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<br /> <br />_. <br />ATfi1lTMlDD/YYI <br />NCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THI <br />' <br /> <br />PRODUCER A~ic :910 - 2 2 8 - 0 5 2 5 3~ <br />ORM. <br />COMPANY ~ BWDfiR / <br />HAYWOOD SIMPSON INS AGCY INC TAPCO 0073099BDR <br />110 5 S CHURCH <br />STREET , <br />, <br />El~rnvfi <br />fixPIR <br />T <br />--. <br />. ~ <br />I <br />fi <br />A <br />T <br />rTM <br />P 0 BOX 2038 IM <br /> X AM X I? <br />01 <br /> <br />BURLINGTON NC 27216 <br />7 30 99 <br />12:01 <br />7 30/9 : <br />AM <br /> PM 9 ,~N <br /> <br /> <br />cope: 3 2 0 0171 sus-coDfi: <br />X THIS BINDER a ISSUED TO EXTEND COVERAGE IN THE ABOVE NAMED COMPANY <br />PER I:XPIRINC POLICY ~: C 7 5 5 6 3 <br />cAIUTOMfiR ID: AS TE JAO - 2 DfiscRlPnoN of oPERAnONSrvfilucLSSePROPfiTT;ry Laenlim) <br />INSVRBD <br />JAMES STEWART <br />DBA FAIRVIEW EAGLES CLUB <br />520 HARPER STREET <br />ILLSBOROUGH NC 27278 <br />._{Lh 6: •.. !n{:{.i~n iv4ti:+i'li~ ~ ~J:.~.'G'~'4'v"+C. A. {'$h{l~'~,::~~{i:~i:~>: <br />r <br />rYPE OF INSIIRANCfi COVERAGFJFORMS AM'OUNr <br />DfiDUC[IBLfi COINS 9i <br />PROPERTY CAUSES ~ LOSS <br />BASIC ~ BROAD Q SPEC <br /> <br />tk;NliRAL LIABILITY GENERAL AGGREGATE f <br />X COMMERCIAL GENERAL LIABILITY PRODUCTS - COMPADP AGG S 6 O O, 0 0 0 <br /> CLAIMS MAD£ a OCCUR PERSONAL & ADV INIURY f 3 O O O O O <br /> OWNER'S A CONT'RACTOR'S PROT EACH OCCURRENCE f 3 O O, 0 0 0 <br /> FIRE DAMAGE (Amr one fire) S 5 O O O O <br /> <br /> RETRO DATE FOR CLAIMS MADE: MED EXP (Any ane pasoa) S <br />AUT OM081LE LIABILITY COMBINED SINGLE LIMIT S <br /> ANYAUI'O BODIl.YWURY(Perperwe) f <br /> ALL OWNED AUTOS BODILY IN7URY (Per axident) S <br /> SCHEDULED AUTOS PROPERTY DAMAGE S <br /> HIRED AUT05 MEDICAL PAYMENTS f ' <br /> NON-0WNED AUTOS PERSONAL IWURY PROT f <br /> UNINSURED MOTORIST f <br /> S <br />AUTO PHYSICAL DAMAGE DEDUCTIBLE ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VAWE <br /> COLLISION: STATED AMOUNT' i <br /> OTHER THAN COL: OTHER <br />GARAGE LIABD,TfY AUTOONLY - EA AO"..IDENI' f <br /> <br />ANY AUTO <br />OTHER'I'HAN AUTOONLY: ................ <br /> EACH ACCIDENT S <br /> AGGREGATE f <br />EXCIs'SS LIABILITY EACH OCCURRENCE S <br /> UMBRELLA FORM AGGREGATE f <br /> OTHER THAN UMBREU.A FORM RETRO DATE FOR CLAIMS MADE: SELF-INSURED RETENTION S <br /> STATUTORY LIMBS <br />WOR[OiRS COMPENSATION EACH ACClDEM f <br />AND <br />EMPLOYER'S LIABILITY DISEASE - POLICY LIMIT f <br /> DISEASE -EACH EMPLOYEE S <br />GROUP ACCIDENT POLICY NATIONWIDE INSURANCE EFF 7-30-99 $8,500 PER <br />sPficIAL <br />°N~ PER PERSON <br />covfiRACfis <br />.. - . .. , ................ •;,:;:: -..~ , <br /> <br />{Y~ v <br />~ a:'-~{.~ <br />r• ~ ' <br />~ <br />~ <br />~ <br />~ o : .. .. '?"`~ Ate. ...y~, ,. r• .;~a'>~~~>> ~_:<:: <br />. <br />• <br />C <br />' <br />•r <br />3": <br />~G' <br />`:J"{ j <br />'}}:ti~ ~ r fi <br />~' <br />'{; <br />f~'~'~i ii' <br />: <br />~ <br />~" <br />` <br />• <br />r <br />+" <br />.l <br />+ <br />x:..:.:r. ::::_-'-:iGV:.:::.:. f..xr .n?.n _ •... r. • .. .. <br />.'{.,.-..{+ <br />{..-.i. <br />G . <br />. • <br />n <br />~ <br />, <br />• <br />- <br />y <br />: n <br />i4. <br />: <br />v : <br />{: <br />v <br />'Y.':F.......v : :. n..ttt. \~4:ri.: r. f..::4?. <br />.M?l`:.'.. .L. ..., ................. <br />_ ?~A .:n. ..MNY <br /> MORTGACE£ ADDI170NALINSURED <br /> LOSS PAYEE <br /> LOAN / <br /> AUTHORIZED RfiPRESENTATIYfi <br /> <br />l Dixie L. Vernon <br />-ri-,~>:.:~~:::tx=A:::,..: v. ,v ,- v.:. •.. ..~•~?:;;.,. ,Y <br />...:.,:.::..::::~'.::r:~,;::<; <br />f-..,if/r:l~:•y9,3,t1~•~°dY..: <br />:.:..... , t ".fig,::.`.:,....-: <br />` ~. ;. .. r•.iY;i::Y~v!`^':';v:.':r'.i~''`' :O<.; >:•'_-.-~:: <br />~ .fv.. p,:.:{fA.::, :: t+AS:a•:r-:t`' .2' ,'oU:.jv.>ru eG' q :attec.'},{M;•.:> <br />?, ~ f ~'~}~.' . <br />''y~y~~r~ S, tt''! i t°• . ~`~I~~ <br />