05/22/1995 Council Packet - Laserfiche WebLink

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Renewal Declarations Named Insured: LaForest, Mary Address: 4819 Wood Avenue White Bear Lake, MN 55110 Policy No.: 95MN002585 Effective Date:(Standard Time at Locations of Risk) From: 12:OIAM 4/01/1995 To: 12:OIAM Agent or Broker: Roth Insurance Agency, Inc 325 Gibbs Street Maumee, Ohio 43537 (800) 78 -FLY ME 4/01/1996 General Insurance Company of Trieste and Venice and/or Generali, U.S. Branch One Liberty Plaza, New York, l icw York 10006 Tel: (212) 602-2633 Coverage is provided only where an amount is shown and a prenniuni charged. Insured Balloons Balloon #1 Balloon #2 Balloon #3 Balloon #4 Year Make 1979 Raven Model S -55A Coverage I - Liability Coverage A. Combined Bodily Injury Liability Coverage including passengers but not more than $100,000 each passenger each occurrence or $300, 000 all passengers B. Bodily Injury/Property Damage, excluding passengers C. Liquor Liability Combined Annual Aggregate for Coverage A, 13 R . C Coverage II - Medical Expense Coverage A. Medical Expense Coverage Including Pilot(s) [X] if box checked Endorsements Attached 01 G-03-91 Additional insured Special Conditions N-Nwnbcr Usage N5563Y Limited Comm_ 25% 3 Passengers Limits of Liability Premium $459.00 $1,000,000 each occurrence $1,000,000 annual aggregate $1,000,000 each occurrence $Included $100, 000 each occurrence $Included $100,000 annual subaggregatc for this coverage only $1,000,000 annual aggregate $5, 000 cacti person $20,000 each occurrence TOTAL PREMIUM Policy Fee & Taxes $46.00 $505.00 $0.00 Notice_ This policy is issued through your risk purchasing group. Your risk purchasing group may not be subject to all of the insuranc laws and regulations of your state. State insurance and solvency guarantee funds may not be available for your risk purchasing grout i Date of Issue Pilot Schedule Coverages afforded apply only while balloon is operated by the following: LaForest, Mary Mogren, Patricia Rae Counters' gh5ed By