Southern-Owners Umbrella Policy Declarations Oct 2024

--- ## Page 1 Southern-Owners Page 1 26354 (05-94) Issued 10-28-2024 Policyholder since 2016 UMBRELLA POLICY DECLARATIONS INSURANCE COMPANY 6101 ANACAPRI BLVD., LANSING, MI 48917-3999 AGENCY HUB INTERNATIONAL FLORIDA 12-0025-00 MKT TERR 052 (727) 797-0441 INSURED JOHAN JONGSMA TATYANA JONGSMA ADDRESS 851 BRIGHTWATERS BLVD NE SAINT PETERSBURG FL 33704-3719 Renewal Effective 12-12-2024 POLICY NUMBER 50-989-154-01 Company Use 20-20-FL-1612 Company Bill POLICY TERM 12:01 a.m. to 12:01 a.m. 12-12-2024 12-12-2025 In consideration of payment of the premium shown below, this policy is renewed. Please attach this Declarations and attachments to your policy. If you have any questions, please consult with your agent. EXECUTIVE SEE SCHEDULE A FOR UNDERLYING LIMITS REQUIRED LIMIT OF LIABILITY: $ 5,000,000 Each Occurrence UNINSURED MOTORIST LIMIT OF LIABILITY $1,000,000 NON-STACKED PREMISES LOCATION: 851 BRIGHTWATERS BLVD NE SAINT PETERSBURG FL 33704-3719 RATING INFORMATION: Territory 004 Pinellas County, FL FORMS THAT APPLY TO ENTIRE POLICY: 26029 (05-00) 26351 (10-18) 26394 (10-97) 26083 (05-12) 26326 (03-91) 59154 (02-86) 26265 (05-12) 26331 (09-91) 26043 (02-82) 26474 (09-02) 66006 (05-12) 66111 (11-15) 59243 (06-00) 66126 (06-17) 66166 (12-17) 66203 (02-19) 66080 (06-21) 66204 (02-19) 66222 (06-21) 66223 (07-21) 66224 (06-21) BASE UMBRELLA PREMIUM PREMIUM $458.00 ADDITIONAL CHARGES Number of Private Passenger Automobiles/Motorhomes: 1 Included Number of Drivers Under 25 Years of Age: 1 261.00 Uninsured Motorist Coverage 156.00 Excess Millions Charge 1,538.00 Discount(s) 637.00- Mature Discount Applies. Umbrella/Auto Multi-Policy Discount applies. TOTAL POLICY PREMIUM TERM $1,793.76 The Total Policy Premium shown above includes: Emergency Florida Insurance Guaranty Association Assessment 17.76 Countersigned By: HUB INTERNATIONAL FLORIDA --- ## Page 2 SOUTHERN-OWNERS INS. CO. AGENCY HUB INTERNATIONAL FLORIDA 12-0025-00 MKT TERR 052 INSURED JOHAN JONGSMA Page 2 26354 (05-94) Issued 10-28-2024 Company POLICY NUMBER Bill Company Use 50-989-154-01 20-20-FL-1612 Term 12-12-2024 to 12-12-2025 SCHEDULE A (Underlying Insurance Requirements) | NAME OF INSURER | TYPE OF POLICY | YOU HAVE AGREED TO MAINTAIN LIMITS AS FOLLOWS: | | :--- | :--- | :--- | | AUTO-OWNERS INSURANCE COMPANY | COMPREHENSIVE PERSONAL LIABILITY | COMBINED SINGLE LIMITS $300,000 Per Occurrence | | SOUTHERN-OWNERS INSURANCE COMPANY | AUTOMOBILE LIABILITY | BODILY INJURY AND PROPERTY DAMAGE $500,000 $500,000 $100,000 Per Person Per Occurrence Uninsured Motorist/Underinsured Motorist Included |