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HomeMy WebLinkAboutCRA-R-16-0056 Backup DocumentKen Russell Board Chair MEMORANDUM September 27, 2016 Wilshire Insurance Company PO BOX 3328 Omaha, NE 68103 Re: Omni Redevelopment District Community Redevelopment Agency Commercial General Liability Wilshire — Policy No. CL00175744 Policy Term: 10/10/15-16 To Whom It May Concern: Jason Walker Executive Director Effective immediately, please recognize Century Risk Advisors (Century Advisory Services, Inc. d/b/a CRA), 2600 North Military Trail, Suite 240, Boca Raton, FL 33431 as our appointed retail Broker of Record and AmWins Access Insurance Services — Orlando, FL , 11315 Corporate Blvd., Suite 300, Orlando, FL 32817 as our mutual wholesale Broker of Record with respect to the above -noted policy. This letter immediately rescinds and revokes any previous Broker or Agent of Record Letter/s. CRA and/or AmWins is/are hereby authorized to negotiate with the insurance company as respects changes in the above -referenced coverage. CRA and/or AmWins shall not be responsible for any return commissions, uncollected premiums, audits or other financial arrangements, nor shall CRA and/or AmWins be accountable for any deficiencies in the current insurance coverage or contracts to which this letter applies. This letter also constitutes the authority of any company underwriter to furnish representatives of CRA and/or AmWins with any information pertaining to any and all insurance contracts, rates, schedules, surveys, reserves, losses, retentions or other financial data they may require regarding our current or prior insurance. This Letter of Authorization is effective immediately and supersedes any previous authorization provided. I also respectfully request that any waiting period specifically be waived. Y9urs truly, 13 so1I M. W tl'cer ecutive Director OMNI COMMUNITY REDEVELOPMENT AGENCY OF THE CITY OF MIAMI 1401 N. Miami Ave 12"8 Floor I Miami, FL 33136 Tel (305) 679-6868 Ken Russell Board Chair September 27, 2016 General Star Indemnity GuideOne National/ Promont RE: Omni Redevelopment District Community Redevelopment Agency New Business Submission Property and General Liability To whom it may concern: Jason Walker Executive Director Please accept this letter as confirmation that to my knowledge, there have been no Property or General Liability losses to either of the following locations: 1. 1401 N Miami Ave., Miami, FL 33136 2. 50 NW 14th St., Miami, FL 33136 Regards, n M. Walker Ex tutive Director OMNI COMMUNITY REDEVELOPMENT AGENCY OF THE CITY OF MIAMI 1401 N. Miami Ave 12nd Floor j Miami, FL 33136 Tel (305) 679-6868 Client Authorization to Bind and Election of Coverage ImportantInformation: Please keep in mind coverage cannot be bound when severe weather is threatening rega►idless of the expiration date. After review and careful consideration of your Proposal dated September 16, 2016, we accept your insurance program as presented with the following exceptions, changes, and/or recommendations: Coverage Total Cost of Insurance Yes No Commercial Property — Locations 1 (Firehouse) and 2 (MEC) $80,354.37 X Commercial Property — Location 2 Only (MEC) $64,094.18 x Commercial General Liability — Location 1 (Firehouse) and 2 (MEC) $12,748.39 X Services Option 1 Yes I No Document Delivery (Policies, Endorsements, Audits) Email x Mail Comments: Client Si (\\---'' na d Jason M Walker Print Name Omni Redevelopment District Community Redevelopment Agency 4/ao/2.01(0 Date Sigpied Executive Director Title c::: -- A Consultative Insurance and Risk Management Century Risk Advisors Advisors & Brokers Surplus Lines Disclosure and Acknowledgment At my direction, Century Advisory Services, Inc. d/b/a Century Risk Advisors has placed my coverage in the surplus lines market. As required by Florida Statute 626.916, I have agreed to this placement. I understand that superior coverage may be available in the admitted market and at a lesser cost and that persons insured by surplus lines carriers are not protected by the Florida Insurance Guaranty Association with respect to any right of recovery for the obligation of an insolvent unlicensed insurer. I further understand the policy forms, conditions, premiums, and deductibles used by surplus lines insurers may be different from those found in policies used in the admitted market. I have been advised to carefully read the entire policy. Omni Redevelopment District Community Redevelopment Agency Named Insured BY: Signature of med Insured Jason M Walker, Executive Director (014.011,6 Da Printed Name and Title of Person Signing General Star Indemnity / GuideOne Promont Name of Excess and Surplus Lines Carrier Property / General Liability Type of Insurance Effective Date of Coverage fi;f1C IRI\ Consultative Insurance and Risk Management Century Risk Advisors Advisors & Brokers PaAeJ18 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE Date: 91812016 APP ID: 1768968 Insured Name: OMNI REDEVELOPMENT DISTRICT COMMUNITY REDEVELOPMENT AGENC` TRIA PREMIUM AMOUNT: $4,000 (plus applicable premium tax) You are hereby notified that under the Terrorism Risk Insurance Act as amended. you have a right to purchase insurance coverage for losses resulting from acts of tenurism. As i efttted in Section 102,11 of the Art: The term "act of terrorism" means any act or arts that are certified- bl- lie Secretary of the Treasury -- iu consultation with the Secretary of Homeland Security. 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 iufiestrncture: to have resulted in damage within the United States. or outside the United States in the case of certain air carriers or vessels. or premises of a United States mission: and to have been con:mitred itted by an individual or individuals as pact of an effort to coer.e the civilian population of the United States or to intkueace 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 T5E UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED EY FEDERAL LAW. HOWEVER YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH M1G1-7 AFFECT YOUR COVERAGE. SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. L�NDER THE FORMULA. THE tNTITED STATES GOVERNMENT GENERALLY REIMBURSES [85 6 through 2015: 84% beginr•.ing on turnery 1. 2C16: 53% beginning an January- 1. 2017: 62% ben+i+niiug on January 1. 20IS; S' a6 begins ng on January 1. 2015 anti S0% begriming on armory I, 202 )) OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURANCE COMPANY PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR niis 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 K2c07rt THAT THE TERROR.-.S1,: RISK 'INSURANCE ACT. AS AMENDED. CONTAINS A 5100 BILLION CAP THAT Lt TS U.S. GOVE.RIvMEN7 REIMBURSEMENT AS WELL AS INSURERS' LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCIi LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS SFr) BILLION. 2" TIIE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED.S100 BZLIOK YOUR COVERAGE MAY BE REDUCED. indicate your election to purchase or not purchase terrorism insurance coverage by placing an X" in the box provided. Then sign, date and immediately return the form to us. Acceptance or Rejection of Terrorism insurance Coverage I hereby elect to purchase certified acts of terrorism coverage for a prospective premium of S4000. X I hereby decline to purchase terrorism coverage for certified acts cf terrorism. I understand that I will have no coverage for losses resul'ing from certified acts of terrorism. The following is applicable to Property accounts to Standard Fire Polley (SFP) states where required by state law. These states include California, Georgia, Hawaii, Illinois, Iowa, Maine, _Missouri, New York, North Carolina, Oregon. Washington, West Virginia. and Wisconsin. 1 hereby decline ro purchase coverage for certified acts cf terrorism. However. I understand that by state law coverage will be provides for loss from Ere due ro an act of terrorism if required. A premium charge tzf S500 auolies. General Star Indemnity Company Policyholder Applicant's Signature Insurance Company Omni Redevelopment District Community 176876E Redevelopment Agency 9/ 19/16 Named Insured Date CRA App ID Consultative Insurance and Risk Management Century Risk Advisors Advisors & Brokers Page 119 DISCLOSURE NOTICE OFFER OF TERRORISM INSURANCE COVERAGE Date: 911212016 Named Insured: Omni Redevelopment District Community Red GuideOne National Insurance Company Is required to send you this Notice pursuant to federal legislation concerning terrorism insurance. You are hereby notified that under the Terrorism Risk insurance Act of 2002 (the "Act"), effective November 26, 2002, you now have a right to purchase Insurance coverage for losses arising out of an act of terrorism as defined in Section 102(1) of the Act (`Terrorism insurance Coverage"). The term "act of terrorism" means any act that is certified by the Secretary of 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 on the premises of a United States mission; and to have been committed by an individual or Individuals acting on behalf of any foreign person or foreign interest, as part of an 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, IF YOU PURCHASE IT, COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IS PARTIALLY REIMBURSED BY THE UNITED STATES UNDER A FORMULA ESTABLISHED BY FEDERAL LAW. UNDER THIS FORMULA, THE FEDERAL GOVERNMENT PAYS 90% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURANCE COMPANY PROVIDING THE COVERAGE. THE PREMIUM CHARGED FOR THIS TERRORISM INSURANCE COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT. The provisions of the Terrorism Risk Insurance Act of 2002 can limit our maximum liability for payment of losses from certified acts of terrorism. That determination will be based on a formula set forth In the law involving the national total of federally Insured terrorism losses in an annual period and Individual insurer participation in payment of such losses. If one or more certified acts of terrorism In an annual period causes the maximum liability for payment of fosses from certified acts of terrorism to be reached, and we have satisfied our required level of payments under the law, then we will not pay for the portion of such losses above that maximum. However, that is subject to possible change at that time, as Congress may, under the Act, determine that payments above the cap will be made. The insurance coverage being offered in this Notice is strictly limited to the Terrorism Insurance Coverage mandated by the federal government. Should you elect to purchase Terrorism Insurance Coverage, your policy will remain subject to a Terrorism Exclusion excluding all other acts of terrorism not covered under the Act. ELECTION TO PURCHASE COVERAGE: You must notify the Company in writing of your decision whether or not you wish to purchase Terrorism Insurance Coverage by completing, signing, and returning this Notice prior to the issuance of any binder or Policy. it;4111 Century Risk Advisors Adviors& CRA Consultative Insurance and Risk Management NOTE: YOU MUST COMPLETE, SIGN AND RETURN THIS NOTICE EVEN IF YOU DECIDE NOT TO PURCHASE TERRORISM INSURANCE COVERAGE. This Is the only Notice you will receive on this subject. Thank you for your attention to this matter and prompt response. Please check the appropriate box below: I hereby elect to purchase Terrorism Insurance Coverage for an additional premium of $ 250 . x I hereby waive my right to purchase Terrorism Insurance Coverage. I understand that I will have no coverage of losses arising from "acts of terrorism" as defined in the Policy or by Endorsement. The following must be signed by en owner ar corporate officer of the Named Insured. Omni Redevelopment District Community Red Jason M Walker, Executive Director Print N ami & PasitionrTitie R Date o 4ao CRA Consultative insurance and Risk Management Century Risk Advisors Advisers & Byers SURPLUS LINES DISCLAIMER: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the admitted market and at a lesser cost. However, CRA has not located this form of insurance for you from insurers admitted in the State of Florida. We are therefore offering you insurance issued pursuant to the Surplus Lines Laws. Persons insured by Surplus Lines carriers do not have the protection of the Florida Insurance Guaranty Act which means that there is no right of recovery via the Florida Insurance Guaranty Association in the event a Surplus Lines Insurer becomes insolvent. Surplus Lines policies that are subject to audit provide for additional premium charges, but may not allow for return premium. In addition, most Surplus Lines policies contain Minimum Earned Premiums (if cancellations are permitted). Signature of authorized representative confirms s/he understands that Property & Liability coverage are each to be placed with a non -admitted Surplus Lines Carrier PREMIUM FINANCING DISCLAIMER: You may request financing trom a premium finance company to pay the premiums for insurance placed on your behalf by CRA. Premium finance companies that CRA recommends may pay compensation to CRA for helping to arrange the premium financing. It is CRA's practice to seek premium financing through an independent vendor with which CRA has an existing relationship and experience. You may wish to investigate other premium finance arrangements and companies yourself. Unless you instruct us to the contrary and desire premium financing, CRA will arrange premium financing as described above. If you wish to know further details of any compensation which CRA may receive in connection with arranging for your premium financing, we will be pleased to supply the information. INFORMATION CONCERNING OUR FEES: Unless otherwise specifically negotiated and agreed to with our Client, our professional fees are customarily based on commissions paid to us by the insurer, calculated as a percentage of the premium collected by the insurer. We may also receive additional compensation (monetary and non -monetary) from insurers and insurance intermediaries that may be contingent on volume, profitability or other factors pursuant to agreements we may have with them relating to all or part of the business we place with those insurers or through those intermediaries. Such agreements may be in effect with one or more of the insurers with which your insurance is placed, or with the insurance intermediary we engage to place your insurance. We will be pleased to discuss with you further details of any contingent compensation agreements involving to your placement upon your request. Note: This is a coverage summary of proposed renewals, and is not a legal contract. This summary is provided to assist in your understanding of your insurance program, and while terms, conditions, and exclusions have been summarized, the foregoing pages are Rol all-inclusive. Please refer to the actual policies for specific terms, conditions, limitations and exclusions that will govern in the event of a loss. Specimen copies of all policies are available for review prior to the binding of coverage. In evaluating your exposure to loss, we have been dependent upon information provided by you. If there are other areas that need to be evaluated prior to binding of coverage, please bring these areas to our attention. Should any of your exposures change after coverage is bound, such as your beginning new operation, hiring employees in new states, buying additional property, etc., please let us know so proper coverage(s) can be discussed. Higher limits may be available. Please contact us if you would like a quotation for higher limits or for additional types or extensions of coverages. CFRI/\ Consultative Insurance and Rd Management Century Risk Advisors Advisors& Brokers PRIOR CARRIER INFORMATION {continued AGENCY CUSTOMER ID: 00000972 YEAR CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE LOSS HISTORY Check if none (Attach Loss Summary for Additional Loss Information • 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 TOTAL LOSSES: $ DATE OF OCCURRENCE LINE TYPE I DESCRIPTION OF OCCURRENCE OR CLAIM DATE OF CLAIM AMOUNT PAID AMOUNT SUBRO- GATiON YIN CLAIM OPEN YIN SIGNATURE I 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% 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.) (Applicants InRlals): 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 conceming 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 calm 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 Toss, 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 terrn 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. 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. PRODUCER'S>s10t1ATU C. ��ds PRODUCER'S NAME (PteasePrinl] Crystal Romero -Sherman STATE PRODUCER LICENSE NO (111935 ) APPLICANT'S SIGNATURE pp 7/8O90801 NATIONAL PRODUGER NUMBER -` ACORD 125 (2014/12) - INS175r0n1A*v1 r Page 4 of 4 GENERAL INFORMATION (continued AGENCY CUSTOMER ID: 00000972 XPLAtN ALL YES RESPONSES (For all 'last or present operations) Y1N 16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? N 17. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? N LEASE TO WORKERS COMPENSATION COVERAGE CARRIED (YIN) LEASE FROM WORKERS COMPENSATION COVERAGE CARRIED (YM) 18. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? N 19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? N 20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS? N 21. IS THERE A FORMAL. WRITTEN SAFETY AND SECURITY POLICY IN EFFECT? N 22. DOES THE BUSINESSES PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? N REMARKS (ACORD 101, Additional Remarks Schedule, may be attached If more space is required) SIGNATURE 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: My 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 conceming 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 dvil 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 daim 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. 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. PRODUCERSSle ATU PRODUCER'S NAME (Please Print) Crystal Romero -Sherman , STATE PRODUCER LICENSE NO (R E119535da) C.—is "S:fse -4---.-.-1 APPLICANT'S SIGNATURE N / NATIONAL PRODUCER NUMBER ickDAr el /9(A L 8090801 1 ACORD 126 (2014/04) INS126/2014041 Page 4 of 4 SIG AGENCY CUSTOMER ID: 00000972 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 Toss 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 conceming 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. 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. PRODUCERS INGS141U Cc�{s APPLICANT'S TU RE PRODUCERS NAME (Plana Print) Crystal Romero -Sherman ACORD 140 (2014112)\y Page 3 of 3 INS140 (201412) STATE PRODUCER LICENSE NO (Requlredin Florida) E119535 DAtklNATIONAL PRODUCER NUMBER I(0 8090801 SIGNATURE AGENCY CUSTOMER ID: 00000972 Applicable In AL, AR, DC, LA, MD, NM, RI and WV My 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 conceming 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)* indude 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 ($10,000), or a fixed term of imprisonment for three (3) years, or both penalties. Should aggravating circumstances [be] present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) years. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCEICSiNA' PRODUCER'S NAME (Please Print) Crystal Romero -Sherman APPLICANTS SIGNATURE ACORD 890 (2014112) Page 3 of 3 INS870I2014121 may. •+�i STATE PRODUCER LICENSE NO (Required In Florida) E119535 NATIONAL PRODUCER NUMBER 8090801 A`� d STATEMENT OF VALUES DA�a�UDD 6 ) AGENCY Century Advisory Services, Inc. 2600 N Military Trail, Ste 240 Boca Raton FL 33431 CARRIER NATO CODE: PAGE Marketing Carrier Non -Specific OF 1NSUREDIAPPLICANT Omni Redevelopment POLICY NUMBER 2ois ea/cap sB EFFECTIVE DATE 9/30/2016 HEADQUARTERS ADDRESS 1401 N Miami Avenue Miami FL 33132 IPCUCalear Crystal Romero -Sherman PHONE p: (561)409-2420 COINS% APPLICABLE _— _ X CAUSES OF LOSS BASIC BROAD SPECIAL EARTHQUAKECAV FLOOD SPRINKLER LEAKAGE EXCL VANDALISM EXCL RICAVERAGE RATE REQUESTED EQUE BLANKET RATE REQUESTED IA1CC.Nol: (561)367-3126 80% EMAIL crystal . romero-shermanecentU ADDRESS:rY ryra.com 90% CODE: I SUBCODE: 100% AGENCY CUSTOMER ID: 00000972 APPLICABLE FORM NUMBER$ (Attach completed forms and endorsements that require completion to provide necessary Information affecting rates or Toss costs) CLASS LAC BLDG DESCRIPTIONAND ADDRESS OF PROPERTY ATIQN SUBJECT 100% VALUES RATE OR LOSS COST PREMIUM 1 DESC: BI w/ Extra Expense BUSIN 150,000 ADDRESS: 1401 N Miami Avenue Miami FL 33132 1 DESC: Building RC B 3.000.000 ADDRESS: 1401 N Miami Avenue Miami FL 33132 1 DESC: Business Personal Property RC BPP 500,000 ADDRESS: 1401 N Miami Avenue Miami FL 33132 2 DESC: Building RC B 14,000,000 ADDRESS: 50 NW 14th Street Miami FL 33136 2 DESC: BI w/ Extra Expense AA BUSIN 250,000 ADDRESS: 50 NW 14th Street Miami FL 33136 2 DESC: Business Personal Property RC BPP 2,000,000 ADDRESS: 50 NW 14th Street Miami FL 33136 DESC: ADDRESS: DEsc: ADDRESS: DESC: ADDRESS: DESC: ADDRESS: DESC: ADDRESS: DESC: ADDRESS: Totals include items found on all pages, not including Loc if G BLNK. TOTAL $ 19.900,000 NIA $ SIGNATURE ALL VALUES AND LOCATION INFORMATION ARE CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. \N„7---"- INSURED'SSIGNATURE TITLE Executive Director DA Soho (b ACORD 139 (2014109) INS139 (201409) ®1996-2014 ACORD CORPORATION. A I iightgreserved. The ACORD name and logo are registered marks of ACORD