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Cert of Insurance
t jig ig to Certitp that the HIGHWAY CASUALTY COMPANY has
issued to
Assured... �a c r1 a s_ _139.1sa*s t.
Address - - - -- = 1_ t,. a •__ 1 th_ t eQt ° v , - _De ep__F 1oriclr.
POLICIES OF INSURANCE DESCRIBED AS FOLLOWS:
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Kind of Policy
Workmen's Compensation
Public Liability
Property Damage
Number
li 3
GL 47772
GL 47772
Term
142...53 to 1 -12 -54
1-12 -53 to 1 -12 ®54
1-12-53 to 1 -12 -54
Limits
Provided by Workmen's
Compensation Law of
.1:- 1ox.,1 .
One Person: $...104.000.00
One Accident: $20,.000
One Accident: $_..1
Total Liability: $
Locations
Covered
a ',.,1 , 4, hiS ..0ITE L.110 Eir3E7:.illERE
IN '..Hi HE STL TE OF
FIORLDL,
Classifications
of Work
Covered
C, IOC C
CnP K RY NOC
CLIIFENTiRY FOC
This
Name
Address----
whom we
Certificate is issued at the
C ity of Aami ,Shores
_Bldg :mi - Sharers,
will advise 5 days notice
- -
request of:
- -F-lo r-3t7a
b m t.erci n ail
%f ca r n e c`� latton e or any changes affecting this Certificate.
HIGHWAY CASUALTY COMPANY
T)FY'ross pie 0 Li on a Inc.
Dated ati , ,!ro i .E.each 1o_ido By - Cf ,-
(Authorized Representative)
JciaL1 'y- 19 54
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Form 2012 T
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of
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Certijicate of Insurance
MbiE4 iii to &rtifp that the HIGHWAY CASUALTY COMPANY has
issued to
Assured ,..� L _ A.. 4 r* xy
Address LOA tx_ ..__ 115th ' t rt 0, . i,--it . t# ..
POLICIES OF INSURANCE DESCRIBED AS FOLLOWS:
Kind of Policy
Workmen's Compensation
Public Liability
Property Damage
Number
7
47770;-4
.: i
Term
2�....4 1 % 0 1.42-1`,
I-� , 43 to 14;.
a �
* •,i.' :!.6 ,14.• ..'%4
Limits
Provided by Workmen's
Compensation Law of
rig.
One Person: $ AO.C •
One Accident: $ �
i ,c0CP
One Accident: $
Total Liability: $
Locations
Covered
'
' . .-A1+`. t
Classifications
of Work
Covered
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i x ,,^sry
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This
Name
Address
whom we
Certificate is issued at the
f ce . n r'#
' 1 r.• t ' •
will advise I days notice
request of:
►. if t. tort ,;..,
o cancellation or an than . es al ectin this C
Ir 0 • I I I t 0 / • I ) s In.r % ` sr z' ' i y or - at ure to give suc notice.
HIGHWAY CASUALTY COMPANY
Dated at M J
P ar ! ` t -: By (.) (--�4 t" ,-- -- --/
(Authorized Representative)
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Cert of Insurance
e j io to to &rtitp that the HIGHWAY CASUALTY COMPANY has
issued to
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Assured j q ' cfi p fir , f . 4 s' $fo C. c s 6.
T � 'Y ��5 it 7 ° i . ^'.4 r a
Address
POLICIES OF INSURANCE DESCRIBED AS FOLLOWS:
Kind of Policy
Workmen's Compensation
Public Liability
Property Damage
Number
_. 194:t
�y ss r
:. 1 ■' 7 .- o 10.4. r.�.i -�
. 47772
`.� s (} ry SI
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,ew-n, 1 0 4 V
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One Person: $ tat e.;Ff, _.
One Accident: $
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eq..'a* a •., {} 1 4. M 4
yyr
One Accident: $
Total liability: $
Term
Limits
Provided by Workmen's
Con .t�pq Law of
Locations
Covered
Classifications
of Work
Covered
°s,:
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This Certificate is issued at , the request of:
Name
Address , i ,. r t '
w
Highway Casualty Co. assumes no responsibility or liability for failure to give such notice.
LOGHWAY lifiSUALCY 'Oi4 'ANY
Dated at , By
(Authorized Representative)
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Form 2012 T