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:y <br />WAIIState. <br />Nmem in a WI 1w%I /. <br />ALLSTATE INSURANCE COMPANY <br />Home Office Northbrwk, Illinois <br />Ca I enda r Date 10/08/200? <br />1=LORILV% <br />CUSTOMER StIiVICE Rf.QIIESI <br />COMMERCIAL A010 POLICY <br />Policy Number*: 0411194765 09/14 <br />BUSiNESS NAME PROFESSIONAL WELDING INC <br />RUSN ADDRESS 6/5 NW 5 STREET <br />CITY MIAMI ST: FL ZIP: 33128 <br />1 M PHONE ( 305 ) 986 - 4039 BUSINESS PHONE. i 305 :174 0101 <br />CHANGC COVLRAGFS These are the coverages l.hat apply to your, <br />vehic'P(0 after your, r-equested change Pas been made. <br />t <br />ITEM OU1 ITCM 007. <br />A8 Combined Of 8 PO 500000 500000 <br />=VA Basic PIP (Ded) C 0 <br />PIP Plan 01 ()1 <br />CHMGE POLICY ADDI I fONAL INSURCO <br />1)ir Code: 000000 <br />N.arrx,- : CITY OF MIAMI BEACH <br />CiLy: MIAMI BEACH <br />Tt1IS LNJORSEMENT HAS AFFECTED THE FOLLOWING POLICY FORMS: <br />For•rs 0PIrt•ed:CA9C127 018/ SPLIT LIA1311.11Y <br />. .. .. - - - - -- . -- - -- - - -- - -_.. ... 0.. -. - - .- - - - - - "- . . . . .. -. - . - - - - -- ... - .. .... <br />THIS S REQUEST IS SIlRJFCT TO POLICY TFRMS ANU IS EFFFCT IVE ONLY IF <br />THE PO;.ICY NOTED IS CURRENTI -Y IN FORCE <br />EFrF(;)1 VE 12:01 AM 1010012002 <br />Notice: it. is a crime Lo knowingly prY,vide false, inc(ariplete Cr <br />misleachng information 1.0 an insurance ewpany for the ptArl)0sc! of <br />defral:dlrn;) khe tianpany. Penalties include irnprisonlnent, fines and <br />denial of insurance Ixanetiis. <br />N' �iCj)YlIOLQ1R gnature <br />1 d(. -N0: 016117 LOC: 749 305..854 1684 <br />s , re Agent's Phonef <br />Page 1 of 01 <br />