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HomeMy WebLinkAbout26324AGREEMENT INFORMATION AGREEMENT NUMBER 26324 NAME/TYPE OF AGREEMENT MACEDONIA MISSIONARY BAPTIST CHURCH OF MIAMI, INC DESCRIPTION AMENDMENT NO. 2 TO MFE GRANT FUNDING AGREEMENT/REQUEST FOR EXTENSION/FILE ID: 14315/R- 23-0334/MATTER ID: 26-2614 EFFECTIVE DATE October 8, 2026 ATTESTED BY TODD B. HANNON ATTESTED DATE 10/20/2026 DATE RECEIVED FROM ISSUING DEPT. 10/21/2026 NOTE DOCUSIGN AGREEMENT BY EMAIL r P CITY OF MIAMI DOCUMENT ROUTING FORM ORIGINATING DEPARTMENT: Office of Management and Budget DEPT. CONTACT PERSON: Gabriel Brito EXT. 305-416-1203 NAME OF OTHER CONTRACTUAL PARTY/ENTITY: Macedonia Missionary Baptist Church of Miami, Inc. (MFE) IS THIS AGREEMENT TO BE EXPEDITED/RUSH YES ENO TOTAL CONTRACT AMOUNT: $397,118.00 FUNDING INVOLVED? ®YES NO TYPE OF AGREEMENT: ❑ MANAGEMENT AGREEMENT ❑ PROFESSIONAL SERVICES AGREEMENT ® GRANT AGREEMENT ❑ EXPERT CONSULTANT AGREEMENT ❑ LICENSE AGREEMENT ❑ PUBLIC WORKS AGREEMENT ❑ MAINTENANCE AGREEMENT ❑ INTER -LOCAL AGREEMENT ❑ LEASE AGREEMENT ❑ PURCHASE OR SALE AGREEMENT OTHER: (PLEASE SPECIFY): AMENDMENT #2 TO THE MIAMI FOR EVERYONE (MFE) GRANT PURPOSE OF ITEM (DETAILED SUMMARY): Approval of an amendment to the MFE Grant Agreement with Macedonia Missionary Baptist Church of Miami, Inc to extend the grant term through October 30, 2026. MMBCM, a not -for -profit organization providing social services and educational programming in the West Grove area, is constructing a new classroom annex funded by the grant. MMBCM requested the extension due to delays related to seasonal slowdowns, labor availability, archaeological monitoring, and permitting. MMBCM also requested a budget line adjustment to address increase cost of construction. The proposed amendment will: I.) modify the term referenced in Section 2 of the Agreement, effectively providing an extension through October 30, 2026; and II.) modify the line -item budget in Exhibit C. III.) add Section 37 and Exhibit H, "Anti -Human Trafficking Affidavit." COMMISSION APPROVAL DATE: 07/27/20203 FILE ID: 14315 ENACTMENT NO: R-23-0334 IF THIS DOES NOT REQUIRE COMMISSION APPROVAL. PLEASE EXPLAIN: ROUTING INFORMATION Date PLEASE PRINT AND SIGN APPROVAL BY DEPARTMENTAL DIRECTOR October 9, 2026 1 09:24:56 EDT PRINT: MARIE "MAGGIE" SIGNATURE:7 GOUIN DocuSigned by: GANA, littida ;: SUBMITTED TO RISK MANAGEMENT October 16, 2026 111:02:34 EDT i� RUIZ PRINT: DAVID ID R V IL.i SIGNATURE: 799F394C731444E... DocuSigneddby: fi ,/�b �J 34� 1db$0 SUBMITTED TO CITY ATTORNEY October 16, 2026 114:51:44 EDT October 16, 2026 1 14:58:54 EDT Matter ID:26-2614 PRINT: GEORGE K. SIGNATURE: WYSONG III Signed by: 1 �{ bV6�t Wt�Sbl�ld� ��� assn6E9FEsszasB... APPROVAL BY ASSISTANT CITY MANAGER October 17, 2026 118:30:36 EDT PRINT: ERICA T. PASCHAL SIGNATURE: DARLING, CPA, CFO ,-DocuSigned by: u� P6 `— APPROVAL BY DEPUTY CITY MANAGER October 19, 2026 110:48:16 EDT PRINT: NATASHA COLEBROOK-WILLIAMS SIGNATURE: E6s�56�3 �s4$c... ,—DocuSigned by: N4 i. Co144064-WAIL:,, RECEIVED BY CITY MANAGER" October 20, 2026 116:43:11 EDT PRINT: JAMES REYES SIGNATURE: 64D7069%S6E*4-1B... —Signed by: SUBMITTED TO THE CITY CLERK October 20, 2026 118:47:23 EDT PRINT: TODD B. HANNON SIGNATURE: et5e�ze6xa�a... ,—DocuSigned by: `— E4607560DCF1459... PLEASE ATTACH THIS ROUTING FORM TO ALL DOCUMENTS THAT REQUIRE EXECUTION BY THE CITY MANAGER AMENDMENT NO. 2 TO THE MIAMI FOR EVERYONE ("MFE") GRANT FUNDING AGREEMENT WITH MACEDONIA MISSIONARY BAPTIST CHURCH OF MIAMI, INC This Second Amendment to the MACEDONIA MISSIONARY BAPTIST CHURCH OF MIAMI, INC. Miami For Everyone ("MFE") Grant Funding Agreement ("Amendment No. 2") is entered into the 8th day of October , 2026 between the City of Miami, a municipal corporation of the State of Florida ("CITY") and MACEDONIA MISSIONARY BAPTIST CHURCH OF MIAMI, INC a Florida Not For Profit Corporation ("RECIPIENT"). RECITALS WHEREAS, the City created the Miami For Everyone ("MFE") Program to assist communities facing the long-term complications resulting from declared emergencies and to address the specific needs of the most vulnerable residents and businesses, through a strategy of focusing the provision of support towards priority areas of need that will further stabilize economic conditions within City Districts; and WHEREAS, pursuant to Resolution No. 23-0334 adopted on July 27th, 2023 ("R-23- 0334"), the City Commission awarded RECIPIENT Three Hundred Ninety -Seven Thousand One Hundred Eighteen and 00/100 Dollars ($397,118.00) in Miami For Everyone Funds ("MFE") in order to construct and complete a new classroom annex at the Macedonia owned property located at 3515 S. Douglas Road ("Project"); and WHEREAS, RECIPIENT executed the MFE Grant Funding Agreement ("Agreement") with the CITY dated March 20, 2024 ("Effective Date") for the use of the MFE Funds pursuant to the terms of the Agreement and applicable laws, rules, and regulations; and WHEREAS, RECIPIENT executed Amendment No. 1 to the MFE Grant Funding Agreement ("Amendment No. 1") with the CITY dated April 3, 2026; and WHEREAS, Section 2 of the Agreement establishes a term beginning on February 26th, 2024, and ending on August 31, 2026 ("Term"); and WHEREAS, Exhibit C of the Agreement provides a budget summary; and WHEREAS, the RECIPIENT has experienced several delays due to required archaeological monitoring, seasonal slowdowns, labor availability, and permitting, has reviewed their project schedule, and has provided a written letter to the CITY requesting a term extension through October 30, 2026; and WHEREAS, this Amendment No. 2 only amends the Term of the Grant Agreement, while amending "Exhibit C", and does not increase the total MFE Funds that were approved and awarded pursuant to R-23-0334; and Page 1 of 4 NOW, THEREFORE, in consideration for the covenants set forth herein and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the parties hereto agree as follows: 1. All of the above recitals are true and correct in all respects and are incorporated by reference herein as though set forth in full herein. 2. Section 2 of the Agreement, titled "TERM", shall be removed and replaced in its entirety as follows: "2. TERM: The term of this Agreement shall commence on February 26th, 2024, and shall continue until October 30th, 2026." 3. " Exhibit C" of the Agreement is amended with the "Exhibit C-Amended" attached to this Second Amendment and incorporated herein by this reference. 4. Except as modified herein, all other terms and conditions of the Agreement, shall remain unmodified and in full force and effect. 5. This Second Amendment may be executed in any number of counterparts, each of which so executed shall be deemed to be an original, and such counterparts shall together constitute but one and the same Amendment. The parties shall be entitled to sign and transmit an electronic signature of this Amendment (whether by facsimile, PDF or other email transmission), which signature shall be binding on the party whose name is contained therein. Any party providing an electronic signature agrees to promptly execute and deliver to the other parties an original signed Amendment upon request. 6. This Second Amendment may not be amended, suspended, superseded or otherwise modified except by a written instrument, expressly identifying the modifications made and signed by the authorized representative of each of the parties. Remainder of page intentionally left blank. [Signatures on the Following Page] Page 2 of 4 MIAMI FOR EVERYONE FUNDING AGREEMENT EXHIBIT C — Amended Budget Insert Page 5 from Miami For Everyone Funding Request Form Page 3 of 4 City of Miami Miami For Everyone Program Funding Request Form FUNDING REQUEST INFORMATION: Amount Requested: $ $397,1 18 Explain how the City of Miami's Miami For Everyone funding will be utilized: See attached backup. Itemize MFE funding related to expenditures below: Personnel Salaries & Wages: $ Personnel Benefits $ Space Rental: $ Utilities (Electricity, Phone, Internet): $ Supplies: Equipment Marketing: $ Transportation (Participants): $ Meals (Participants): $ Professional Services (List each): $ Construction (attach schedule of costs): $ Other (please describe): Other (please describe): Other (please describe): Page 5 of 6 Return this form to: gbrito@miamigov.com (March 28, 2023) Funding Request Form Backup Funding Request Information Amount Requested: $397,118 Explain how the City of Miami's Miami For Everyone funding will be utilized: The construction of the new classroom annex will be adjoined to the existing structure on two levels. This new building extension will provide dedicated learning space for afterschool and summer programming, offices, and community meeting space. The budget breakdown below highlights the associated costs of the new construction: Concrete Work for Classroom Addition $ 26,474 Masonry Work for Classroom Addition $ 12,298 Site Work for Classroom Addition $ 1,894 Metal Work for Classroom Addition $ 6,002 Wood & Plastics Work for Classroom Addition $ 32,172 Doors & Windows for Classroom Addition $ 10,363 Interior Finishes for Classroom Addition $ 13,427 Duct Work / HVAC for classrooms $ 19,850 Install Exterior Lighting System $ 23,896 Paving & Parking Lot Improvements $ 25,857 Exterior stucco wall repairs and reinforcement $ 8,283 Repair Drive Gate Openings $ 4,250 Repair Security Fencing $ 6,750 Renovate current bathrooms on first floor and bring to ADA code $ 28,732 Exterior painting $ 5,000 Repair Entire Perimeter Fence $ 1,300 Mechanical, Electrical, Plumbing (MEP) for renovation and new construction $ 47,802 Architectural / Engineering Services $ 43,055 Contractor Fees for Classroom Addition Construction, General Conditions $ 63,337 Furnish classroom annex - furniture, equipment, wall mount room divider $ 16,376 Total $ 397,118.00 The Classroom Annex improvements are designed to provide functional, accessible educational space while remaining architecturally compatible with the historic character of Macedonia Missionary Baptist Church. The classroom windows, although not stained glass, were designed with shapes and proportions similar to the stained- glass windows of the historic sanctuary. This compatibility is particularly important as the Church completes its Florida Master Site File (FMSF) documentation and pursues historic designation through the National Register of Historic Places. The project also required remodeling the existing bathrooms to meet ADA accessibility requirements because these facilities will serve children, program participants, visitors, and other attendees using the new Classroom Annex. Accordingly, these improvements are directly related to the accessibility and operation of the new educational space. The mechanical, electrical, and plumbing work necessary to support the Classroom Annex is included within the project budget and Schedule of Values under the categories MEP, ADA, Duct, HVAC, and Windows. These costs include classroom HVAC and ductwork, plumbing improvements, electrical wiring and related infrastructure, ADA-required improvements, and the architecturally compatible classroom windows. Together, these components are necessary for the classrooms to be safe, accessible, code -compliant, operational, and compatible with the historic church property. IN WITNESS WHEREOF, the parties hereto have caused this First Amendment to be executed by their respective officials thereunto duly authorized on the date above written. ATTEST: PV !M a Dogg(as Signature Print Name: Wanda Douglas CITY: CITY OF MIAMI, a municipal Corporation of the State of Florida Signed by: October 20, 2026 116:43:11 EDT a cas4F2csva78... James Reyes City Manager Date: APPROVED AS TO INSURANCE REQUIREMENTS cDocuSigned by: I 16, 2026 111:02:34 EDT 5sz4nB495F254BO... David Ruiz Interim Director Date: PROVIDER: MACEDONIA MISSIONARY BAPTIST CHURCH OF MIAMI, INC. a Florida Not For Profit Corporation By:C e f/diZ id it - Print Name: Carolyn Donaldson Titl - • _ nsibstr A TEST: LDocuSigned by: E4frD-7-566DEF1459... Todd Hannon City Clerk 26 118:47:23 EDT Date: APPROVED AS TO FORM AND CORRECTNESS: ��SignedAAAAAAbbbby: AA 587�8 E9FE88248B... 01026 1 14:58:54 EDT George K. Wysong III City Attorney rPa Matter ID:26-2614 October 16, 2026 114:51:44 EDT Page 4 of 4 Date: / A� o® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 02/25/2026 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Roe Insurance Inc. 9851 State Road 54 New Port Richey FL 34655 CONTACT Gertrude Rosencrans NAME: PHONE (727) 376-0030 FAX (727) 376-2262 (A/C, No, Ext): (A/C, No): E-MAIL trudy@roeins.com ADDRESS: y@ INSURER(S)AFFORDING COVERAGE NAIC # INSURERA: James River Insurance INSURED Neiel Group, LLC 4314 Blonigen Ave Orlando FL 32812 INSURER B : Evanston Insurance Company INSURER C: American Builders Insurance Company 11240 INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: MASTER CERT 26-27 REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CERTIFICATE 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY 001291983 03/26/2026 03/26/2027 EACH OCCURRENCEDAMAGE $ 1000000 CLAIMS -MADE X OCCUR TO RETED PREMISES (Ea occurrence) $ 100,000 MED EXP (Any one person) $ 5,000 PERSONAL &ADV INJURY $ 1'000,000 GEN'L X AGGREGATE POLICY OTHER: LIMIT APPLIES JECT PRO-LOC PER: GENERAL AGGREGATE $ 2,000,000 PRODUCTS -COMP/OPAGG $ 2'000,000 Employee Benefits $ 0 AUTOMOBILE _ LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY SCHEDULED AUTOS NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LIAB EXCESS LIAB X OCCUR CLAIMS -MADE EZXS3194884 03/26/2026 03/26/2027 EACH OCCURRENCE $ 5000000 AGGREGATE $ 5,000,000 DED X RETENTION $ 10,000 $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y/N N N /A WCV023690309 03/15/2026 03/15/2027 X PER STATUTE OTH ER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE $ 1'000,000 E.L. DISEASE - POLICY LIMIT 10, 00000 $ , DESCRIPTION OF OPERATIONS / LOCATIONS /VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Workers Compensation applies to Florida operations only. CITY OF MIAMI IS INCLUDED AS ADDITIONAL INSURED AS REQUIRED BY WRITTEN CONTRACT ON PRIMARY AND NON-CONTRIBUTORY BASIS. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN CITY OF MIAMI ACCORDANCE WITH THE POLICY PROVISIONS. 444 SW 2ND AVE AUTHORIZED REPRESENTATIVE ,^,� Miami FL 33130 {5� I ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD THE HARTFORD BUSINESS SERVICE CENTER THE 3600 WISEMAN BLVD HARTFORD SAN ANTONIO TX 78251 City of Miami 444 SW 2ND AVE MIAMI FL 33130 Account Information: Policy Holder Details : MACEDONIA MISSIONARY BAPTIST CHURCH OF MIAMI INC. October 7, 2026 Contact Us Need Help? Chat online or call us at (866) 467-8730. We're here Monday - Friday. Enclosed please find a Certificate Of Insurance for the above referenced Policyholder. Please contact us if you have any questions or concerns. Sincerely, Your Hartford Service Team WLTR005 ACORD CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 10/07/2026 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER AUTOMATIC DATA PROCESSING INS AGCY 76250871 1 ADP BLVD M/S 625 ROSELAND NJ 07068 CONTACT NAME: PHONE (800)524-7024 FAX (800)524-4013 (A/C, No, Ext): (A/C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURERA: Hartford Fire Insurance Company 19682 INSURED MACEDONIA MISSIONARY BAPTIST CHURCH OF MIAMI INC. 3515 S DOUGLAS RD MIAMI FL 33133 INSURER B : INSURER C: INSURER D : INSURERS: INSURER F : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CERTIFICATE 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. LIMITS SHOWN ARE INCLUSIVE OF AMOUNTS REQUESTED BY THE CERTIFICATE HOLDER AND MAY NOT REFLECT POLICY LIMIT AMOUNTS IN EXCESS OF THOSE REQUESTED. "Not Applicable in WY INSR LTR TYPE OF INSURANCE ADDLSUBR INSD WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CLAIMS -MADE OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ MED EXP (Any one person) $ PERSONAL & ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES POLICY ❑PRO-LOC JECT OTHER: PER: GENERAL AGGREGATE $ PRODUCTS - COMP/OPAGG $ $ AUTOMOBILE _ LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY _AUTOS SCHEDULED NON -OWNED AUTOS ONLY COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ _ UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE $ AGGREGATE $ DED RETENTION $ $ A WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N / A 76 WEG BZ2EKA 01/21/2026 01/21/2027 X PER STATUTE OTH- ER E.L. EACH ACCIDENT $ $1,000,000 E.L. DISEASE -EA EMPLOYEE $ $1,000,000 E.L. DISEASE - POLICY LIMIT $ $1,000,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Those usual to the Insured's Operations. CERTIFICATE HOLDER CANCELLATION City of Miami 444 SW 2ND AVE MIAMI FL 33130 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2025/12) © 1988-2025 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD i A. GuideOne Elite Insurance Company GUIDEONE" INSURANCE 1111 Ashworth Road, West Des Moines, IA 50265 www.guideone.com 877-448-4331 • COMMON POLICY SCHEDULE OF FORMS AND ENDORSEMENTS P0U i NI!mhPr: 00-1275-976 Named Insured: Agent Information: MACEDONIA MISSIONARY BAPTIST CHURCH OF Sovereign Insurance Group MIAMI INC Agent Number: 09BBT Policy Period: 09/24/2026 to 09/24/2027 At 12:01 A.M. Standard Time at the mailing address shown in the Common Policy Declarations. FORMS AND ENDORSEMENTS APPLICABLE TO THE COMMERCIAL PROPERTY COVERAGE PART: Form Number Edition Date Description CP 01 25 02 23 Florida Changes GN 10044 07 19 Building And Personal Property Coverage Form (CP 00 10 06 07) - Table Of Contents CP 00 10 06 07 Building And Personal Property Coverage Form CP 00 90 07 88 Commercial Property Conditions CP 01 40 07 06 Exclusion Of Loss Due To Virus Or Bacteria CP 10 30 06 07 Causes Of Loss - Special Form CP 10 32 08 08 Water Exclusion Endorsement CP 10 54 06 07 Windstorm Or Hail Exclusion CP 12 18 06 07 Loss Payable Provisions GCP 04 45 07 14 Fire And Security Alarm System Upgrade Coverage GCP 23 11 07 14 Faithguard Property Enhancement Endorsement GCP 27 08 07 14 Exclusion Of Designated Premises PCP 73 57 04 09 Equipment Breakdown Coverage FORMS AND ENDORSEMENTS APPLICABLE TO THE COMMERCIAL CRIME COVERAGE PART: Form Number CR 01 51 CR 01 75 GN 14005 CR0020 GCR1501 GCR2201 Edition Date Description 08 07 Florida Changes - Legal Action Against Us 10 10 Florida Changes - Binding Arbitration 07 19 Commercial Crime Coverage Form (CR 00 20 11 15) (Discovery Form) - Table Of Contents 11 15 Commercial Crime Coverage Form (Discovery Form) 07 14 Religious And Volunteer Workers Included As Employees 07 14 Increased Limit Of Insurance For Special Observance Days FORMS AND ENDORSEMENTS APPLICABLE TO THE COMMERCIAL GENERAL LIABILITY COVERAGE PART: Form Number CG 02 20 GCG 52 42 Edition Date Description 12 24 Florida Changes - Cancellation And Nonrenewal 11 23 Florida Amendatory Endorsement - Punitive Damages THE COMMON POLICY SCHEDULE OF FORMS AND ENDORSEMENTS FORM(S) A PART OF THE COMMON POLICY DECLARATIONS. Copyright 2014 GuideOne Insurance Date Created: 07/26/2026 GIL 10 20 07 14 Page 1 of 3 Ao COMMON POLICY SCHEDULE OF FORMS AND ENDORSEMENTS (Continued) GUIDEONE" INSURANCE Form Number Edition Date GCG 52 43 09 20 GN 16804 07 19 C00001 0413 C00069 1223 CG 20 01 04 13 CG 20 26 04 13 CG 21 06 12 23 CG 21 47 12 07 CG 21 67 12 04 CG 21 70 01 15 CG 40 32 05 23 CG 40 35 12 23 GN 16806 07 19 GCG 04 04 01 15 GCG 04 06 09 15 GCG 05 51 02 03 GCG 20 03 07 14 GCG 20 09 09 24 GCG 21 01 04 07 GCG 25 10 07 14 GN 16808 07 19 GCG 28 10 04 18 GCG 28 31 11 24 GCG 33 03 07 14 GN 16814 07 19 GCG 74 10 07 14 PCG 75 43 02 03 GCG 33 05 05 20 Policy Number: 001275976 Description Florida Changes Commercial General Liability Coverage Form (CG 00 01 04 13) - Table Of Contents Commercial General Liability Coverage Form Exclusion - Violation Of Law Addressing Data Privacy Primary And Noncontributory - Other Insurance Condition Additional Insured - Designated Person Or Organization Exclusion - Access Or Disclosure Of Confidential Or Personal Material Or Information Employment -Related Practices Exclusion Fungi Or Bacteria Exclusion Cap On Losses From Certified Acts Of Terrorism Exclusion - Perfluoroalkyl And Polyfluoroalkyl Substances (PFAS) Exclusion - Cyber Incident Violent Incident Response Coverage (GCG 04 04 01 15) - Table Of Contents Violent Incident Response Coverage Religious Expression Coverage General Aggregate Limit Amendment Additional Insured - Specific Activities Additional Insured - When Required In Written Contract Or Agreement - Special Events Exclusion - Religious Disaffiliation Or Schism FaithGuard General Liability Endorsement Legal Expense Reimbursement Coverage (GCG 28 10 04 18) - Table Of Contents Legal Expense Reimbursement Coverage Florida - Special Events Limited Endorsement Exclusion - Lead Liability Sexual Misconduct Liability Coverage (GCG 74 10 07 14) - Table Of Contents Sexual Misconduct Liability Coverage (Occurrence) Director And Officer Liability (Occurrence) Exclusion - Asbestos FORMS AND ENDORSEMENTS APPLICABLE TO MORE THAN ONE COVERAGE PART: Form Number Edition Date GN 70122 GN 16820 GN 16829 GN 70074 IL0175 IL0255 IL0401 09 23 04 09 09 20 07 14 09 07 12 24 02 12 Description Florida Policyholder Notice Important Notice Amendment Of Insuring Agreement - Disease Or Illness Producing Pathogens Endorsement Advisory Notice To Policyholders State Of Florida - Loss Control Florida Changes - Legal Action Against Us Florida Changes - Cancellation And Nonrenewal Florida - Sinkhole Loss Coverage THE COMMON POLICY SCHEDULE OF FORMS AND ENDORSEMENTS FORM(S) A PART OF THE COMMON POLICY DECLARATIONS. Copyright 2014 GuideOne Insurance Date Created: 07/26/2026 GIL 10 20 07 14 Page 2 of 3 Ao COMMON POLICY SCHEDULE OF FORMS AND ENDORSEMENTS (Continued) GUIDEONE" INSURANCE Policy Number: 001275976 Form Number Edition Date Description GIL 00 01 08 14 Additional Common Policy Conditions GIL 03 05 07 14 Combined Deductible GIL 09 02 07 14 Actual Cash Value Provision GIL 09 04 03 19 GuideVantage Coverage Enhancement GIL 09 05 07 21 Amendment Of Insuring Agreement - Disease Or Illness Producing Pathogens GIL 42 21 04 21 Nonassessable Policy Provisions IL 00 03 09 08 Calculation Of Premium IL 00 17 11 98 Common Policy Conditions IL 00 21 09 08 Nuclear Energy Liability Exclusion Endorsement IL 09 35 07 02 Exclusion Of Certain Computer -Related Losses IL 09 52 01 15 Cap On Losses From Certified Acts Of Terrorism IL 09 85 12 20 Disclosure Pursuant To Terrorism Risk Insurance Act THE COMMON POLICY SCHEDULE OF FORMS AND ENDORSEMENTS FORM(S) A PART OF THE COMMON POLICY DECLARATIONS. Copyright 2014 GuideOne Insurance Date Created: 07/26/2026 GIL 10 20 07 14 Page 3 of 3 i A. GuideOne Elite Insurance Company GUIDEONE" INSURANCE 1111 Ashworth Road, West Des Moines, IA 50265 www.guideone.com 877-448-4331 L COMMERCIAL PROPERTY DECLARATIONS - STATEMENT OF VALUES Policy Number: 00-1275-976 Named Insured: Agent Information: MACEDONIA MISSIONARY BAPTIST CHURCH OF Sovereign Insurance Group MIAMI INC Agent Number: 09BBT Policy Period: 09/24/2026 to 09/24/2027 At 12:01 A.M. Standard Time at the mailing address shown in the Common Policy Declarations. INSTRUCTIONS 1. The values shown on the attached page(s) of this Statement of Values form must be the Replacement Cost Values (100%) or the Actual Cash Value (100%), and should reflect the basis of coverage for each Building, Personal Property of the Insured, or both. 2. The values shall be submitted to the Insurance Company and shall be subject to its acceptance. 3. This Statement of Values shall not include the values desired for Business Income and/or Extra Expense coverage. 4. Nothing contained in these Instructions shall be construed as changing in any manner the conditions of the policy. 5. The Company may require this Statement of Values to be signed by the Insured, or in the case of firms, by a partner or an officer. ACKNOWLEDGEMENT AND ACCEPTANCE This Statement of Values form is filed with the designated insurance company shown above. All values submitted are correct to the best of my knowledge and belief. Printed Name Signature SEE SIGNATURE ON FILE (Authorized Representative) Title Date THE COMMERCIAL PROPERTY DECLARATIONS - STATEMENT OF VALUES FORM(S) A PART OF THE COMMERCIAL PROPERTY COVERAGE PART DECLARATIONS. Date Created: 07/26/2026 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright 2014 GuideOne Insurance GCP 10 30 07 14 Page 1 of 2 i I\ oe COMMERCIAL PROPERTY DECLARATIONS - STATEMENT OF VALUES (Continued) GUIDEONE INSURANCE ■ DESCRIPTION OF COVERED PROPERTY Location/Premises Address 0001 3515 S Douglas Rd Miami, FL 33133-5707 Policy Number: 001275976 Blanket Building' Occup Description Coverage Const2 Valuation3 100% Values Group BLDG 001 Other Building JM RC $ 1,110,000 002 Other All Personal Property RC $ 199,300 1 BLDG = Building; SP = Special Property 2 FR = Fire Resistive; JM = Joisted Masonry; MFR = Modified Fire Resistive; MNC = Masonry Non -Combustible; NC = Non -Combustible 3 ACV = Actual Cash Value; FV = Functional Valuation; RC = Replacement Cost (Valuation is also subject to other terms and conditions. Please read your policy carefully.) THE COMMERCIAL PROPERTY DECLARATIONS - STATEMENT OF VALUES FORM(S) A PART OF THE COMMERCIAL PROPERTY COVERAGE PART DECLARATIONS. Date Created: 07/26/2026 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Copyright 2014 GuideOne Insurance GCP 10 30 07 14 Page 2 of 2 Ao COMMERCIAL GENERAL LIABILITY COVERAGE PART DECLARATIONS (Continued) GUIDEONE" INSURANCE Policy Number: 001275976 ADDITIONAL COVERAGES Director And Officer Liability Coverage Director And Officer Liability Each Claim Limit $ 1,000,000 Director And Officer Liability Aggregate Limit $ 1,000,000 Deductible $ 2,500 Legal Expense Reimbursement Coverage Legal Expense Reimbursement Each Incident Limit $ 15,000 Legal Expense Reimbursement Aggregate Limit $ 45,000 Deductible $ 1,000 Religious Expression Coverage Religious Expression Each Claim Limit $ 1,000,000 Religious Expression Aggregate Limit $ 1,000,000 Religious Expression Legal Expenses Reimbursement — Hourly Limit $ 250 Religious Expression Legal Expenses Reimbursement— Each Incident Limit $ 150,000 Religious Expression Legal Expenses Reimbursement — Aggregate Limit $ 300,000 Sexual Misconduct Liability Coverage Sexual Misconduct Liability Each Claim Limit $ 250,000 Sexual Misconduct Liability Aggregate Limit $ 500,000 Sexual Misconduct Medical Expense Limit $ 10,000 Violent Incident Response Coverage Violent Incident Aggregate Limit $ 300,000 Individual Counseling Expenses Each Person Limit $ 2,500 Medical Expenses Each Person Limit $ 50,000 Individual Expenses Aggregate Limit $ 200,000 Organizational Expenses Aggregate Limit $ 100,000 —7 SCHEDULE OF LIABILITY CLASSIFICATIONS AND EXPOSURES Location Class Annual Number Classification Code Premium Basis Exposure Premium 0001 Churches or Other Houses of 41650 Area 5,236 $1,886.00 Worship Directors And Officers Liability 49999 Flat Charge $193.00 Coverage (Occurrence) Religious Expression Coverage 73201 Flat Charge $100.00 Copyright 2014 GuideOne Insurance GCG 10 00 07 14 Date Created: 07/26/2026 Page 2 of 3 POLICY NUMBER: 00-1275-976 PRIMARY AND NONCONTRIBUTORY - OTHER INSURANCE CONDITION THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART PRODUCTS/COMPLETED OPERATIONS LIABILITY COVERAGE PART The following is added to the Other Insurance Condition and supersedes any provision to the contrary: Primary And Noncontributory Insurance This insurance is primary to and will not seek contribution from any other insurance available to an additional insured under your policy provided that: (1) The additional insured is a Named Insured under such other insurance; and (2) You have agreed in writing in a contract or agreement that this insurance would be primary and would not seek contribution from any other insurance available to the additional insured. © Insurance Services Office, Inc., 2012 CG 20 01 04 13 Page 1 of 1 POLICY NUMBER: 00-1275-976 ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s): THE CITY OF MIAMI 444 S. W 2nd Ave Miami, FI 33130 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule, but only with respect to liability for "bodily injury', "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf: 1. In the performance of your ongoing operations; or 2. In connection with your premises owned by or rented to you. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. © Insurance Services Office, Inc., 2012 CG 20 26 04 13 Page 1 of 1 POLICY NUMBER: 00-1275-976 ADDITIONAL INSURED - SPECIFIC ACTIVITIES THIS DOCUMENT IS AN ENDORSEMENT THAT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name And Address Of Person Or Organization: The Childrens Trust Specified Activity: Summer Reading Camp Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A. Section II - Who Is An Insured is amended to include as an additional insured the person(s) or organization(s) shown in the Schedule above, but only with respect to their liability arising out of activities described above. However: 1. The insurance afforded to such additional insured only applies to the extent permitted by law; and 2. If coverage provided to the additional insured is required by a contract or agreement, the insurance afforded to such additional insured will not be broader than that which you are required by the contract or agreement to provide for such additional insured. B. With respect to the insurance afforded to these additional insureds, the following is added to Section III - Limits Of Insurance: If coverage provided to the additional insured is required by a contract or agreement, the most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the contract or agreement; or 2. Available under the applicable Limits of Insurance shown in the Declarations; whichever is less. This endorsement shall not increase the applicable Limits of Insurance shown in the Declarations. Includes copyrighted material of Insurance Services Office, Inc., with its permission. GCG 20 03 07 14 Copyright 2014 GuideOne Insurance Page 1 of 1 POLICY NUMBER: 00-1275-976 ADDITIONAL INSURED - WHEN REQUIRED IN WRITTEN CONTRACT OR AGREEMENT - SPECIAL EVENTS THIS DOCUMENT IS AN ENDORSEMENT THAT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE FORM A. Section II — Who Is An Insured is amended to include the following as an additional insured: Any person or organization to whom you are obligated in a "written contract or agreement" to name as an additional insured on your policy, but only as respects liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omissions of those acting on your behalf, in connection with an event: 1. Held or hosted by you on premises owned or managed by such person or organization; and 2. Specifically named or described in the "written contract or agreement" described in Paragraph A. above. Such person or organization does not qualify as an additional insured with respect to the independent acts or omissions of such person or organization. B. The insurance afforded to such additional insured described in Paragraph A. of this endorsement: 1. Only applies to the extent permitted by law; 2. Will not be broader than that which you are required by the "written contract or agreement" to provide for such additional insured; and 3. Applies only for the duration of your event. The person's or organization's status as an additional insured under this endorsement ends at the conclusion of your event or upon the end date of the "written contract or agreement", whichever first occurs. This endorsement does not serve to create coverage for an event excluded under this policy. C. With respects to the insurance afforded to these additional insureds, the following is added to Section III — Limits of Insurance: The most we will pay on behalf of the additional insured is the amount of insurance: 1. Required by the "written contract or agreement" described in Paragraph A., or 2. Available under the applicable limits of insurance; whichever is less. This endorsement shall not increase the applicable limits of insurance. Includes copyrighted material of Insurance Services Office, Inc., with its permission. GCG 20 09 09 24 Copyright 2024 GuideOne Insurance Page 1 of 2 D. For the purpose of this endorsement, Paragraph 2., of Section IV — Commercial General Liability Conditions is amended by the addition of the following: 1. The additional insured must give us written notice as soon as practicable of an "occurrence" or an offense which may result in a claim. To the extent possible, such notice should include: a. How, when and where the "occurrence" or offense took place; b. The names and addresses of any injured persons and witnesses; c. The nature and location of any injury or damage arising out of the "occurrence" or offense; and d. A copy of the "written contract or agreement" described in Paragraph A. above. 2. If a claim is made or "suit" is brought against the additional insured: a. Immediately record the specifics of the claim or "suit" and the date received; b. Notify us as soon as soon as practicable and see to it that we receive written notice of the claim or "suit" as soon as practicable; and c. Immediately send us copies of all legal papers received in connection with the claim or "suit", cooperate with us in the investigation or settlement of the claim or defense against the "suit", and otherwise comply with all policy conditions. E. For the purpose of this endorsement, the following definition is added to Section V — Definitions: "Written contract or agreement" means a contract or agreement that is either a printed or electronic document, signed by both parties, that requires you to add a person or organization as an additional insured, provided that the contract or agreement: 1. Becomes effective during the policy period; and 2. Was executed prior to the "bodily injury", "property damage" or "personal and advertising injury'. ALL OTHER TERMS AND CONDITIONS OF THE POLICY REMAIN UNCHANGED. Includes copyrighted material of Insurance Services Office, Inc., with its permission. GCG 20 09 09 24 Copyright 2024 GuideOne Insurance Page 2 of 2 / A� o® CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) 2/09/2026 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Sovereign Insurance Group 920 Cassatt Road Suite 100 Berwyn PA 19312 CONTACT Mike Belardo NAME: PHONE o, Ext): (800) 222-4478 FAX No): (610) 535-6810 E-MAIL MBelardo@sovinsurance.com ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC # INSURERA: Guideone Elite Insurance Company 42803 INSURED Macedonia Missionary Baptist Church of Miami Inc 3515 SW 37th Ave Miami FL 33133 INSURER B : GuideOne Insurance Company INSURER C: Technology Insurance Company 42376 INSURER D : INSURER E : INSURER F : COVERAGES CERTIFICATE NUMBER: 25-26 Liabw/AI REVISION NUMBER: THIS IS TO CERTIFY THAT 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 CERTIFICATE 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. INSR LTR TYPE OF INSURANCE ADDL INSD SUBR WVD POLICY NUMBER POLICY EFF (MM/DD/YYYY) POLICY EXP (MM/DD/YYYY) LIMITS A X COMMERCIAL GENERAL LIABILITY Y 001275976 09/24/2025 09/24/2026 EACH OCCURRENCE $ 1,000,000 CLAIMS -MADE X OCCUR DAMAGE TO RENTED PREMISES (Ea occurrence) $ 1,000,000 X Sexual Misconduct: MED EXP (Any one person) $ 10,000 $250,000/$500,000 PERSONAL &ADV INJURY $ 1,000,000 GENIIAGGREGATE P POLICY OTHER: LIMIT APPLIES JECT PRO PER: LOC GENERAL AGGREGATE $ 3, 000,000 PRODUCTS -COMP/OPAGG $ 3,000,000 $ B AUTOMOBILE X _ LIABILITY ANY AUTO OWNED AUTOS ONLY HIRED AUTOS ONLY ...,e• /• ...,e• /• SCHEDULED AUTOS NON -OWNED AUTOS ONLY 001829494 12/31/2025 12/31/2026 COMBINED SINGLE LIMIT (Ea accident) $ 1,000,000 BODILY INJURY (Per person) $ BODILYINJURY(Peraccident) $ PROPERTY DAMAGE (Per accident) $ Underinsured motorist $ INCLUDED UMBRELLA LIAB EXCESS LIAB OCCUR CLAIMS -MADE EACH OCCURRENCE WREN $ AGGREGATE $ DED RETENTION $ $ C WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes, describe under DESCRIPTION OF OPERATIONS below Y / N N /A TWC4680405 10/10/2025 10/10/2026 PER STATUTE OTH- ER E.L. EACH ACCIDENT 1,000,000 $ E.L. DISEASE - EA EMPLOYEE $ 1,000,000 E.L. DISEASE - POLICY LIMIT 10, 00000 $ , DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Certificate holder is listed as an additional insured to the General Liability policy. CERTIFICATE HOLDER CANCELLATION I The City of Miami 444 SW 2nd Ave. 4th Floor Miami FL 33130 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE a/ i, c ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD ADDITIONAL COVERAGES Ref # Description Medical payments Coverage Code MEDPM Form No. Edition Date Limit 1 1,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description PIP -Basic Coverage Code PIP Form No. Edition Date Limit 1 10,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description DEATH BENEFITS Coverage Code DTBEN Form No. Edition Date Limit 1 5,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Uninsured motorist combined single limit Coverage Code UMCSL Form No. Edition Date Limit 1 1,000,000 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Increased employer's liability Coverage Code INEL Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $6.00 Ref # Description Expense constant Coverage Code EXCNT Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $160.00 Ref # Description Add'I for policy minimum premium Coverage Code APMP Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium $114.00 Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref # Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001, AMS Services, Inc. Olivera, Rosemary From: Brito, Gabriel Sent: Wednesday, October 21, 2026 10:40 AM To: Olivera, Rosemary; Hannon, Todd Cc: Martinez, Maribel; Ewan, Nicole Subject: RE: MFE Grant Amendment #2 - MMBC Annex Attachments: Docusign_MFE_Grant_Amendment_2_-_Macedonia_.pdf RE: MFE Grant Amendment #2 - MMBC Annex Hello , Please find attached a fully executed copy of the above referenced Grant Amendment from Docusign that is to be considered an original for your records. Thank you, Gabrlelf. Brito CIP Budget Coordinator Office of Management & Budget 444 SW 2 Avenue, 5th Floor Miami, Florida 33130 Phone: 305.416.1203 Gbrito@miamigov.com 1