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<br />i <br /> <br />.i~ <br /> <br />.,':' <br />?:.-, <br /> <br />"'{. <br />~~i:, <br /> <br />~ <br /> <br />4} <br /> <br />,;;.> <br /> <br />.~,:. <br />:t,' <br /> <br />,~~;~ <br />'%; <br /> <br />~;:; <br /> <br />'f.; <br /> <br />i~~ <br /> <br /> <br />t$ <br /> <br />~- <br /> <br />COMMERCIAL LINES POLICY - COMMON POLICY DECLARATIONS <br />NAUTILUS INSURANCE COMPANY <br /> <br />Scottsdale, Arizona <br /> <br />Transaction Type: New <br />Renewal of Policy # <br />Rewrite of Policy # <br />Cross Ref. Policy # <br /> <br />Policy No. NC950215 <br /> <br />Inspection Ordered: <br />[Xl Yes 0 No <br /> <br />THIS INSURANCE IS ISSUED PURSUANT TO THE <br />FLORIDA SURPLUS LINES LAW. PERSONS <br />INSURED BY SURPLUS LINES CARRIERS DO NOT <br />HAVE THE PROTECTION OF THE FLORIDA <br />INSURANCE GUARANTY ACT TO THE EXTENT OF <br />ANY RIGHTOF RECOVERY FOR THE OBLIGATION <br />OF ANY INSOLVENT UNLICENSED INSURER., <br /> <br />Named Insured and Mailing Address <br />(No., Street, Town or City, County, State, Zip Code) <br />INFERNO CHALLENGE <br /> <br />8861 S.W. 22ND STREET <br />MIRAMAR FL 33025- <br /> <br />Agent and Mailing Address Agency No. 00922 - 00 <br />(No., Street, Town or City, County, State, Zip Code) <br />Gabor Insurance Services, Inc. <br />7270 NW 12th Street, Suite 700 <br />Miami, FL 33126 <br /> <br />NO FLAT CANCELLATION <br />Policy <br />Perioa: From 08/25/2009 to 08/25/2010 at 12:01 AM. Standard Time at your mailing address shown above. <br />Business Description: PERFORMS CIRCUS TYPE SHOWS FOR PA..t(TIES, ETC. Tax State ~ <br /> <br />Form of Business: IX] Individual 0 Partnership 0 Joint Venture 0 Trust 0 Limited Liability Company (LLC) <br />o Organization, including a Corporation (but not including a Partnership, Joint Venture or LLC) <br /> <br />IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO AlL THE TERMS OF THIS POLICY, <br />WE WILL PROVIDE YOU THE INSURANCE 5T ATtO IN THIS POLICY. <br />THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PAHTS FOR WrllCH A PREMIUM IS INDICATED. <br />THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. PREMIUM <br /> <br />Commercial General Liability Coverage Pare <br /> <br />$ <br />$ <br />$ <br />$ <br />$ <br />$ <br /> <br />1,000.00 <br /> <br />Tax & Fee Schedule <br />POLICY FEE <br />INSPECTION FEE <br />SURPLUS LINES TAX <br />SERVICE FEE <br />FHCF FEE <br /> <br />TOTAL ADVANCE PREMIUM <br />35 . 00 Minimum & Deposit <br />75.00 <br />55.50 TOTAL TAXES & FEES <br />1.12 <br />11.10 <br /> <br />1,177.72 <br /> <br />1,000.00 <br /> <br />s <br /> <br />$ <br /> <br />177.72 <br /> <br />$ <br /> <br />TOTAL <br /> <br />Form(s) and Endorsement(s) made a part of this policy at time of issue: <br />Refer to Schedule of Forms and Endorsements. <br /> <br />Agent: Mckinley Financial / <br /> <br />Surplus Lines Agent: Ronald <br />License Number: A091647 <br /> <br />Countersigned: Miami, FL <br />08/27/2009 <br /> <br />James Drake <br />S. Gabor <br /> <br />--~~ <br /> <br />Countersignature or Authorized Representative, wh'i'C'hever is applicable <br /> <br />By <br /> <br />MG <br />SF <br /> <br />THESE DECLARATIONS TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART COVERAGE <br />FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY, <br /> <br />I..._I....J........ __.........:_'"'......;.1 ..................:...1.....' I..........,..........,.. Cn..ui.....n... ("\f.Ji,..o In,.. \&,j+h it~ nQrrni~<:,inn <br />