7-Exhibit C.1 EOCPI SA Concess RFP Sample Evidence.pdf

SAM

PLE

DATE (MM/DD/YYYY)

PHONEPRODUCER NAME, COMPANY NAME AND ADDRESS NAIC NO:

(A/C, No, Ext):CONTACT PERSON AND ADDRESS

FAX E-MAIL IF MULTIPLE COMPANIES, COMPLETE SEPARATE FORM FOR EACH

(A/C, No): ADDRESS:

POLICY TYPECODE: SUB CODE:

AGENCY

CUSTOMER ID #:

NAMED INSURED AND ADDRESS LOAN NUMBER POLICY NUMBER

EFFECTIVE DATE EXPIRATION DATE

ADDITIONAL NAMED INSURED(S) THIS REPLACES PRIOR EVIDENCE DATED:

LOCATION/DESCRIPTION

YES NO N/A

LENDER SERVICING AGENT NAME AND ADDRESS

NAME AND ADDRESS

AUTHORIZED REPRESENTATIVE

CONTINUED UNTIL

TERMINATED IF CHECKED

PERILS INSURED BASIC BROAD SPECIAL

CONTRACT OF SALE LENDER'S LOSS PAYABLE

MORTGAGEE

LOSS PAYEE

BUILDING OR BUSINESS PERSONAL PROPERTY

THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS EVIDENCE OF PROPERTY INSURANCE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS

OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.

$COMMERCIAL PROPERTY COVERAGE AMOUNT OF INSURANCE: DED:

BUSINESS INCOME RENTAL VALUE If YES, LIMIT: Actual Loss Sustained; # of months

BLANKET COVERAGE If YES, indicate value(s) reported on property identified above: $

TERRORISM COVERAGE Attach Disclosure Notice / DEC

IS THERE A TERRORISM-SPECIFIC EXCLUSION?

IS DOMESTIC TERRORISM EXCLUDED?

LIMITED FUNGUS COVERAGE If YES, LIMIT: DED:

FUNGUS EXCLUSION (IF "YES", specify organization's form used)

REPLACEMENT COST

AGREED VALUE

COINSURANCE If YES, %

EQUIPMENT BREAKDOWN (If Applicable) If YES, LIMIT: DED:

ORDINANCE OR LAW If YES, LIMIT: DED:- Coverage for loss to undamaged portion of bldg

- Demolition Costs If YES, LIMIT: DED:

- Incr. Cost of Construction If YES, LIMIT: DED:

EARTH MOVEMENT (If Applicable) If YES, LIMIT: DED:

FLOOD (If Applicable) If YES, LIMIT: DED:

WIND/HAIL INCL If YES, LIMIT: DED:

PERMISSION TO WAIVE SUBROGATION IN FAVOR OF MORTGAGE

HOLDER PRIOR TO LOSS

NAMED STORM INCL If YES, LIMIT: DED:

YES NO Subject to Different Provisions

YES NO Subject to Different Provisions

THIS EVIDENCE OF COMMERCIAL PROPERTY INSURANCE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE ADDITIONAL INTEREST NAMED BELOW. THIS EVIDENCE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS EVIDENCE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE ADDITIONAL INTEREST.

PROPERTY INFORMATION (ACORD 101 may be attached if more space is required)

COVERAGE INFORMATION

CANCELLATION

SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE

DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS.

ADDITIONAL INTEREST

ACORD 28 (2016/03)

Page 1 of © 2003-2015 ACORD CORPORATION. All rights reserved.

The ACORD name and logo are registered marks of ACORD

ACORDTM EVIDENCE OF COMMERCIAL PROPERTY INSURANCE

XXXXX

Carrier Name

Carrier Address

Carrier City, ST ZIP

KANSATUR

DATE

Agency Name Agency Address Agency City, ST ZIP Agency Phone Number

XXX.XXX.XXXX

XXX.XXX.XXXX Email Address

POLICY TYPE

Insured Name Insured Address Insured City, ST ZIP

POLICY NUMBER

EFF DATE EXP DATE

X

Restaurant, Building & Fuel System, Topeka Service Area Restaurant & Fuel Establishment

Location #71; $4,851,104 Building

X

4,851,104 As Determined by KTA 10,000

X

X

X

X

X

X

X

X

X 4,851,104 10,000

X

X 500,000 10,000

X 500,000 10,000

X

X

X X

X

Kansas Turnpike Authority Attn: Credit Manager 9401 E Kellogg Wichita, KS 67207

X Bldg Owner Loss Payable

2S 392083

MMSAS

SAM

PLE

EVIDENCE OF COMMERCIAL PROPERTY INSURANCE REMARKS - Including Special Conditions (Use only if more space is required)

ACORD 28 (2016/03) Page

Policy shall be endorsed to require thirty (30) days notice of cancellation in writing via postal mail and email (rpettersen@ksturnpike.com) prior to the cancellation of any required policy.

2 of 2S 392083 MMSAS

Job 1: Kansas Turnpike Authority