CITY OF HILLSBORO

CERTIFICATE OF INSURANCE

LAKE HILLSBORO AND GLENN SHOALS LAKE

This is to certify that _______________________________has a minimum of $100,000.00 liability coverage,

policy number ___________________ insured by ______________________________(Company Name) on

the watercraft listed below.  This coverage is written by _____________________________ as insured's

agent/agency.  Policy period is from _______________ to _________.

WATER CRAFT MAKE & MODEL NO. _____________________________________________

HULL I.D. NO./ WATERCRAFT SERIAL NO. _________________________________________

MOTOR MAKE __________________  HORSEPOWER _______

MOTOR TYPE:     ____ Inboard                     _____ Outboard        ______ I/O       ______Jet     Other:______

____________         _____________________        ___________________

    Date                         Signature of Agent                 Agent's License #

TO THE ISSUING AGENT:  Please FILL OUT IN FULL   the above information.

                                                   Insured will unable to obtain a permit if any information is omitted.