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HomeMy WebLinkAboutCRA-R-14-0045 BackupDetail by Entity Narne Page 1 of 3 FLORIDA DEPARTMENT OF STATE DIVISION OF CORPORATIONS Detail by Entity Name Florida Non Profit Corporation PEOPLE HELPING PEOPLE SELF REALIANCE INC Filing Information Document Number FEI/EIN Number Date Filed State Status Last Event Event Date Filed Event Effective Date Principal Address 10426 CABARY ISLE DR. TAMPA, FL 33647 Changed: 01/15/2014 Mailing Address 10426 CABARY ISLE DR. TAMPA, FL 33647 N00000006045 651084859 09/06/2000 FL ACTIVE AMENDMENT AND NAME CHANGE 01/15/2014 NONE Changed: 01/15/2014 Registered Agent Name & Address SHARMA, SEWNARINE 10426 CANARY ISLE DR TAMPA, FL 33647 Name Changed: 01/20/2009 Address Changed: 01/04/2012 Officer/Director Detail Name & Address Title PTD LINCOLN, SHOSHANA MREV. 210 NW 16TH STREET MIAMI, FL 33136 http://search.sunbiz.oxg/Inquiry/Corpo:rationSearch/SearehResultDetai /EntityName/dorn... 6/23/2014 Detail by Entity Name Page2of3 Title VPD ILORIA, ADELA MRS. 1600 N.W. 3RD AVENUE MIAMI, FL 33136 itle SD HARRIS, ULTRINA MS. 1622 N.W. 1ST AVENUE, APT. 2 MIAMI, FL 33136 Title D SHAMLALL, RABENDRANAUTH MR. 349 SHERIDAN AVENUE MIAMI BEACH, FL 33140 itle D SHARMA, SEWNARINE MR 10426 CANARY ISLE DR AMPA, FL 33647 Annual Resorts Report Year 2012 2013 2014 Document Imases Filed Date 01/04/2012 01/21/2013 01/09/2014 01/15/2014 -- Amendment and Name Change 01/09/2014 -- ANNUAL REPORT 01/21/2013 --ANNUAL REPORT 01/04/2012 --ANNUAL REPORT 01/19/2011 -- ANNUAL REPORT 01 /08/2010 -- ANNUAL REPORT 03/10/2009 -- ANNUAL REPORT 01/20/2009 -- Req. Agent Change 04/25/2008 -- REINSTATEMENT 08/04/2006 -- ANNUAL REPORT 03/22/2005 -- ANNUAL REPORT 02/11/2004 -- ANNUAL REPORT 04/14/2003 -- ANNUAL REPORT 05/12/2002 -- ANNUAL REPORT 11/01/2001 --Amendment View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image in PDF format View image In PDF format http://search. sunbiz.org/Inquiry/CorporationSearch/SearchResultDetail/EntityName/domn... 6/23/2014 Detail by Entity Name Page 3 of 3 10/09/2001 -- ANNUAL REPORT 09/06/2000 _- Domestic Non -Profit View image in PDF format View image in PDF format ,__ ..w,.. _ ntort.ils linsSf ke oruniant Saarnhe .4RYItgh © and pity ccyPolicies Stake of I'farida, Department of State http://search.sunbiz.org/Inquiry/CorporationSearch/SearchResultD etail/EntityName/domn, .. 6/23/2014 fix-Fg.,,o0,vh. W CONSTRUCTION • REMODELING • .JOFINO • ADDITIONS and more ASTER MIND CONSTRUCTION INC If you can dream it, we can Master Mind it December 25, 2013 People Helping People - Self Reliance, Inc. 210 NW 161h Street Miami, Florida 33136 RE: Construction Proposal 210 NW 16th Street Rehabilitation Project We are pleased to submit this proposal for construction services on the above referenced project located In Miami, Florida. MASTERMIND CONSTRUCTION, inc. will perform the work outlined below: DEMOLITION Removal and disposal of all interior doors, baseboards, door trims, and door casing Removal and disposal of all flooring materials (I. e. -- tiles), and kitchen cabinets Removal and disposal of all drywall Removal and disposal of exterior doors and windows • Removal and disposal of all existing debris/trash (furniture, etc.) In each of the six (6) units No other demolition work is included in this proposal MECHANICAL- Bldg. No. 210 NW 16th Street - Furnish and Install six (6) NC units (i.e. - air handler w/ heater kits, and condenser units) Furnish and install new duct work Furnish and Install new refrigerant lines and covers, drain lines, and NC stands Furnish and install six (6) new metal cages for condenser units No other mechanical work Included in this proposal 1854 NW 204t Street, Miami, FL 33056 Tel: 305.562.0347 Fax: 305.974.4690 smathere305@gmall.com • LOW VOLTAGE ELECTRICAL — Bldg. No. 210 NW 16th Street Furnish and Install new phone and cable drops in each of the six (6) units - No other low voltage electrical work included in this proposal ELECTRICAL — Bldg. No. 210 NW 16th Street Upgrade Electrical Service and Panel Boxes (Including all new Interior wiring, electric boxes, switches, plugs, smoke detectors, breakers, and Interior electrical panels) Upgrade Electrical Service and Meter Room (including new meter banks, pipe supports, main disconnects, and associated electrical piping from new Interior electrical panels to new meter bank locations). Relocate from north elevation to appropriate side. Install new electrical service wires between new meter rooms and new interior electrical panels Install new exterior lights No other electrical work is included in this proposal PLUMBING — Bldg. No. 210 NW 16th Street Provide new sewer lateral Provide six (6) new individual water services Furnish and install new toilets, tubs, shower valves, vanities, faucets, kitchen sinks, water heaters, and ancillary piping No other plumbing work is included In this proposal CONCRETE — Bldg. No. 210 NW 16th Street Identify and repair all exterior cracks on existing bldg. exterior Repair concrete spawl on existing stair treads, decks, etc. Apply cool deck to stair treads Stucco Entire bldg. including facade upgrade for north elevation Pressure clean and paint building exterior No other concrete work is Included in this proposal ROOF — Bldg. No. 210 NW 16th Street Remove existing roof covering to expose existing sheeting Replace existing sheeting as necessary Replace metal drip edge, fascia, and soffit, and roof trusses as necessary Install new roof covering (Le. — Insulation, asphaltic material, etc.) No other roof work is Included in this proposal DRYWALL — Bldg. No. 210 NW 16th Street Remove existing drywall throughout entire building Install and finish (i.e. — smooth finish) new drywall throughout entire building, Including Insulation Install new framing and soffits as necessary Paint building interior with colors to be determined by the Owner No other drywall work Is included in this proposal WINDOWS & DOORS — Bldg. No. 210 NW 16th Street Remove existing windows, and exterior doors throughout entire building • Install new impact windows and exterior doors throughout entire building No other window and door work is Included in this proposal METALS — Bldg. No. 210 NW 16th Street Remove existing metal stair railings - Install new metal stair railings Remove existing chain -link fence Install new metal fence No other metal work is included in this proposal FLOORING - Bldg. No. 210 NW 16th Street Remove existing flooring material (Le. - tiles) Remove existing damaged (i.e. - by water or termite ) wood sub -floor, and wood floor joists as necessary install new ceramic floor tile, new sub -floor, and new floor Joists No other flooring work is included in this proposal CARPENTRY -- Bldg. No. 210 NW 16th Street Remove all existing cabinets, Interior doors, door trims, and baseboards Install new wood kitchen cabinets with granite countertops, 4" granite backsplash, and door handles install new interior doors, door trims, and baseboards No other carpentry work Is included In this proposal LANDSCAPING - Bldg. No. 210 NW 16th Street Install new Landscaping (Le. - sod, ground cover, trees, etc.) around bldg. exterior - install new mailbox enclosure No other landscaping work is included in this proposal DUMPSTER ENCLOSURE - Bldg. No. 210 NW 16th Street install new concrete dumpster pad Install new metal pure fence with gates for dumpster enclosure No other dumpster enclosure work is included in this proposal NW 16th STREET IMPROVEMENTS - Bldg. No. 210 NW 16th Street Milling and resurfacing existing asphalt roadway disturbed during the new water and sewer connections per City of Miami Public Works right of way permit requirements Installation of new striping City of Miami Public Works right of way permit requirements Removal and disposal of existing concrete sidewalk damaged disturbed during the new water and sewer connections Installation of new concrete sidewalk (5' wide) including water meter boxes, cleanouts, and expansion joints No other street Improvements are included in this proposal DESIGN SERVICES - Bldg. No. 210 NW 16th Street Obtain boundary survey for this site Obtain ROW survey for the water, sewer, and civil plans Prepare engineering plans to be submitted to Miami -Dade WASA, DERM, Health Department, and the City of Miami Public Works for review, approval, and permit Prepare architectural plans to be submitted to the City of Miami Building Department for review, approval, and permit Coordinate with FPL Central Office to provide service for the project No other design services work is included In this proposal Notes: �. MASTERMIND CONSTRUCTION, Inc. will furnish the labor and materials to complete the alterations and improvements described in herein. 2. Match existing textures and colors, and tiles as close as possible. 3. This proposal is based upon the observation of conditions. Conditions which could not be known by a reasonable Inspection, such as termite damage, hidden water damage, hidden code violations, or other concealed conditions, may require extra labor or materials. People Helping People shall pay MASTERMIND CONSTRUCTION, Inc. for the performance of completed work, as authorized and outlined by this agreement. The contract sum is Three Hundred Eighty Thousand Dollars, ($380,OOO OO). Date: Signature: Owner Date: 12, —IS 13 Signature: MASTERMIND CONSTRUCTION, Inc. cc; File ACC:MD ‘..1.rrritrnT-1-N,a..IML. iu ur J r1%..c ArrLIt:A 1 1VN A'' APPLICANT INFORMATION SECTION DATE(MMVDDrYYYY) 05/16/2014 AGENCY C. BRIAN HART INSURANCE 8874 NW 7TH AVENUE FAX 305 696-8634 MIAMI, FL 33150 CARRIER PENN AMERICA INSURANCE COMPANY NAIL CODE UNDERWRITER: PHILLIP LEE UNDERWRITER OFFICE; REGENCY POLICIES OR PROGRAM REQUESTED POLICY NUMBER INDICATE SECTIONS ATTACHED ELECTROMC DATA PROC EQUIPMENT FLOATER GARAGE AND DEALERS GLASS AND SIGN INSTALLATION/BUILDERS RISK OPEN CARGO PROPERTY TRANSPORTATION! MOTOR TR Ur`K CARGO _ X TRUCKERSIMOTOR CARRIER UMBRELLA VEHICLE SCHEDULE WORKERS COMPENSATION YACHT VACANT BUILDING ACCOUNTS RECEIVABLE/ VALUABLE PAPERS BOIL ER &MACHINERY BUSINESS AUTO COMMERCIAL GENERAL LIABILITY CRIME/MISCELLANEOUS CRIME DEALERS DRIVER INFO SCHEDULE - -- ------- - CNAPE CT CAREY PHONE INC No. Exly 805.836-5206 INC.No}L 305-696-8634 E-MAIL ADDRESS: CAREY@CBRIANHART.COM CODE: SUB CODE; AGENCY CUSTOMER ID: ..rAi-11 .. -•- • -- OF TRANSACTION QUOTE X I ISSUE POLICY BOUND (Give Date and/or Attach Copy): CHANGE DATE TIME CANCEL 05/16/2014 12:30 APPLICANT INFORMATI RMATION RENEW AM PM ENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES, PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN AUDIT DIRECT BILL AGENCY BILL PACKAGE POLICY PREMIUM: $ 05/16/2014 05/16/2015 NAME (First Named insured & Other Named Insureds) PEOPLE HELPING PEOPLE SELF REALIANCE INC MAILING ADDRESS INCL ZIP+4 (of First Named Insured) 210 NW 16TH STREET MIAMI, FL 33136 {aP Fl T Tmed neared): 651084859 PHONE (AIC. No. Ext): E-MAIL ADDRESS(ESI: WEBSITE ADDRESS(ES); P ID NUMBER; 'NSPECTION CONTACT: REV LINCOLN ACCOUNTING RECORDS CONTACT: REV LINCOLN A/C, No, Ext}: ADDAIL RESS; FRIEND1937(ov3GMAIL,GOM ((A/CPHONN EA: DADR ESS: FRIEND1937@GMAIL.COM ADDR PREMISES INFORMATION ACORD 823 attached for additional premises LOG tt BLDtI STREET, CITY, COUNTY, STATE, ZIP+4 CITY LIMITS INTEREST YR BUILT NANNUAL EMPLOYEES REVENUES % OCCUPIED 1 1 210 NW 16TH STREET, MIAMI, FL 33136 X INSIDE X OWNER TENANT 1952 INSIDE OUTSIDE _ OWNER INSIDE OWNER TENANT AIATI IDC "C DI IQIIJCo@mC re+r,inTi.-.0 o..- ....,-,-,. �,....... _.. �__--'__'_' INSIDE OWNER TENANT VACANT BUILDING ACORD 125 (2007/07) Page 1 of 3 a 1993-2007 ACORD CORPORATION. All rights reserved. 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BRIAN HART INSURANCE 8874 NW 7TH AVENUE FAX 305 696-8634 MIAMI, FL 33150 APPLICANT (First PEOPLE HELPING. PEOPLE SELF REALIANCE INC Named Insured) CODE: SUB CODE: AGENCY CUSTOMER ID: COVERAGES EFFECTIVE DATE 05/16/2014 FOR COMPANY USE ONLY LIMITS EXPIRATION DATE 05/16/2015 DIRECT BILL AGENCY BILL PAYMENT PLAN AUDIT X COMMERCIAL GENERAL LIABILITY CLAIMS MADE X OCCURRENCE OWNER'S & CONTRACTOR'S PROTECTIVE GENERAL AGGREGATE $ 2,000,000 PREMIUMS PRODUCTS & COMPLETED OPERATIONS AGGREGATE $ 1 ,000,000 PERSONAL & ADVERTISING INJURY $ 1,000,000 PREMISESIOPERATIONS EACH OCCURRENCE $ 1,000,000 DEDUCTIBLES PROPERTY DAMAGE BODILY INJURY $ PER CLAIM PER OCCURRENCE DAMAGE TO RENTED PREMISES (each occurrence) $ 100,000 PRODUCTS MEDICAL EXPENSE (Any one person) $ 5,000 EMPLOYEE BENEFITS $ OTHER OTHER COVERAGES, RESTRICTIONS ANDIOR ENDORSEMENTS (For hlred!non•owned auto coverages attaoh the applicable state Business Auto Seaton, ACORD 137) TOTAL SCHEDULE OF HAZARDS LOC N HAZ N CLASSIFICATION CLASS CODE PREMIUM BASIS EXPOSURE TERR RATE PREMIUM PREMIOPS PRODUCTS PREMIOPS PRODUCTS 1 1 VACANT APARTMENT BUILDING 3,121 SQUARE FEET RATING AND PREMIUM BASIS (P) PAYROLL - PER $1,0001PAY (C) TOTAL COST - PER $1,000 COST (U) UNIT • PER UNIT (S) GROSS SALES - PER $1,000ISALES (A) AREA - PER 1,000ISQ FT (M) ADMISSIONS - PER 1,000/ADM (T) OTHER CLAIMS MADE (Explain all "Yes" responses EXPLAIN ALL "YES" RESPONSES Y 1 N 1. PROPOSED RETROACTIVE DATE: 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF -INSURED FROM ANY PREVIOUS COVERAGE? 71 4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? [ EMPLOYEE BENEFITS LIABILITY 1. DEDUCTIBLE PER CLAIM: $ 2. NUMBER OF EMPLOYEES: 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: 4. RETROACTIVE DATE: ACORD 126 (2007105) Page 1 of 4 p ACORD CORPORATION 1993-2007. All rights reserved. The ACORD name and Togo are realstered marks of ACORD CONTRACTORS EXPLAIN ALL "YES" RESPONSES (For past or present operations) Y / N 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS? 2, DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? 3, DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING? 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? C 1 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? DESCRIBE THE TYPE OF WORK SUBCONTRACTED $ PAID TO SUB- % OF WORK CONTRACTORS' SUBCONTRACTED: # FULL- TJME STAFF: # PART - TIME STAFF: PRODUCTS ANNUAL GROSS SALES # OF UNITS TIME IN MARKET EXPECTED LIFE INTENDED USE PRINCIPAL COMPONENTS _XPLAIN ALL "YES" RESPONSES (For any past or present product or operation) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC. Y / N 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? r r N 1 2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (IF "YES", attach ACORD 815) N 3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED? r r N1 4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS? - N 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? N 6. PRODUCTS RECALLED, DISCONTINUED, CHANGED? IN 7. PRODUCTS OF OTHERS SOLD OR RE -PACKAGED UNDER APPLICANT LABEL? I I N 6. PRODUCTS UNDER LABEL OF OTHERS? r� 9. VENDORS COVERAGE REQUIRED? - - INSUREDS? r N D. DOES ANY NAMED INSURED SELL TO OTHER NAMED -------------------------- A rnor, i. Al A5 ADDITIONAL INTERESTICERTIFICATE RECIPIENT ACORD 45 attached for additional names RANK: MORTGAGEE LIENHOLDER EMPLOYEE AS LESSOR NAME AND ADDRESS REFERENCE #: CERTIFICATE REQUIRED INTEREST IN ITEM NUMBER CITY OF MIAMI SEOPWCRA 1490 NW 3RD AVENUE MIAMI, FL 33136 LOCATION: VEHICLE: BUILDING, BOAT: SCHEDULED ITEM NUMBER: OTHER ITEM DESCRIPTION' GENERAL INFORMATION EXPLAIN ALL "YES' RESPONSES (For all past or present operations) Y/ N 1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? N 2, ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? N 3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) I N 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS? N 5. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS? N 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? N ANY PARKING FACILITIES OWNED/RENTED? N S. IS A FEE CHARGED FOR PARKING? N 9. RECREATION FACILITIES PROVIDED? I N I 10. IS THERE A SWIMMING POOL ON THE PREMISES? N 11. SPORTING OR SOCIAL EVENTS SPONSORED? r N i 12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? N 13. ANY DEMOLITION EXPOSURE CONTEMPLATED? I N l 14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? I N 15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? DILI 1.16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? N ACORD 126 12007I051 Pane 3 of 4 INTEREST X ADDITIONAL INSURED LOSS PAYEE GENERAL INFORMATION {continued EXPLAIN ALL "YES" RESPONSES (For al! past or present operations) Y ! N 17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? I N 18, HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3)YEARS? r N 19, IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT? r Nil 20. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? N ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVIL PENALTIES. (Not applicable In CO, FL, HI, MA, NE, OH, OK, OR or VT. In DC, LA, ME, TN, VA and WA Insurance benefits may also be denied). IN FLORIDA, 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, ACORD 126 (2007105) Pape 4 of 4 NOTICE -OFFER OF TERRORISM COVERAGE AND DISCLOSURE OF PREMIUM You are hereby notified that under the federal Terrorism Risk Insurance Act, as amended ("the Act"), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act: The term "act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the Secretary of State, and the Attorney General of the United States to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States, or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals as part of a n effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. YOU SHOULD KNOW THAT WHERE COVERAGE IS PROVIDED BY THIS POLICY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM, SUCH LOSSES MAY BE PARTIALLY REIMBURSED BY THE UNITED STATES GOVERNMENT UNDERA FORMULA ESTABLISHED BY FEDERAL LAW. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE. UNDER THE FORMULA, THE UNITED STATES GOVERNMENT GENERALLY REIMBURSES 85%OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURANCE COMPANY PROVIDING THE COVERAGE, THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT. YOU SHOULD ALSO KNOW THAT THE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT, AS WELL AS INSURERS' LIABILITY FOR LOSSES, RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED. COVERAGE FOR "INSURED LOSSES" AS DEFINED IN THE ACT IS SUBJECT TO THE COVERAGE TERMS, CONDITIONS, AMOUNTS AND LIMITS IN THIS POLICY APPLICABLE TO LOSSES ARISING FROM EVENTS OTHER THAN ACTS OF TERRORISM. YOU SHOULD KNOW THAT UNDER FEDERAL LAW, YOU ARE NOT REQUIRED TO PURCHASE COVERAGE FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM. The Act provides that a separate premium Is to be charged for insurance for an "act of terrorism" covered by the Act. 51010 (01/08) NEJECTOAN R 0.74001100 orrootoroom orsuRANce cokimog it otiodiwidi 1 pray ueo covd,ragofor atigioia.riw 10 oflortariemypiA thoptil. #odlcap )rw�aa6 Wow bir`nindld�dlfrt #h prdrt, if *PA 049.10 pinchrle GoViaragl.toe r9 i # oflOomE $04 $40Utd kidtcOte00 in I is booriv riot rl+n# rAtitit000 riie.0011101140.ed 14 a8kn i 1rr ! ),:or porgy erf ofr y t ptetatonaa cnnver�Do, ri led t ci retr¢41s tat 1 turi#raa °• o porch ud7 l tder81 d ilk) I h no =var s � erT In ru f " elmfloputehose tiai iOrtlii Taft rtorram far poarrilom Nate` It Nrou t f pey the Polnlarri t p till ft l h T42411,010m rage 00r-1We 001014tit det1044. of 'the Aot R&M t $ n afa form ri rooltiot Drum nrar PEOPLE HELPING PEOPLE SELF RELIANCE, INC PENN AMERICA INSURANCE COMPANY Ap _REV. S M LINCOLN Priet t4ton0 ileAr TBD 5-16-2014 , suRpLus L1N ES DISCLOSURE and ACKNOWLEDGEMENT At it on, B HAW T CORP' hasplaided my it a to the � s lines market, As required by Fl:orld statr to 6:916, 1 ham _.ram to this *wont: ont t. u derstand that adiOarlor may be Letrallabla in te adrnfi d m et and at lesser And that persons itiOred by stiirples lines ..catirlers Ora t1 prote ed.by the Florida lrt erance war ty sooiatten wllh ''respet to t rl *ooverY tot the dblfgatlon of an ir -1 r* 'unlicensed insurer:, I f urtheranderetanciiNkpoliny for , ditlQrra, prenliurns! and dedaptibI s u d b. surplus tines:lnEur iay i*diff6iiigitl r rn o found lrr ppil 1 used 10 the adMitted readitit,1. h beerad9itedier eutnlly read h a ate Policy. Th reis no 11 Ia1Il y on he pert. t, and 1 haand 'I ghavieno Ciaipa of ,melon. ainst, my a ping .wares :in a 441tis Mat .rar. PEOPLEIISPINO OPLE SELF`R E, C thstr—i;OnsUrod 1gnat re:dr In 9 a horin d Representative p14N AMERI _. None eT xeass..nd Grp lut tames Carder COMMON, ON, GENERAL Lk iE rU Type f l suritt 5-4 14 =€live J �t r 6-16-2014 M8 PREMI&M FINAODE A6RETAIONT6NDNOD.LOPYRA STA7EMSNT MAIL PAYMENT a PRO P.REM1UMFINANCE COMPANY1NC. ` AO; 13*..70ua,.Haywood, v31 1 Eh.:......snifficiqlln dale indicated balm heftean the es red ( UM. : . NI • p: the 'balance di the Roil umg on ma ins drama- pal me tram -rearm -Pr BEM A2E4530 opopooI1$4 Z 1 i 1�ele<l liar hg r :3$74 lW 7TH AVE ;M1 r1 a IIIs i }, tl I, , Na e 0 ROIttE ELl INQ PEOPL I rl {" r.1411 • 1 OTTrI RE T" 4- t ;i;34 28- li ik AND fgtd�LA r1If ": GG" RAGE . T ...ittd7 il'OEIxCFO 1 ' 7064 l CliAi tAtot l l Perin lantrica l l 000,1+411-. REGEN.4c f .! FFtFikiEl 4 S - L - : 1 i Cl •� 1� 1t'rrr2O1 i t fN k6 ei CARR ,pavv tM PAYMENT N. Ar10 .-trA. E U RE. AMMO' f.ffilM4 ED _ '17io rookrit afCridit pl tided tts yet er nrf yq1urrbehEif F W4 E c IMMO:- `' �Il& mrrrnOnt -: tb Caedit> I i Put TOM ttf PAYMENT T Agiocay tk lra psi r yap . h rnadri 3II pay".Brtrreot*s NUAI,. :. PF D T. BATE - e 1 rgf: 782 3i1 U2 45258- ..... "I:T.0 4 454.83" •63.311 T6472 .123 If:role . — stSm r R r4rrad b7l.tiw En llad Y UR AYMENT f IIIIL W11: I :.. ... rrrr}xr:- Hai 'Atli: an .o e Ue - #-flevekrsra tartiwte � f�fr<trrr�ii t746tkIBr39 ii4119$}F8. kit 114418ar1 Ira earl NttrubbrbrP mama ii ti f1 a l3ua � �R�19idlr li3r:. �_: did. Each of thli iifonthTT pJn hla.Es dyer an um soma day a(wit .succeedi ECIi. You.era �. eteetarrliy In t in a en # I aneernad return" rhiums which.: rein became 1d. OBARVg; a p rtant la rala v.1 'be �pki Etri€Hm:s of T1 Cr. i 061.4 riat 0ii es r 536'cs €talett Fi€FA'YHI i1f 1T 7,r A* ollf y#ir xis Ot l*V pay, a p> na1ty Brsri ycur tnay 15g eirllil a refund [>r o1 ire sae ilia iallo:r, �xulslone farad l lnfrsr tlan out a eai* lit slalealt, any r�gteiied rraprtyme tit Eh III baba s pr th tiI talanr19 8i drtianalti� - '. - - , .'-' ., :.._ : ffE QVE FORMA ION PRt8 +1T a ' QV!$ fTEOliiz y'IIC44 A 4D D1ZCL r3tJ riwnti1 unili kid In Tula esr itra. eayis errs aderritaieraal r atLie: fluted da1Q - _ . E: �1he unrlaes i Asslr pro sea anrtA reea payla rt�F7i11 :FIHAN . OMPANY1ha stop. i" . u.'T2 singtlyelanai*.pa *o1 re1:put-taantleallOfdryJarrrreet • dItinntmnkain Inttre c ?rMaatme• rri�are.lncurpur red here i, (1T1BE 1PQNM SIB R1 116E KEMEb TSEFCRE OU 'R IT- OR IF IT cDisrimU76 ANY BLANK BPACE, 2 YCi4.1 ► IE N1T t 1"t?,A VCMFLETE-Y FIL :NQCPY' FT11ITt i EMENT 3 UNDER lE1 Y HAVIE"THERIC1ti?TOP T.OFFINADVA IcET I FULL TITOUtdr_DfIANDUI4 Et RTAI CONDITIONS 1 O OBTAIN. A PARR LY.EF !RD CP itlr: EEltyl E CHAR > TLIE _U ITSIDN1 3 EXECUTED TJB WAN AGRR1 MrN .AND EN ) A DOPY 1`HEPElil 0rire eDODn170452 r?ktr, 0.5i.1 4 V riltitaE3R Tiff; Tt[fb: - +"Op':. 15...., i!IFLPmila .c ildrt igr rat .1 1 rlIA- @ih 1 .A8d3ds 1}lt F FOVIAtea11,11fi Ir# 1orot1 .. t h 4T`IJ F 1 URE i fi iscratlt 'i lr 1rf O01* SI . ABEURED AGENTS31fiJiE;"Ella u ned Agenl+Brolger heriabyr cerilkte bat air p.;fopl3elee fi '[hat titer down p ertt a in et: reel tee betfl p by cr an aclaa l or Ih vientyr The uniliar rted vierfents tdiel the aety reartir c a n * b ns a es d * 1Si e etltr I� g urn$ adage zalti$rwlett 1hewn . wt> fsrrrv13 tt a C�I COiAPP�1 a'rd'zeLrace `thin If I alto wont of �alkvtr €d i l V'fl.REDF: R Ft OR APENT. The federal St101 OtedCl 4ai n1ly .A rd11,,1 Vadltpte bare I$c lraating jnpl Nit ap licants ae tlf buti �ri e0t i t marital it lus...Thelederil. an iii islata ..cairn y1lui e caned-ming I �a rtilura InuniXt company �a tie Faders] Tide ' rrllmualcr 7311 14.aechtiw..tireat, �r1�, GeerpT, P ia1 I1405 bare r have Karin leaded and dellAged y h1a may and siimd and that .all p ,Males ltstsd1 tairalh, ire fa hy- r1s i ratleal that the Aseurad lard taael Aigia and :04113iimite ae owleriaat . that it mat eelllleied b mny+ dEy c,r. rnaauser ar ha gs miad , nt mmtons ,or itnearn nitres ti le -TIRE J 6oil41ar 1 for fhti peyanant.ofthia &bilgatian the party- puling ll s Agreementa r g; at1o; a , a no as toobrIty forthe Mat amount. :Oityattla tiaratOr spy Ali ataorearnad l tin*e h1r h. e me payable cinder the p�Qiiol�lletdd on itr dtlle c' p6il0I her . here r eppolnts Firil 0e r iteattorpay-in7fact 0 full etittiorlty wheel and t Wpotio r , of as l'Rtillaie '>tet de die reverse alde harbor, sluts f for agorOeyment �Ir1 ;11tsurari opriip rniee �v du1e''of pal ee her aria juiltitt0c1 aid _rArecd,-.up+l pia quest 0! 'rer Flamm: poirripany. to e `al�1d p ee acid to t Y the . Flriarr a , otripany Manned r to s premium$ thereon without !roof pf dE 9.1 he flder Roh h f Or:. of -the _timour ' 0 hereund - Aft Nokia 144.trlay bet me 4.10 tom the � P Y(1ee .sl li # : asdtte •iv tna balanoo 4tl tierr•undar and It'1h re lawny a .6f.t.teast One tita110r Z,r1,00) ra t e baiar da i It shawl Iaa • paid to the tired The,i aesur .tll Orne1.6 ,'ogriolorOy. tagatfisrtlrli it i et iaoti it to b104eita#fav l [a 9 a1 rat K a if pQIky is nest l e i. t the tine 1hL egr emeni txocuted Alfa .Hurd;.Ives Flr� t3a mp�rsy: *rU trr lilf In the` bar a of She 106urin0 eapm wiy : po1k (. ritrrnher;' tt3Ci- cltta 4af6 $f this drat pa f•m?•t fl J0611 reef ltie' friar nett the pr triir3rrr finan :i ontpany. cr y adyatit to ia. rad`a went fir iha 1n u 1t cornparty Ord' : 1hunal ' n[00a that -rnay baoome d'I a lees._nr�rrarral. dtnrm psych t ceding tb i'a arriisurrt rrlus Orly itn 0'44 tv ir` er presortt f rr#ract 4 The Assuied -gees ttiot-'10fautt Irk pa. sent of !ay InshiIirriortz hhrtof fir a 'arlod ar tad 1 d y^S ltia1 b rn tt a de au1t In life oonir di, used -tlrir taut t1 a 100.100 slrali bs clue and: p ble 'ilia , sured i pay re ptitabta al eY % zOar to 06404 aattu due land • p0 le ncler ttita chant if it is relferred rot .0if to y ttarrt r,` rat a t t pI y f li> F1 rtt tapaI o•We1 r-t ple. i=l ahoe ofroorly.pf any defrurlt; hail to aoaxatrUad laa a wwMiar fdr any rher:-ot su meant; dvi*it nor shelf l'trrou* er ref rights er iS ni les 100d6ot. tllarett; "t'trrr wired re r,i a its api 1.ha itkwi Cod ` y Iandar,errct not=an rusts c aridttiat 474 i ft .4 a et a ab sty her ttridr as rz The ure ttndV 1 n s i d roe fat ,th e. tit t o aotlelt tltt$ p 1lala :ls nak rrt adnt aF to. pow* A d 4r as 113.4:;a11 p :ra.$.reun i4.r elh It 1* mode.°:.0*.rty' to 00 Pranceo ppny atd pay rent by is , sired. ta: arty frttn r son, ii, ii ur r1 audit trt ins it n rxrrrrp y 0a11'bOt 091.01.tute. j y lxt•to tlae: roue ire-Gornpany.TAi uss* slid l r d to9 Ilia 100i of the hate of blot*, 1 l a lie tii6 41e4• n04:_ibis seam tl 4.4urrid aoreee ltiatt ttpbri del u* palm* - rare itsr,.atIcta4di fiefs It rift lnA dam, pay .e daUn onay arid r rliaatio sir +0 i 7rastalirne t paid not: lase it n (5) d The Largo tMposaii tiros bi m 7 i U r e s: 'ten 4 ($IQ ) for 0001.1al;polfoleS: r Zfilia a raddled paymeni for 05Irrrrrter sal_ poll0ea e agmd deeds nd n..greus that �d tilt ;in p ymerrt bn y ietaUmaht ltiereor for per od of tars t1't?) ,d4 4,106 deed tQ 1 a r ufor nar0114on 0140 'pOlidc4:11$4tid or .the reveres alb 1f the ureci: pays to balanoa lho scrota#: :Oils under.. tat tit prior to fNirturfty,- is fund e e eher> fler fiat dedus r cf $ ,t1fi, n this 19e 'Of 78 s. `.refund deed Da-0r9 ie kyle Fuel dne l Noii ibiteat OW. . Its s gear; lftpk amity rtyr ens :rvc l+ d :. er eer►caltalltat : ts11l pplle>i. t ttttraa ifiaa trr• l ted•r a but r, it net . riOtfita • ttap Ivry mar 04nOalidon, nail' fie 60-n41d by the Fin amps iy fii sn tpianyy_ ,a0ocini r y Stook- relnst Brno Qf p! I es why 400i t reezaiyadt rii.nottg6triontisup.16liresreUrarr riparlira tIlesole&oralicnn, $. In the t.34i tt two 'payment is ride by' thookmind the chuck 111 tar to becauea ct" Ifiti ffial it nds: t { , tt, fivedi re to yhis Fjpanci Oailip aOrki *fiiftoon 6e110. ib.tiO) '111 t r ottal iybe 1 nad widths: hbldnr.rirr tiler a C o o iifibe tigfpa,as t 1=in a a ip .y. Arlie l duel. goat credit -Opportunity rtunity . : irl ib1ts crad f ry mr til es ilir*Ond against adlt appll me on. .be sac or aritat atttuts. Ito Fedetil 9nq Mirth. minMera tornPflotitO with. this low ,co. noo ing thin PiOrAfiEff Mamie rrp #i a Ptiderai Trade OorfuniOloni aohoti a Stoat, T4,t Room BOO,, tI nia., Ga la 210308. Ariodied last am F1 s