED:
CAft1 cr V-J' f\-fei. S:-ge J~-S
~ J111-tles ,
D reo. h) , \f lS IOn Stud io
/l}o cJrrlJ p;...; bI, &V PICe 7:> v c 17 0 p/ ~
NAME & ADDRESS OF CERTIFICATE HOLDER:
DATES:
____PR1.!jA~Y c:,g~j;BAQ...~..."__
EXCESS COVERAGI;___
.._--~-------_._.
C: Cllnp i.'il1'lLJ '
T H. E. Insurance
Company
Policy Number 97MF5571
LIABIL.ITY LIl"llTE;
G I /PI) DCe: ~J_L9(JQ!J.~ru;L,.___._..__,____...___
Bodily Injury &
Pr'op eT.t1~ Damag e
Bodily Injury ~<
Pl'operty Damaqe
!,Q-------,--.--,--,-.-..--,.
Excess of
$0
$C)---.----.::-..:::=--=
AGG:
':!.Q,..--,---.,-...."........---...,...."..-.-----."...._ $ 9_....___....______________
Excess of
$0
!3J==:=-=-=-~======
T" 0 0 d P r' 0 d u c.: t" '!.J._L OQ.Q!...Q.QO ___"_'_'''''___'.__
Politij per'ie,;j,
From. 04/0J /97
io' 04,lOi/i:78
00/00/00 00/00/00
00/00/00 00100/00
* - COMBINED SINGLE LIMIT
Coverag~ shown herein applies only to those items scheduled on or endorsed to
the POllCy.
This certIficate is not valid unless an original signature appears below.
(Copies Not Valid)
t'1';:'T'C h 1 ~2, 1997
OA1T-1lt--C-rnTltICATE"'1liISURANCE
A ALLIED SPECIAL TV INSURANCE, INC.
!~/~O/!~~1 !~:q~
':ltlq-q:tt:l-l/bq
T~E SECRET~RI~L SHOP
p~GE 02
..
CERTIFICATE OF INSURANCE
372&10
Q"7
K & K Insurance Group, Inc.
1712 Maqnavox Way
P 0 S 2338
THIS C~~T1FICATE IS ISSUED AS' MATTER OF INFORMATION
ONL v AND CONFEfltS NO RIOH1'S UPON TH! C!FmFlc.a.rc
HOt.OER. THIS CERTIFICATE ooes Nor AMeND. exTEND CR
"LJ"!:::t THI! COJERAOE AFFOA~O BY THE 1lI0LlCIES BelOW.
~
. . ox
Fort Wayn., In 46901 COMPANIIS AFFORDING COVIFlAQi i
;1I'<$.)Iii(O - ,~ I
COMPANY A ,
,
I OAVI~ FOWLER/fOWLER TAFFY LeTT!R TIC INSUR~CE COMPANY I
I i:l/B/A AMERICAN CANOY CORP. COMPANY B I
I 97S CLAYTON DR. LETTER !
OELTONA, &'L 32725 COMPANY C !
LeTTeR i
COVIIRAQIES i
-:-..18 1110 c:l1V'Ff TffAT TIolI JIOUCI&8 OF INSURANce LIST!:> 8li1.CW IoIAVi BEEN .SSU@O 11:l Tlole NSUIiIED NAMED AlG'\li IrOR Tl'fE POLICY PI!!RIOO !N- I
Ol~l), ~lT14TANDlNG R4V -'IQUtRerdHT, 11" 0" OON)lMN 0' ANY ~TMCT OR OTHER DOCUMENT WITH RE!~ -:tl WHICH Tto4I. ClltTlFICAfE I
MAY oelS$t.'E)~ l\UlY"'II'!T~N, TH! !N8UftAl\lC! APfOftClOlV'TME ~LK:la o.sC;:~leI!!C He~I!INlS aU&JI!c:TTO "LL "l1eT!l'llfl5. !XCLUI!llONS"'NDQONOIo
-10",9 C>F SlJC.. IIIO&.ICSC. UMIT8 SHOWN W/IN HAve SEEN RlEJuC.D lIY IWO CL.A.....
CO, TYpe OF JNSU~NCC POUCY NUMII&A POLICV iFFiCTIIII iPOLlCY iiXPIAATION UMITS (in It'lOU.,dI) I
~ L.lFl , OAT! (tAI/DO/n') OR! (MM/DO/VY)
I c.n.ra1 L..ltIIlty Glner.' Aao....aate , 1000 I
A' ~ CamlMlCiIl Gt"~nty FSP37S1180200 12s01AM 12:01AM Produ~s-Cornlll OJ- Ada~oat. , 0
! o CUrl. MIdt ~I,l'. 12/04/97 6/04/98 PersoNl .. AlIwnisjnl Inilll\' S
I , 8Or"'" C4m1rIClon Ptot. Each Occur~c' S
I Rrt o.rnaat ~ ont fn} :, i
I MIdlc., ftl'trllt (J.Ify one D8IIOnl ~ i
ParticiDaflI LICIII UIbiIitv i$ NCNr!
I , ~ LIlIINIHy Co!:'IllII1td !s !
$Il9"
, DAny auco Umil ;
i I I
o All owned 8ua;I Ioflly ; !
I i I
o $oI'!ecNIed 1'110' InjUl1 I I
I (IlIr';lIISOI!) : I J
i 0 HIr~ lulo. J 8ocI11y ! :
I lnIury !
I 8 Non-ewllect .ulell I Ilotr .lNi<<tIltll S
I i
: 0 Ganl~' l.;IDlllry PrOItfl1)l 1$
, ! DI",'9' i
..,... Llalltllty I I e"'ft I
i 0 Occur...n~ ~gr", I
i I
! o Oltll' ....n Umb",lIa form i Is s I
I StltulerJ I
f , I
I , WOI'bra' eom,."..UOlt , S EIIGt1 AoolcMnl I
! ."d
: Il!.~.'" LleWUty ! S OIU.....PcIicv LimIt
$ O"as~1!.ao1t EmDlcv..
i AD.lO S
: hltldpant .-rIma", ~e4'l;a1 $
,
i ! A,ocldenl Excess MlNlioal $ 1
I WMklY Inc.",,,ity S X ,
I I M' I
i CER'l'IrICA'IE HOLDER IS AN ADDITIONAL INSURED WITH RESPECTS 'IO ~ OPERATIONS
OF TH!: NAMID INSURED FOR THE DATE OF DECEMBER 13, 1997
CUTI~fCArl ~OLOIR
-
If. ON
--1
DREAM VISIONS STUDIOS D/B/A DREAM
QUEST MUSIC CASH 4 TItLE, CITY or
WINTER SPRINCS, MOUNTAIN VIEW
~RODUC~:ONS, INC.
SMOULO ANY OF' Tlie A80VE OeSCRIBED PC1ICIES BE
CANC!!.LI!O .JIORE THE EXPIf=lATION o~S THeJI':f8F. THE
'$SUING COMPANY WILL ENDiAlIOR TO MAlL DAYS
WRITTI!N NOTICI '"' THe e!RT1~ HOl.DI!R NANEC '1'0 "!'HI
LliFi. IIUT ILURE All. SUCH NarlCE SHALL IMPOSE NO
08l13AT R L TV 0111 API'( Kl'4D UPON THE COMPANY.
ITS AG lS R ESENTATlVE9.
~
12/05/1997 13:43
9134-428-1754
T~E ;E:RET~RrA~ 3~J~
:::>AGE a1
..
CERTIFICATE OF INSURANCf
372631
e."
K & X Insurance Group, Inc.
1712 Maqnavox Way
~.O. Box 2338
Fort Wayne, In 46801
THIS CERTIFICATE IS ISSUED AS A MATTER OF I~FORMATION
ONLY AND CONFERS NO FllGH1'1i UPON TH! CEAnPlCATI!
~OLDER. THIS C&FmFICATE DOES Nor AMEND, EXTEND O~
ALTE~ THE CCVERAGE AFFORDEO In' THE 1I0LlCI!S BELOW.
COMPANIES AFFORDING COVERAGE
JIM SCRAFANO
D/B/A JIM'S OASIS
318 PATRICIA DRIVE
NEW SMYRNA BEACH, FL 32168
COMPANY A
LETTER TIC INSURANCE COMPANY
COMftANV B
LeTTER
COMPANY C
LETTER
COVERAGES
THIS III 'TO e5~IFY TWtT THE tIOUCI&S OF INSURANCE LIST!D BI!LOW ......VE seeN issueo '10 '""I N8UAEO NAUIE'O A90VE !=OR TJoC! POLICY PERIO::! iN-
OI(;.lll'IQ HCrNml8TANDING "',.,., MQlMl!UENT, TlftM 0" OONOmoN OF ANY CONTRACT OR OTHER DOCUMENT WITH ~E!lPECT TO WHICH THIS CEfmFICAn
MAY "II! t$SUf%l ~ ~ 1"1!!JIn'A1N. fit!! INSURANCI! AI"1OADI!O '" THe "OIJCIU DEa<:..ell!C HE~IIN~ SUBJ!CT 1Q 1'1..1. THC TCAM5. PCl.USIOHS AND CONOlo
'nONS OF SUCiot ~.cll&$. UMITS CHOWN MAV HAVI! "IN AECUCiD 8'1' PAID CLAIM8.
Co. i POLICY EFFECTlW POlICY EXPIRATDI
LTR i TV.-. (W INSURANCE POuev NUMBER DATE (MM/OOiYY) DATE tMM/DOIVY) l'~ITS (In 'hoycand.)
I I a.".,.. LIUIIV
i A I '9 COl1llllll'Cll. ~.n"!Uflbl*Y
! DCl~s 'Made l1J~r.
I Down....., Conlractort PIOl
,D
i
!'SP31S1180200
12:01AM
6/24/97
12:01AM
)12/24/91
I
I
I
.wlllete
AIltOmoIlIIe Lllbllty
o An'1ll.ll0
o All ClWned .utes
o S~I'l.~" ~os
o Hired ."tos
o Non....",tct .1ol1Oll
OGlrq, Lilllillty
o .
! EmM. Llabllhy
o
o om.r ",n Umbrella form
WOfUq' COm,....lIon
Iftd
Emp~...' LhIWllty
Sl...!
Each Aoctjent
OI.e.....PoIicy LilM
~
hltlclpant
Accident
~ lLOCRIONS'VIHlO I a
CERTIFICATE HOLDER IS AN ADDITIONAL INSURED WITH RESPECTS TO THE OPERATIONS
OF THE NAMED INSURED FOR THE WINTER SPECTACULAR 97' ON DECEMBER, 13, 1997
CeRTIFICATE HOLDIR
CANClLLATION
DREAM VISIONS STUDIOS D/B/A DREAM
QUEST MUSIC CASH 4 TITLX, CITY OF
if INTER SPRINGS, MOUN'1'AIN VIEW
PRODUCTIONS, INC.
SHOULD ANY OF THE ABOVE DESCAlsec POliCIES BE
CANCElLED BEFORE THE EXPIAA'1'ION DATI! THER~, rHE
ISSUING COMPANY WiLL ;NDEAVOA ~ MAL DAYS
WRrrnN NOTICE 10 THE ceRTfFI~ HOLD!" NAAAI!D 'IC TH!
LEFT. BU1' IUJAE" JJl SUCH NOTice SHAtJ. '''''POSE NO
0811GAT I:!l L TV OF ANY KIND UPON THE COMPANY,
ITS ~ TS A ESENTATIVES.
DEc-a4-97 a1:24 AM
p.a5
11<'191'97
it,: 31
I,.:. I'!, r.(I~.E'=;8,CCI. EF'CIIo.l118H1.II'1F'HF:E'( . 19044375(?)15
NO. 391
~l
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CERTIF'ICATE OF INSURANCE
Oat.: November 19, 19Q7
iAOOUC~. - ...._..::;;=::.==""~~
BaoWH AND HUMPJlREY SURPLUS
UNES INSURANCE BRORf1RS
400 MONTGOMJ1RY ST., StJl'J'li ~OO
SAN fRANCISCO, CA 94104
INS[jRLlJ-"'--'-" --... ... . ----..--. .
fireworks By Santore, Inc.
P.O. Box 364
Bunnell,FL 32110
u.__ __.....,.,.~____ _ ~....,.,~_ .
1 'I'hb ecJti!i~le is uS\lcd as a matterollalurmadODolllY .od
I WDfCl'5DOrigbl5 UPOD lbuertific:ateboldcr. llu:c;ert.lBeate
doesDolamel1l:1, Clllendor alter lhe<:ov\lraF affotded by
policies beJow,
..---. -COMPANiES AFPORDING COWRAGE:'
Company CNA International RfJln$urance Co
Letter A 30,00" Participation I
Company Underwriters at Lloyd',. London
..._____.._,_.... Letter B.. ..!O.OO% Parr.iciPation ..
COVERAGES
nil iI to certify Ih~l th, poUciel litl.:!l "f'f<.o~ ~a;" bun inwcll 1<) .he insurtd nallllld I\t~ for the poliC')' j'etiod ItId.icoled. ~l.hItalldiAi Ul)I
~quIR!DeDI. 1~'Il1. or CODOitio~ of a")' r.<Jlllroc! or olhr d(Y,:ijrllt,lI\ .-Itll r'.peel to whlcll rbi, QCrlir~IC: ffll1Y be illllcd or may por...'", IIIe WutOMt
alrolded b tile lic:itl dt.~ri~~'~ ',tll:~!!.!~~ill.U~~U~!.!!l~...5r~I\I,~m.1&lId eorl~.i!l.2!!!_Or .lJCb oliciu. _,.. _. .
..., olley 'Policy liability Limits In S 1000's
Co Type Of ! POlicy . EHective expiration !sch
Ltr -~~~~~r8i&miY" r--.~-~mb.~I-i Date ."._R~ .__'" . Accident _Apgregat.,
aaimi Made FClfIn I i Ul "1'U r
X Prcmlses/OpuiltJollS I CombiDed ',000, 2,000,
A X ConHa(tllilJ l.ial1Wty ;
I X l'roducts/Completed ! F97/2697/000) 8/04/97 8/04/98 I
B Operatiori~, I Penoaal /ncl. Inol.
.. X YU~=-'f.TablfitY'l . ---__,~___....._. ____._. lD"u "._._
U~~~':;..l!1'1I.Lu__1__.L_ . ~~~d. ...,.i
~t1l&6 doet 1I0l apply 10 Bodily InjllT)' 0' PW()nalll1ju~ It', or lou, Of dAltlt:8e to, or lost 01 ule of lhe shooter(I), UI ItIlt(S), QIldJo, II\~ OInet I
'J')' iatludwl IIlY\(lI\l.n..\!~t0) P.Yt..k!~:ltinl i!I~..1..!!t!!L~httl1.l&..l.\U~or clecIl1lon,U}' "lIpllY or .~lal elred.. ~ .
. ~ype of Display: Fireworks Display
Site of Display: Cenlfal Winds Park, Winter Park, FL
_ ..~ D~t, ~!.~~I~L Oece~ber 13,1997 _._. ..__._.___. ..
Additional Insureds with respect to th~ abOVtf di$pl,y only:
1) Mountain View Productions I Inc.
2) Dreamvision StudIOS DBA Dreamq~~est Music
3) C~h 4 Titles
4) City of Wintor Springs, FL
.
.
CER1iFicA TE-FiOL~ER' .....
Mountain View Productions, Inc.
812 Meadow Park Drive
L_c~m:t,~: ~:.~~_~.o"..~".._._ J
r----.," CANCELLl..riON~-'--
I Sbould aa, of t.be .~ve polieicl be 40Uttled before
, tbe npiratiort dat" lhreof. tU ulllaa ClOmpaay will
maU 30 da)'S wrJUell Doli" to tho certlfIaate holdor
Damed to the left. :::::---J
. _.... .-- . AuthoflietfR rei.nta6ve: I
. I
I
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----:---,-------r--r-.;-~____:__sT
I":U~
'Q"-4U I 3~~3:JUJt
\farshlITf~frns-
tal 004
---------r"". ;':--::o:';,~:-:r...~
,"
J1
J,;, A_ii>>III.. ')r~,~~""
;::::; ; ';:., : :.': . '.:.:~~''':'':~~f:'~.~:.~~;;:.~::<~::;~;.::;:~~':::~.. :..': !:'::?-:
JlAODOCIR
<"""'~~1:~:::;~;\!i:i ..., iiA,n (M~D^", ",
::ll:l; .<:.::,:.~.. _1/~~1 97
THIS CERTlPlCATIIS ISSUED AS A MATTER OF INFORMATION
ONlV AND CONPERS NO AlGHTS UPON THE CERTIFICATE
HOLDER THIS CERTI'ICAn DOES NOT AMINO, EXTEND OR
ALTER THE COVERAGE AFFORDED BV THE POUCIES BELOW.
COMPANII!S AFFORDINCI COVERAGE
Mar'~ll in~.rtaLnment Insurance, Ine
S\;:.~. 6;15
ac: Ln~verlal 9tudi~s Plaza
la~de
PL 3~aU.
CClMPANV
A~or:h ~.ric&ft Spec,
COMPANY
B
"J'l JS).~S3"
IISUIllED
~a~~:a~~ V1ew Productioaa, Inc.
d:2 Meadow Park Dr!ve
COMPANY
C
Clel:'l'lllXlt
PI. 34711-
COl\IP-'/IlY
o
(JS2} 3t4~:&aS5
~~_M~~,h:~i.4.:~:!~lli':i~t. :~ ", ,.dW~1Wt@~Ji1 :J*~~l!itr.i~~?&~..':": '11fu;ii41$tt1U~ltntii!tm~~k~diJ)'UclgfiJ~~~t~~~1~ .:ltii::~iMt[MMit
THIS IS ro CERTIFY THAT Tfo1I! POUClES OF INSURANCE US~ SElOW HAVE BEEN ISSUI!!D TO THE INSURED NAMED ABOvE FOR ThE POUCY PEAIOO
INDICATED. NO'TWITH8TANOINO ANY REQUIREMENT. TERN OR CONDlnON OF ANY CONTRACT OR O"ER OOCUMEt. T WITH RESPECT TO WHICH THIS
CERTlFICA'C MAY BE 18SI.JED OR 'My PERTAIN. THE INSUAANCE AWORDED !tV THE POLICIES OESCRIBeO I"ER=IN IS SUBJECT TO All THE TERMS,
exCLUSIONS AND CONDITIONS OF SUCH POllCles. UPetTS S"CWN MAY HAVE BEEN RECUCEO Ftf PAlO CLAIMS,
'IIOUCYVl'ECTMi l~iXI'_nOfl
OA TlIMIMlDNY) ; Dl\ft ClAllDDIY'I) .
CO
lTJI
l'tN 01' I""!WCI!
rcucy MUII_.II
UMlft
A ClINI!ML UU1U1V
.-~
,X i c;:)MMER:::AL. GEI\ERAL. UA8IUlY t7222MBI
~! I I ClAIMS \AACE !!J OCCUA
; OWNE"'S . CClNl"R.fCTClF pqQT
I
'---'
Da/u/,?
01/14/"
'l,OOO,oeo
.wrOIlO.LI UUIU'IV
:J ANY AJ..'TO
I AU.~EDAl;TOS
il SCHEClJI..!!) AUTOS
. HflED AUTOS
; NON-aWNED AUTCS
50,ODO
5,000
/ /
/ I
jl
; BOOILVIN.J:JRY
~, perxn]
.
BOOIL Y I~URV
(Pw ICCIdenlJ
II
II
I
i "fIOP!:ATY OAMAGE
I G.UW11! LWIIUT'I
-,
i , Il.HY .aUTO
'--i
I I
/ I
I "lJTC CNLV . EA ACClDEillT I
f OTHER TJ.Wl AUTO ONLY:
~ ACCIOENT I
AOGAEGATE I
:ItCH CCCUAFlENCE .
4OOIlEBA1E .
I
---!
i
IXc:eu UA8IUTY
, UlAlPEllA FOFlM
! On.eil TJ.Wl UMI!AEU.A FORM
WOMl.. COllf'lNSAlIOIII AlID
1IiW'LCMM' UA8IUT'f
TIooE ~ETOl'II II\ICl.
FAAllIJERSIElCECUTlVE
OF"lCERS 4AE~ EXCL
OT!fIR
I /
I "
I I
I I
STATUTORVLMTS
iACH ACCIOENT .
::llSEi'SE ' PQJCY UMfT .
: :J1;e.lSe . EACH EMPLOYEE .
I I
I
I
I
I
OESCNPTION OF OI'I!""lIONl1JLOCAnolll{YlH~lALmMS
The Certitie&te Kelder i. 1nelY4e~ .. an Addtt10Dal Inwured,
C~;i o~ Winter 3prin~s
~~2~ S, St&~. ~., 414
: :::::'''':''-:''~~~:~ffiIjf. ~~~'}
.'
12/05/1997 14:24
'304-428-1754
T~E 3E8RETARIAL 3~OP
OAGE 01
"'Me
L J'B conce..ion
Mary :K KIWJ dba
27630 Nancy Ave
Paisley, FL 32767
'" 'DATI~OMl' ,
12/05/97 '
1M
ONLY AND 110 RIGIft'I lJIOII ". ClllTIllCA1I
HOLDIIR. TN. Q!"T1~T! DOlI NOT ~ OR
ALTIR THI CCNIUCII flY 1HI .ow.
=-- AI~
OOM',,"'
1~.r1can Suret ,casualt
I eo~,lHv
I ·
QQ~ANY
C
.-
MID. ~
1~1~lto1l:~:t>:',"':~~::1~~
100.....
.ton InsuranQG ACJe1'lCY, Inc:.
,0. 80x 291970
731 Nova Road
ort Orang., FL 32129-1970
.
....~. :<<- . ~ :~:~.i;' . , ...': ~: .:;ttft' .~: ,......~ . ' ~:. i'.;~. ~. ~.. '...,
THIS . TO ClefIITIIY ~T THe POUCIlI ,. -..wu UIr!D .IPN HAVE 8EBI IllUEO TO lHI ..aIlI!D HAMED AIOV& ~ ,.. POUCY PlflQD
lNDlCA11fO. Nl)'TWmffi'.uIl*Q Nl'f JllGUIBo'ENT. 1EJW ~ OOfIIgmgN ~ /IN'( CCNTIW.7T' OR OntER OOQJIrefr wmt ~ TO wtCH '!'HIt
C!MPQ\'QJ MAY BE IMUII) OR MAY PBlTAlN. ,.. IMIUM/a NPORDED BY M ftOl.lOlII DitCI'II!O teI!.. .. ~ 10 ~ 'M! 'TBI8.
~~AND~g" IUCHPOl"IC:8. u",'....OWN ~V*VEBeEN~1V PAlDCl.UAI.
II MllIIIlIIIUIWlW r-'--;~c:t MUMIII" '
U"''''
, IIUIIW.UAlII.rTT CP400341601
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