2019/20 Earthquake Insurance Policy - Declaration PageCOMMERCIAL PROPERTY
FS C 422 01 13
GENERAL COVER DECLARATIONS PAGE
THE COVERHOLDER
Beazley Insurance Services
CA license #: OG55497
101 California Street, Suite 1850
San Francisco, CA 94111
Please send correspondence to the above address.
Beazley Lloyd's Syndicate 2623-82%
Beazley Lloyd's Syndicate 623-18%
Unique Market Reference: B6012BUSAl9
THE PRODUCER
AmWINS Insurance Brokerage of California - Santa
Ana, CA
1551 N Tustin Ave Ste 700
Santa Ana, CA 92705-8636
POLICY NUMBER: W14D19190601 POLICY PERIOD
Renewal of W14D19180501 From: 07 -Feb -2019
To: 07 -Feb -2020
at 12:01 A.M. Standard Time at the Insured's
Address
INSURED'S NAME AND ADDRESS
City of La Quinta
78-495 Calle Tampico
La Qunita, CA 92253
PERILS INSURED AGAINST: I
PREMIUM:
$98,500
Policy Premium State ax: $2,955.00
Declined
Certified Acts of Terrorism Premium Stamping Fee: $ 197.00
$0
Inspection Fees
$98,500.00
Total Premium for above stated Policy Period
CLAIMS:
In case of loss, please refer notice immediately to:
Claims Manager
Beazley USA Services Inc.
141 Tremont Street, Suite 1200
Boston, MA 02111
Telephone: 617-239-2600
Fax: 617-239-2659
Email: propertyclaimspbeazley.com
FS C 422 01 13 11 -Feb -2019 12:37:36 PM Page 1 of 2
Terms and Conditions Applicable: See FS C 426 12 12 Supplemental Dec Page and /or FS C 424 Schedule of
Forms as attached.
This contract is subject to US state surplus lines requirements. It is the responsibility of the surplus fines broker to
affix a surplus lines notice to the contract document before it is provided to the insured. In the event that the
surplus lines notice is not affixed to the contract document the insured should contact the surplus lines broker.
This Declaration, together with Policy jacket, the above policy wording and endorsements, issued to form a part
thereof, completes the above numbered policy.
Signed:
Date Issued: 11 -Feb -2019
FS C 422 01 13 11 -Feb -2019 12:37:36 PM Page 2 of 2