22-64121506-ITB DJJ Excess Flood Attachment C Acord140.pdf

PDF 179 KB Posted Apr 7, 2022

Attached to: Excess Flood Insurance
Solicitation number: ITB-00404
Issued by: St. Johns County, Holly Hill City, Florida

About this file

Written by GovTribe AI · Jul 30, 2024

This document is an Invitation to Bid (ITB) issued by the State of Florida, Department of Management Services, for Excess Flood Insurance. The ITB seeks responses from interested vendors to provide excess flood insurance coverage for the Department of Juvenile Justice. The State requires a minimum coverage limit of $500,000 per occurrence, with an overall aggregate limit to be determined. Responses must be submitted electronically through the MyFloridaMarketPlace Sourcing portal by the specified due date. There are no pre-bid conferences or site visits associated with this ITB. The resulting contract will be for a one-year term, with renewal options available at the discretion of the State.

The pricing for this excess flood insurance coverage is to be provided on the Attachment D - Price Sheet, which can be downloaded from the MyFloridaMarketPlace Sourcing event. There are no specific set-aside requirements noted in the ITB. The current incumbent vendor is not identified. Funding for this contract will be provided by the State of Florida, Department of Juvenile Justice. Interested vendors must comply with all applicable state and federal requirements regarding insurance and licensing.

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Other files

File	Type	Posted
DJJ Excess Flood ITB Question and Answers.pdf	PDF	Apr 7, 2022
_22-64121506-ITB DJJ Excess Flood Solicitation Document.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment G Draft Contract.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment B Acord 125.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment J Certification of Drug Free Workplace.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment K Broker Information.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment I Certificate of Property Coverage DFS-D0-852.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment F Special Contract Conditions.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment H Certification Requirements for Responsiveness.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment L DFS loss history.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment A Scope of Work.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment E ASSC.pdf	PDF	Apr 7, 2022
22-64121506-ITB DJJ Excess Flood Attachment D Price Sheet.xlsx	XLSX spreadsheet	Apr 7, 2022

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DED

TYPEAMOUNTBLKT #TYPEAMOUNTBLKT #

LIMIT: $REJECT COVERAGEACCEPT COVERAGEMINE SUBSIDENCE COVERAGE (Required in IL, IN, KY and WV)

TYPE

DED

BLANKET SUMMARY

REFERENCE / LOAN #:

EVIDENCE:RANK: CERTIFICATENAME AND ADDRESS

ACORD 45 attached for additional namesADDITIONAL INTEREST

ITEM:CLASS:

ITEM

ITEM DESCRIPTION

BUILDING:LOCATION:

INTEREST IN ITEM NUMBER

MORTGAGEE

LOSS PAYEE

INTEREST

PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK

Y / N

SOLID FUELBOILER

SECONDARY HEAT

IF BOILER, IS INSURANCE PLACED ELSEWHERE?Y / N

SOLID FUELBOILER

PRIMARY HEAT

IF BOILER, IS INSURANCE PLACED ELSEWHERE?

GONG

LOCAL

STATION

CODE NUMBERFIRE DISTRICT

# OF OPEN SIDES ON STRUCTURE:

VALU-

ATION

RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCEFRONT EXPOSURE & DISTANCE

BREAKDOWN OR CONTAMINATION

SELLING

PRICE

POWER OUTAGE

LIMIT: $REJECT COVERAGEACCEPT COVERAGESINKHOLE COVERAGE (Required in Florida)

OPTIONSREFRIG MAINT

AGREEMENT

(Y / N)

DEDUCTIBLE

LIMITDESCRIPTION OF PROPERTY COVEREDSPOILAGE

COVERAGE

(Y / N)

ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION

VALUE REPORTING INFORMATION - Attach ACORD 811BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810ADDITIONAL INFORMATION

SUBJECT OF INSURANCE AMOUNT COINS % CAUSES OF LOSS INFLATION

GUARD % FORMS AND CONDITIONS TO APPLYBLKT

CONSTRUCTION TYPE DISTANCE TO

HYDRANT FIRE STAT

FT MI

PROT CL # STORIES # BASM'TS YR BUILT TOTAL AREA

OTHER OCCUPANCIESROOF TYPETAX CODE

GRADE

BLDG CODE

SEMI- RESISTIVE

RESISTIVE

WIND CLASS

INSTALLED:

DATE

MANUFACTURER:

STOVE OR FIREPLACE INSERT

HEATING SOURCE INCL WOODBURNING

% SPRNK CENTRAL STATION

LOCAL GONG

PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2 / Chemical Systems) FIRE ALARM MANUFACTURER

HEATING, YR:

PLUMBING, YR:

OTHER:

ROOFING, YR:

WIRING, YR:

BUILDING IMPROVEMENTS

YR:

BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE

EXTENT GRADE

CENTRAL

WITH KEYS

BURGLAR ALARM INSTALLED AND SERVICED BY # GUARDS / WATCHMEN CLOCK HOURLY

EFFECTIVE DATE

NAIC CODECARRIER

POLICY NUMBER NAMED INSURED(S)

AGENCY NAME

AGENCY CUSTOMER ID:

The ACORD name and logo are registered marks of ACORD

ACORD 140 (2016/03)

BLDG DESCRIPTION:

STREET ADDRESS:PREMISES #:

BUILDING #:PREMISES INFORMATION

DATE (MM/DD/YYYY)

PROPERTY SECTION

LENDER'S LOSS PAYABLE

Attach to ACORD 125

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

LIMIT: $REJECT COVERAGEACCEPT COVERAGEMINE SUBSIDENCE COVERAGE (Required in IL, IN, KY and WV)

TYPE

DEDVALU-

ATIONSUBJECT OF INSURANCE AMOUNT COINS % CAUSES OF LOSS INFLATION

GUARD % DED FORMS AND CONDITIONS TO APPLYBLKT

REFERENCE / LOAN #:

EVIDENCE:RANK: CERTIFICATENAME AND ADDRESS

ACORD 45 attached for additional namesADDITIONAL INTEREST

ITEM:CLASS:

ITEM

ITEM DESCRIPTION

BUILDING:LOCATION:

INTEREST IN ITEM NUMBER

MORTGAGEE

LOSS PAYEE

INTEREST

PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK

Y / N

SOLID FUELBOILER

SECONDARY HEAT

IF BOILER, IS INSURANCE PLACED ELSEWHERE?Y / N

SOLID FUELBOILER

PRIMARY HEAT

IF BOILER, IS INSURANCE PLACED ELSEWHERE?

GONG

LOCAL

STATION

CODE NUMBERFIRE DISTRICT

# OF OPEN SIDES ON STRUCTURE:

RIGHT EXPOSURE & DISTANCE LEFT EXPOSURE & DISTANCE REAR EXPOSURE & DISTANCEFRONT EXPOSURE & DISTANCE

BREAKDOWN OR CONTAMINATION

SELLING

PRICE

POWER OUTAGE

LIMIT: $REJECT COVERAGEACCEPT COVERAGESINKHOLE COVERAGE (Required in Florida)

OPTIONSREFRIG MAINT

AGREEMENT

(Y / N)

DEDUCTIBLE

LIMITDESCRIPTION OF PROPERTY COVEREDSPOILAGE

COVERAGE

(Y / N)

ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION

VALUE REPORTING INFORMATION - Attach ACORD 811BUSINESS INCOME / EXTRA EXPENSE - Attach ACORD 810ADDITIONAL INFORMATION

CONSTRUCTION TYPE DISTANCE TO

HYDRANT FIRE STAT

FT MI

PROT CL # STORIES # BASM'TS YR BUILT TOTAL AREA

OTHER OCCUPANCIESROOF TYPETAX CODE

GRADE

BLDG CODE

SEMI- RESISTIVE

RESISTIVE

WIND CLASS

INSTALLED:

DATE

MANUFACTURER:

STOVE OR FIREPLACE INSERT

HEATING SOURCE INCL WOODBURNING

% SPRNK CENTRAL STATION

LOCAL GONG

PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2 / Chemical Systems) FIRE ALARM MANUFACTURER

HEATING, YR:

PLUMBING, YR:

OTHER:

ROOFING, YR:

WIRING, YR:

BUILDING IMPROVEMENTS

YR:

BURGLAR ALARM TYPE CERTIFICATE # EXPIRATION DATE

EXTENT GRADE

CENTRAL

WITH KEYS

BURGLAR ALARM INSTALLED AND SERVICED BY # GUARDS / WATCHMEN CLOCK HOURLY

AGENCY CUSTOMER ID:

BLDG DESCRIPTION:

STREET ADDRESS:PREMISES #:

BUILDING #:

ADDITIONAL

PREMISES INFORMATION

ACORD 140 (2016/03) Page 2 of 3

LENDER'S LOSS PAYABLE

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 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 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.

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 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 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 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 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 CO

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.

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 AL, AR, DC, LA, MD, NM, RI and WV

NATIONAL PRODUCER NUMBER

(Required in Florida)PRODUCER'S SIGNATURE

DATEAPPLICANT'S SIGNATURE

PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO

SIGNATURE

AGENCY CUSTOMER ID:

ACORD 140 (2016/03) Page 3 of 3

The edition identifier of the form including the form number and edition (the date is typically formatted YYYY/MM).: ACORD 0140 2016-03r1

Enter identifier: The customer's identification number assigned by the producer (e.g., agency or brokerage). :

Enter date: The date on which the form is completed. (MM/DD/YYYY) :

Enter text: The full name of the producer / agency. :

Enter identifier: The identifier assigned by the insurer to the policy, or submission, being referenced exactly as it appears on the policy, including prefix and suffix symbols. If required for self-insurance, the self-insured license or contract number. :

Enter date: The effective date of the policy. The date that the terms and conditions of the policy commence. (MM/DD/YYYY) :

Enter text: The insurer's full legal company name(s) as found in the file copy of the policy. Use the actual name of the company within the group to which the policy has been issued. This is not the insurer's group name or trade name. :

Enter code: The identification code assigned to the insurer by the National Association of Insurance Commissioners (NAIC). :

Enter text: The named insured(s) as it / they will appear on the policy declarations page. : Department of Juvenile Justice c/o State of Florida, State Purchasing

Enter number: The identifying number for the blanket. :

Enter limit: The maximum amount of coverage provided for the blanket. :

Enter text: The subject(s) of insurance covered by this blanket. Examples include Building, Contents, or Combined Building and Contents. :

Enter number: The identifying number for the blanket. :

Enter limit: The maximum amount of coverage provided for the blanket. :

Enter text: The subject(s) of insurance covered by this blanket. Examples include Building, Contents, or Combined Building and Contents. :

Enter number: The identifying number for the blanket. :

Enter limit: The maximum amount of coverage provided for the blanket. :

Enter text: The subject(s) of insurance covered by this blanket. Examples include Building, Contents, or Combined Building and Contents. :

Enter number: The identifying number for the blanket. :

Enter limit: The maximum amount of coverage provided for the blanket. :

Enter text: The subject(s) of insurance covered by this blanket. Examples include Building, Contents, or Combined Building and Contents. :

Enter number: The location number for the premises. : 1

Enter text: The first address line of the commercial structure. : 765 E. St. Johns Avenue, Hastings, Florida. 32145

Enter number: The building number for the premises. Used when more than one building exists at an individual location. : 1

Enter text: This describes the particular sublocation in a manner sufficient to distinguish it from other sublocations at a given location. An example might be "3 story blue structure on the left of the main building". : Dormitory A; DFS Scheduled location E034

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

B - Building BUSEE - Business Income without Extra Expense BUSIN - Business Income with Extra Expense BUSER - Business Income with Extra Expense and Rental Value BUSRN - Business Income with Rental Value without Extra Expense BPP - Business Personal Property EE - Extra Expense FF - Furniture & Fixtures MACEQ - Machinery, Equipment PP - Personal Property POTOP - Property of Others STK - Stock : BUILDING

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. : 391,032

Enter percentage: The Coinsurance Percentage is the percentage of the total value of the subject of insurance being insured. If the amount of insurance falls below this percentage, the insured must share in the amount of the loss. This field should be completed even when writing agreed amount coverage. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value : R Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake : Flood

Enter percentage: The inflation guard percentage gives an automatic increase in the amount of coverage based on a percentage over time. List both the percentage amount and the period of time during which it applies (e.g., 4% per year). :

Enter deductible: The deductible amount that is to apply to this subject of insurance. : 500K

Enter code: The code indicating the type of deductible that is to apply to this subject of insurance. Examples are percent, dollars and number of days. "Number of days" is used to describe the waiting period (deductible) for business income. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. : Excess Flood Policy

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value :

Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake :

Enter deductible: The deductible amount that is to apply to this subject of insurance. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. :

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value :

Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake :

Enter deductible: The deductible amount that is to apply to this subject of insurance. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. :

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value :

Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake :

Enter deductible: The deductible amount that is to apply to this subject of insurance. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. :

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value :

Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake :

Enter deductible: The deductible amount that is to apply to this subject of insurance. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. :

Check the box (if applicable): Indicates ACORD 810, Business Income / Extra Expense / Rental Value, supplement is attached for this location. :

Check the box (if applicable): Indicates ACORD 811, Value Reporting Information, supplement is attached for this location. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if spoilage coverage applies. : N

Enter text: The description of property to be covered for spoilage. : GPS Latitude/Longitude: 29.72211, -81.49016

Enter limit: The limit applicable to the spoilage coverage. :

Enter deductible: The deductible applicable to the spoilage coverage. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if there is a refrigerator maintenance agreement. :

Check the box (if applicable): Indicates that breakdown or contamination coverage exists. :

Check the box (if applicable): Indicates power outage coverage exists. :

Check the box (if applicable): Indicates selling price coverage exists on refrigerant equipment. :

Check the box (if applicable): Indicates other refrigerant equipment coverage exists. :

Enter text: The description of optional coverages that apply. :

Check the box (if applicable): Indicates that sink hole coverage is accepted. :

Check the box (if applicable): Indicates that sink hole coverage is rejected. :

Enter limit: The limit applicable to the sink hole coverage. :

Check the box (if applicable): Indicates that mine subsidence coverage is accepted. :

Check the box (if applicable): Indicates that mine subsidence coverage is rejected. :

Enter limit: The total limit amount for mine subsidence coverage. :

Check the box (if applicable): Indicates the property has been designated an historical landmark. :

Enter number: The number of open sides on a structure. :

Enter text: The remarks associated with a specific location or sublocation. :

Enter code: The primary construction type of the premises. Common construction classifications are:

* Frame

* Joisted Masonry

* Non-Combustible

* Masonry Non-Combustible

* Modified Fire Resistive

* Fire Resistive :

Enter number: The distance in feet from the nearest hydrant that supports the protection class used. :

Enter number: The distance in miles from the nearest fire station that supports the protection class used. :

Enter text: The property's fire district name. :

Enter code: The property's fire district code number which can be found in the individual states manual pages. :

Enter code: The fire rating protection class for this location. Note: some structures may be located too far from the nearest hydrant, or too far from the nearest fire station, for the protection class of the community to apply. :

Enter number: The number of stories or floors for this building not including any basement. :

Enter number: The number of basements for this building. :

Enter year: The year the building at each location was originally constructed. Specify in the Remarks section any significant additions or renovations and the year they were completed. : 1999

Enter number: The number of square feet of the building at this location for which insurance is being requested. : 11,969 sq. ft.

Check the box (if applicable): Indicates if any wiring improvements have been made since the original construction. :

Enter year: The year the wiring improvements took place. :

Check the box (if applicable): Indicates if any roofing improvements have been made since the original construction. :

Enter year: The year the roofing improvements took place. :

Check the box (if applicable): Indicates if any plumbing improvements have been made since the original construction. :

Enter year: The year the plumbing improvements took place. :

Check the box (if applicable): Indicates if any heating improvements have been made since the original construction. :

Enter year: The year the heating improvements took place. :

Check the box (if applicable): Indicates if any other improvements have been made since the original construction. :

Enter text: The description of other improvements that have been made to the structure. :

Enter year: The year the other improvements took place. :

Enter code: The industry code used to collect the building code effectiveness grade code. The source of this code list is public protection classification or individual insurer rating manuals. :

Enter code: The city, county or state tax code, if applicable. :

Enter code: The material used to construct the roof. Examples include:

* Composition (fiberglass, asphalt, etc.)

* Metal

* Poured

* Slate

* Tile

* Wood Shake (Please note this list is not all inclusive) :

Enter text: The description of any other occupancies located in the building not operated by the insured and not listed in the Description of Operations section on the ACORD 125. If no other occupancy, enter None. :

Check the box (if applicable): Indicates the wind class is resistive. :

Check the box (if applicable): Indicates the wind class is semi-resistive. :

Check the box (if applicable): Indicates the wind class is other than those listed. :

Enter text: The description of the other wind class. :

Check the box (if applicable): Indicates the presence of a solid fuel heater such as a wood burning stove or fireplace insert. :

Enter date: The installation date of the solid fuel heater. :

Enter text: The manufacturer of the solid fuel heater. :

Check the box (if applicable): Indicates if a boiler is the primary heating on the premises. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if the heating boiler is insured elsewhere. :

Check the box (if applicable): Indicates if solid fuel is the primary heating on the premises. :

Check the box (if applicable): Indicates primary heating source is other than those listed. :

Enter text: If applicable, describe the other primary heat source. :

Check the box (if applicable): Indicates if a boiler is the secondary heating on the premises. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if the heating boiler is insured elsewhere. :

Check the box (if applicable): Indicates if solid fuel is the secondary heating on the premises. :

Check the box (if applicable): Indicates secondary heating source is other than those listed. :

Enter text: If applicable, describe the other secondary heat source. :

Enter text: The description of the buildings, structures, activities conducted, or use of the adjacent property to the right of the insured premises. :

Enter number: The distance to the adjacent exposure on the right of the insured premises in linear feet. :

Enter text: The description of the buildings, structures, activities conducted, or use of the adjacent property to the left of the insured premises. :

Enter number: The distance to the adjacent exposure on the left of the insured premises in linear feet. :

Enter text: The description of the buildings, structures, activities conducted, or use of the adjacent property to the front of the insured premises. :

Enter number: The distance to the adjacent exposure in the front of the insured premises in linear feet. :

Enter text: The description of the buildings, structures, activities conducted, or use of the adjacent property to the rear of the insured premises. :

Enter number: The distance to the adjacent exposure in the rear of the insured premises in linear feet. :

Enter text: The description of any burglar alarm protecting the building or contents. Descriptive terms such as safe, premises, perimeter, or ultrasonic may be suitable. :

Enter identifier: The Underwriters Laboratories or other testing organization Certificate Number, if applicable. Attach a copy of the certificate to the application. :

Enter date: The expiration date of the certificate. (MM/DD/YYYY) :

Check the box (if applicable): Indicates the burglar alarm rings at an alarm company. :

Check the box (if applicable): Indicates the alarm company, located off the insured's premises, has keys to the applicant's property. :

Check the box (if applicable): Indicates the burglar alarm rings on audible gong located outside the building. :

Enter text: The name of the alarm company that installed and services the alarm. Alarm companies often install, maintain, and service the system in addition to providing Central Station facilities. :

Enter code: The designated extent of protection as described in the Underwriters Laboratories (UL) standard. :

Enter code: The alarm system grade as described in the Underwriters Laboratories (UL) standard (i.e., AA, A, BB, B, CC and C) which indicates the time required to respond to a signal from the alarm system. :

Enter number: The number of guards and or watchmen employed or contracted for by the insured. :

Check the box (if applicable): Indicates the guard / watchman is required to make hourly rounds using a special time recording device or in connection with the central station service. If other than hourly, indicate the time interval in the Other box. :

Check the box (if applicable): Indicates the guard / watchman is required to make some other type of rounds. :

Enter text: The description of the rounds the guards / watchmen are required to make. :

Enter text: The description of the type of fire protection for the premises (e.g. sprinklers, standpipes, chemical systems). :

Enter percentage: The percentage of the structure area covered by the sprinkler system. :

Enter text: The name of the manufacturer of the alarm, and if it is UL listed. :

Check the box (if applicable): Indicates the fire alarm rings at an alarm company, police department or fire department. :

Check the box (if applicable): Indicates the fire alarm rings on an audible gong located outside of the building. :

Check the box (if applicable): Indicates that further additional interests appear on the attached ACORD 45. :

Check the box (if applicable): Indicates the additional interest type is a lender's loss payable. :

Check the box (if applicable): Indicates the additional interest type is a loss payee. :

Check the box (if applicable): Indicates the additional interest type is a mortgagee. :

Check the box (if applicable): Indicates the additional interest is other than those listed. :

Enter text: The description of the other type of additional interest. :

Enter number: The ranking of 'this' additional interest when multiple additional interests are associated with the same item. :

Check the box (if applicable): Indicates if the additional interest requires a Certificate of Insurance. :

Enter text: The additional interest's full name. :

Enter text: The additional interest's mailing address line one. :

Enter text: The additional interest's mailing address line two. :

Enter text: The additional interest's mailing address city name. :

Enter code: The additional interest's mailing address state or province code. :

Enter code: The additional interest's mailing address postal code. :

Enter code: The additional interest's country code. :

Enter identifier: The loan number, account number or other controlling number that the additional interest may have assigned the insured. :

Enter number: The producer assigned number of the location which has an additional interest. :

Enter number: The producer assigned number of the building which has an additional interest. :

Enter text: The description of the item which has an additional interest. :

Enter number: The producer assigned number of the scheduled item which has an additional interest. :

Enter text: The description of the item of interest if needed to further clarify. For a vehicle, list the make, model and VIN number. For a scheduled item, list the description, such as three carat diamond in six point setting. :

Enter number: The location number for the premises. : 1

Enter text: The first address line of the commercial structure. : 765 E. St. Johns Avenue, Hastings, Florida. 32145

Enter number: The building number for the premises. Used when more than one building exists at an individual location. : 2

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. : 2,019,767

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value : R Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake : Flood

Enter deductible: The deductible amount that is to apply to this subject of insurance. : 500K

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. : Excess Flood Policy

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value :

Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake :

Enter deductible: The deductible amount that is to apply to this subject of insurance. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. :

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value :

Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake :

Enter deductible: The deductible amount that is to apply to this subject of insurance. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. :

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value :

Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake :

Enter deductible: The deductible amount that is to apply to this subject of insurance. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. :

Enter code: The code designating all unit at risk / coverages that are to be insured at this particular location number / building number combination.

Examples:

Enter limit: The maximum amount of coverage provided for this subject of insurance or premium-bearing option. :

Enter code: Indicate the method which will be used to determine the amount paid on a claim. If other valuation basis applies, provide necessary information.

Example valuation methods are:

A - Actual Cash Value R - Replacement Cost V - Agreed Amount M - Market Value :

Enter code: The causes of loss the subject of insurance is to be covered for. Examples:

* Basic

* Broad

* Special excluding theft

* Earthquake :

Enter deductible: The deductible amount that is to apply to this subject of insurance. :

Enter number: The identifying number for the blanket under which this subject of insurance is rated. Leave blank if the subject of insurance is not included under a blanket. :

Enter text: The form numbers and special conditions that apply to this subject of insurance. Also indicate here if coverage is blanket or average rated. :

Check the box (if applicable): Indicates ACORD 810, Business Income / Extra Expense / Rental Value, supplement is attached for this location. :

Check the box (if applicable): Indicates ACORD 811, Value Reporting Information, supplement is attached for this location. :

Enter Y for a “Yes” response. Input N for “No” response. Indicates if spoilage coverage applies. : N

Enter text: The description of property to be covered for spoilage. : GPS Latitude/Longitude: 29.72204, -81.48949