22-64121506-ITB DJJ Excess Flood Attachment B Acord 125.pdf

Solicitation No. 22-64121506-ITB Excess Flood Insurance on behalf of the Department of Juvenile Justice, Deep Creek Youth Academy

Acord Application 125, Commercial Insurance Application Attachment B

ACORD COMMERICAL INSURANCE APPLICATION (ACORD 125 (2013/09)

is provided on the following pages.

DATE (MM/DD/YYYY)

The ACORD name and logo are registered marks of ACORD

NAIC CODE

COMPANY POLICY OR PROGRAM NAME PROGRAM CODE

POLICY NUMBER

UNDERWRITER UNDERWRITER OFFICE

STATUS OF

TRANSACTION

DATE TIME

CODE: SUBCODE:

AGENCY CUSTOMER ID:

INDICATE SECTIONS ATTACHED PREMIUM PREMIUM PREMIUM

PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN METHOD OF PAYMENT AUDIT DEPOSIT MINIMUM POLICY PREMIUMPREMIUM

GL CODE SIC NAICS FEIN OR SOC SEC #

BUSINESS PHONE #:

WEBSITE ADDRESS

NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC #

BUSINESS PHONE #:

WEBSITE ADDRESS

NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC #

BUSINESS PHONE #:

WEBSITE ADDRESS

QUOTE ISSUE POLICY RENEW

BOUND (Give Date and/or Attach Copy):

CHANGE AM

CANCEL PM

ELECTRONIC DATA PROCACCOUNTS RECEIVABLE / TRANSPORTATION /

VALUABLE PAPERS MOTOR TRUCK CARGO

BOILER & MACHINERY EQUIPMENT FLOATER TRUCKERS / MOTOR CARRIER

BUSINESS AUTO GARAGE AND DEALERS UMBRELLA

BUSINESS OWNERS GLASS AND SIGN YACHT

COMMERCIAL GENERAL LIABILITY INSTALLATION / BUILDERS RISK

CRIME OPEN CARGO

DEALERS PROPERTY

ADDITIONAL INTEREST PREMIUM PAYMENT SUPPLEMENT

ADDITIONAL PREMISES PROFESSIONAL LIABILITY SUPPLEMENT

APARTMENT BUILDING SUPPLEMENT RESTAURANT / TAVERN SUPPLEMENT

CONDO ASSN BYLAWS (for D&O Coverage only) STATEMENT / SCHEDULE OF VALUES

CONTRACTORS SUPPLEMENT STATE SUPPLEMENT (If applicable)

COVERAGES SCHEDULE VACANT BUILDING SUPPLEMENT

DRIVER INFORMATION SCHEDULE VEHICLE SCHEDULE

INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT

INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT

LOSS SUMMARY

DIRECT AGENCY

CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION

INDIVIDUAL LLC NO. OF MEMBERS PARTNERSHIP TRUSTAND MANAGERS:

CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION

INDIVIDUAL LLC NO. OF MEMBERS PARTNERSHIP TRUSTAND MANAGERS:

CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION

INDIVIDUAL LLC NO. OF MEMBERS PARTNERSHIP TRUSTAND MANAGERS:

CARRIER

SECTIONS ATTACHED

ATTACHMENTS

POLICY INFORMATION

APPLICANT INFORMATION

Page 1 of 4ACORD 125 (2013/09) © 1993-2013 ACORD CORPORATION. All rights reserved.

APPLICANT INFORMATION SECTION

COMMERCIAL INSURANCE APPLICATION

CONTACT

NAME:

PHONE

(A/C, No, Ext):

FAX

(A/C, No):

E-MAIL

ADDRESS:

N/A

Excess Flood

PROPOSED EFF DATE

06/15/2022 06/15/2023

NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4) Florida Department of Juvenile Justice c/o State of Florida, Division of State Purchasing 4050 Esplanade Way, Suite 360 Tallahassee, FL 32399-0950

(850)

X

X State Agency

Florida Department of Juvenile Justice Deep Creek Youth Academy 765 E. St. Johns Avenue Hastings, Florida. 32145

SoderbJ Cross-Out

AGENCY CUSTOMER ID:

CONTACT NAME: CONTACT NAME:

PRIMARY SECONDARY PRIMARY SECONDARY

PHONE # PHONE # PHONE # PHONE #

PRIMARY E-MAIL ADDRESS: PRIMARY E-MAIL ADDRESS:

SECONDARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS:

INSTALLATION, SERVICE OR REPAIR WORK OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK

RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:

DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS

INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER

ADDITIONAL LOSS PAYEE LOCATION: BUILDING:INSURED

BREACH OF MORTGAGEE VEHICLE: BOAT:WARRANTY

CO-OWNER OWNER AIRPORT: AIRCRAFT:

EMPLOYEE REGISTRANT ITEM ITEM:AS LESSOR CLASS:

LEASEBACK TRUSTEE ITEM DESCRIPTIONOWNER

LIENHOLDER REFERENCE / LOAN #: INTEREST END DATE:

LIEN AMOUNT: PHONE (A/C, No, Ext): FAX (A/C, No):

REASON FOR INTEREST: E-MAIL ADDRESS:

INSIDE OWNER SQ FT

OUTSIDE TENANT SQ FT

SQ FT

INSIDE OWNER SQ FT

OUTSIDE TENANT SQ FT

SQ FT

INSIDE OWNER SQ FT

OUTSIDE TENANT SQ FT

SQ FT

INSIDE OWNER SQ FT

OUTSIDE TENANT SQ FT

SQ FT

APARTMENTS CONTRACTOR MANUFACTURING RESTAURANT SERVICE

CONDOMINIUMS INSTITUTIONAL OFFICE RETAIL WHOLESALE

HOME BUS CELL HOME BUS CELL HOME BUS CELL HOME BUS CELL

LOC # CITY LIMITS INTEREST # FULL TIME EMPL ANNUAL REVENUES: $

OCCUPIED AREA:

BLD # CITY: STATE: # PART TIME EMPL OPEN TO PUBLIC AREA:

COUNTY: ZIP: TOTAL BUILDING AREA:

DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS? Y / N

LOC # CITY LIMITS INTEREST # FULL TIME EMPL ANNUAL REVENUES: $

OCCUPIED AREA:

BLD # CITY: STATE: # PART TIME EMPL OPEN TO PUBLIC AREA:

COUNTY: ZIP: TOTAL BUILDING AREA:

DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS? Y / N

LOC # CITY LIMITS INTEREST # FULL TIME EMPL ANNUAL REVENUES: $

OCCUPIED AREA:

BLD # CITY: STATE: # PART TIME EMPL OPEN TO PUBLIC AREA:

COUNTY: ZIP: TOTAL BUILDING AREA:

DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS? Y / N

LOC # CITY LIMITS INTEREST # FULL TIME EMPL ANNUAL REVENUES: $

OCCUPIED AREA:

BLD # CITY: STATE: # PART TIME EMPL OPEN TO PUBLIC AREA:

COUNTY: ZIP: TOTAL BUILDING AREA:

DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS? Y / N

CONTACT INFORMATION

PREMISES INFORMATION (Attach ACORD 823 for Additional Premises)

NATURE OF BUSINESS

ADDITIONAL INTEREST (Not all fields apply to all scenarios - provide only the necessary data) Attach ACORD 45 for more Additional Interests

Page 2 of 4ACORD 125 (2013/09)

CONTACT TYPE: CONTACT TYPE:

STREET

STREET

STREET

X DATE BUSINESS

STARTED (MM/DD/YYYY)

DESCRIPTION OF PRIMARY OPERATIONS

Department of Juvenile Justice

X

STREET

Not for Profit

Jill Soderberg Policy Manager - Division of State Purchasing

850-488-7996 Jill.Soderberg@dms.fl.gov

X

Deep Creek YA, Residential Facility, owned and operated by the Department of Juvenile Justice serves males between the ages of 13 and 18, in a non-secure residential commitment program. Youth in the program may have been assessed as needing dual diagnosis treatment services or Intensive mental health treatment services in a residential environment. The program is highly structured, utilizing evidence-based practices to provide secure care, treatment and supervision. Youth receive daily psychotherapeutic services Including individual, family, and group counseling; cognitive skills training; and relapse prevention training by qualified mental health and substance abuse professionals under the supervision of a licensed psychologist.

765 E. St. Johns Avenue, Dorm A Hastings

32145

FL

St. Johns 11,969 X

X

765 E. St. Johns Avenue, Administration X

X

30,950 Hastings

St. Johns

FL

32145

X

SoderbJ Cross-Out

Y / NEXPLAIN ALL "YES" RESPONSES

CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER:

CARRIER

POLICY NUMBER

PREMIUM

EFFECTIVE DATE

EXPIRATION DATE

PARENT COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED

SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED

SAFETY MANUAL MONTHLY MEETINGS

SAFETY POSITION OSHA

LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER

NON-PAYMENT AGENT NO LONGER REPRESENTS CARRIER

NON-RENEWAL UNDERWRITING CONDITION CORRECTED (Describe):

OCCURRENCE

DATE

RESOLUTION

DATEEXPLANATION RESOLUTION

OCCURRENCE

DATE

RESOLUTION

DATEEXPLANATION RESOLUTION

OCCURRENCE

DATE

RESOLUTION

DATEEXPLANATION RESOLUTION

NAME OF TRUST

YEAR

1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?

1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES?

2. IS A FORMAL SAFETY PROGRAM IN OPERATION?

3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?

5. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR OPERATIONS? (Missouri Applicants - Do not answer this question)

6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?

7. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?

(In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment).

8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS?

9. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS?

HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS?10.

HAS BUSINESS BEEN PLACED IN A TRUST?11.

12. ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES?

(If "YES", attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure)

13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED?

4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers)

REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required)

GENERAL INFORMATION

PRIOR CARRIER INFORMATION

Page 3 of 4ACORD 125 (2013/09)

N

N

N

N

N

N

N

N

N

N

N

N

N

N

CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER:

SUBRO-

GATION

Y / N

CLAIM

OPEN

Y / N

DATE OF

OCCURRENCE LINE DATE OF CLAIM AMOUNT PAID AMOUNT RESERVEDTYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

PRODUCER'S SIGNATURE STATE PRODUCER LICENSE NO

(Required in Florida)

APPLICANT'S SIGNATURE DATE NATIONAL PRODUCER NUMBER

CARRIER

POLICY NUMBER

PREMIUM

EFFECTIVE DATE

EXPIRATION DATE

CARRIER

POLICY NUMBER

PREMIUM

EFFECTIVE DATE

EXPIRATION DATE

ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS

FOR THE LAST YEARS

YEAR

TOTAL LOSSES: $

(Applicant's Initials):

Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.)

PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION.

(Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states.)

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER

KNOWLEDGE.

Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only.

Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree)*. *Applies in FL Only.

Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only.

Applicable in ME, TN, VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.

Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss, shall incur a felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousand dollars ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years.

PRIOR CARRIER INFORMATION (continued)

LOSS HISTORY Check if none (Attach Loss Summary for Additional Loss Information)

SIGNATURE

Page 4 of 4ACORD 125 (2013/09)

5/22/2020 Flood Locations 1 and 2 Damaged by Flood see Attachment L - Loss History