HomeMy WebLinkAboutCRA-R-14-0056 BackupSUPPORTING
DOCUMENTATION
SOUTHEAST OVERTOWN PARK WEST CRA
PREMIUM RECAPITULATION
Annual Premium Check Option
OVIZPONSIIMOIO
Property / Inland Marine / Equipment Breakdown $ 44,625 ❑ 1]
General Liability $ 12,286 ❑ ❑
Workers' Compensation $ 2,891 ❑ 0
I authorize PIUA to request the underwriters to bind coverage on the items indicated above and
acknowledge receipt of the ompensation and Minan. ' Condition Disclosure(s) provided in this
proposal,
ef,e g ged ,6, ( C%,o-
(Name & Title)
j,0e/47)
(Date
Pre erne
�T , GOVFEtNMENTAt
- INtSURANCETRUST
PUBLIC ENTITY
SIGNATURE PACE
Covered Party: Southeast Overtown Park West CRA,
Agreement Number: PK FLI 0134004 14-07
Coverage Period: From:10/01/2014 to 10/01/2016
1 hereby confirm that limits/coverages as shown hereunder, corresponding with the Coverage.Agresmenl, are
correct:
NIA
NIA
Property TIV
inland Marine
$8,893,92013ulldings & Contents Combined
Not Included Communication Equipment
Not Included Contractor`s l Mobile Equipment
$04,108 Electronic Data Processing Equipment
Not Included Emergency Services Portable Equipment
Not Included Fine Arts
Not Inoluded Othor inland Marine
Not Included Rented, Borrowed, Leased Equipment
Not Included Valuable Papers
Not Included Watercraft
reject property TRIA (Terrorism Risk Insurance Act) coverage
Automobile
tl # of Units - Auto Liability
0 # of Units - Comprehensive
0 # of Units - Collision
I hereby confirm that I have received a copy of Preferred's Currant Interlace! Agreement
(which was Irast emended October 1, 2004) and amendment A (which was effective October
1, 2013).
1 confirm having road and agreed to the terms as laid out In the attached PGIT Participation
Agreement (which also requires a signature)
Please remember that a signed copy of the following are also required:
• First Page of PGIT application
• Uninsured Motorist Rejection / Election form, If applicable
• Professional Liability (POL / EPLI or ELL / EPLI) application, if applicable.
Name
Please not: Failure to return this signature page could result 1n cencelfatron of coverage.
The bdoif desalption of coverage contained In this document In being provided en on accommedaann Only and is hot kntendcd to cover or describe all coverage Avoernent terms, For more
complete end detailed Inform stlon dieting to the scope end limits of coVarage, plense roter directly Co thecovorage Agreement documents. Specimen farms are avbtleble upon request,
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Year
:.fry%`�' ,,
8LU
001
Custom Playground
1016 NW 3rd Ave
Miami
FL
33128
Miami -Da
2000-
468
i
x
5 50,000
$ -
002
Oifce f Ait Gallery
249 NW 8th St
Miami
FL
33136
Miami -Da
1970
2128
2
X
$ 251,920
$ 35,000
003
Overtawn Shopping Center
1400 NW arc€ Ave
Miami :
FL
33136
Miami -Da
1970
33061
1.
X
$ 2,457,000
$ 500,000
4
Vacant Building - Under Construction
920 NW 2pd Ave
Miami
FL
331396
Miami -Da
11954
7684
2'
$ 300,000
5
Vacant Building - Church Under Consti
300 NW llth St
Miami :
FL
33136
Miami -Da
1947
4583
1
$ 300,000 -
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company
Buildings & Cartterts
$ 3,293 $201
$ 5,000
$ 36,735
$ 3,893-020
$ 55,000
$ 43,678
Property
Earthgquake
$ 1,00D000
I $ 5,000
r $ 1,000,000
$ 5,000
Exposure
Qitference
$ 4300,000
1822%
Windstorm
Included
5%/$20.000 min.
Included
53/4420,000 min_
Accounts fl c.,ivabie
$ 250,000
$ 5,000
$ 250.000
$ 5,000
AcIcalorol Expense
$ -
$ -
Premium
Rfrreretic
$ 5,$$$
18,71%
Business Income
5 -
$ -
E&Q
5 250,000
$ 5,000
$ 250,000
$ 5,000
inland Marine
Demo&iion 8,10C
$ 500,000
$ 5.000
$ 500,000
$ 5,000
E„nxisona
■ - _- r
e 1 + 1
Communications Equipment
$ -
$ 747
$ -
$ 947
Mobifa Egtiiarreit
$ -
$ -
EDP
$ 74,708
$ 1,000
r
$ 94, 08
$ 1,000
Premium
Dffverence
21
,
Sub -Total
$ 37,542
-
sub -Tote!
$ 44.P>5
geiiIIiIPtii! I
Oampany
F
'Y i F 4 1 1
General Liability
$ 3,000,000
$ - 1 $ 10,325
$ 2,000,000
$ -
$ 12,2$3
Differerraa
. 656
Employee 8errt
$ 1000,000
$ - 1
$ 1,000,000 .
$ -
Lavr Enforcement isatz7rty
$ -
1 $ -
$ -
- - '-
-
Other- Ffease Specify
1r
Sub -Total
$ 10,325
i Sub -Total
$ Y2
i. -.a ? : 1,`e_p - - _,. 'a= n Pli
Payroll
Payroll
Preferred Gavel Ins Tru
11112 Payroll_ $71,000
14/15 Payroll: $80D.0r1Q
Q` -'
w 9Uf 00* s;=
2011 Mod: 1,00
rrerteme Mod:1_00
Eve
Difference
1i9000
24
Workers' Compensation
Statutory I $ -
$ 2,548
dory
$ -
$ 2.891
Employers i.idbtTi
Si mi$Itni$1mn $ -
Included
$irnM1 mi$1 to
$ -
Included
Prettifurn
D7ferenoe
$ 343
1;46%
IBM%
Sub -Total'
$ 2543'
zub-Total
$ 2831
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Difference
This proposal is intended to gyre a finerovertnsw_ Higher limits maybe avaa3bfe. Pease refer b coverage forms for compfete details regard -fag dens fan of iermS, exarrislons and k al-orzs: