EFTA01221263.pdf

Marshall Sterling INSURANCE November 2, 2012 Financial Trust Co., Inc. 6100 Red Hook Qtrs. St. Thomas, VI 00802 RE: Underwritten by certain Underwriters at Lloyd's (LBS) Policy # LBS5I32 Commercial Property Expiration Date: 11/15/12 Dear Ms. Annis: I am pleased to present a renewal proposal for Commercial Property Insurance coverage for Financial Trust Co., Inc. The enclosed proposal includes brief details of the coverage being offered by certain underwriters at Lloyd's (LBS) and is, of course, subject to further terms, conditions and exclusions that will be contained in the policy documents. In accordance with the U.S. Terrorism Risk Insurance Act (TRIA) of 2002, we are required to offer you coverage for losses resulting from an act of terrorism, as defined therein. This proposal includes a quotation for terrorism coverage. The required Policyholder Disclosure Notice of Terrorism Insurance Coverage from your insurer is attached — please read it as you are required to indicate on the fonn whether you want the coverage or not. Once you have had the opportunity to review the proposal, please give me a call so that we can discuss this coverage in further detail. If the proposal is acceptable, you will need to sign the acceptance in the proposal, indicate the desired option in the Policyholder Disclosure Notice; review the Acord application, answer the highlighted questions and sign the first page. Return these three documents to me and 1 will then request coverage to be bound accordingly. Please keep in mind that the premium for this policy is due on or before the effective date of coverage. If you require more flexible payment terms, please contact us in advance of the effective date. I look fonvard to hearing from you. Steven K. Smith, CPCU Customer Service Representative Extension #242 ssmith@marshallstcrling.vi Enclosure(s) 5021 Anchor Way - Gallows Bay, Christiansted, VI 008204671 Tel: (340) 773-2170 Fax (340) 773.9550 EFTA01221263  'Askant erlzng INSURANCE Commercial Property Insurance Renewal Proposal Underwritten by certain underwriters at Lloyd's (LBSI for Financial Trust Co., Inc. Page 1 of 2 Period: November 15, 2012 to November IS, 2013 12:01 A.M. Local Standard Time Description of Operation: Financial Services office Location: 001 001 American Yacht Harbor, Ste. B-3, St. Thomas, VI 00801 Coverage Type: Special Form Including Windstorm & Earthquake with a sub-limit for Theft of $10,000 Premise # 13uildinst # Subject Limit Coinsurance *Deductible 001 001 Business Personal $500,000 80% $2,500 Property *3% of the insured value, per building, per location, in any one occurrence for the peril of Windstorm *3% of the insured value, per building, per location, in any one occurrence for the peril of Earthquake and Volcanic Eruption Terms and Conditions: Service of Suit Clause (U.S.A.) Co-Insurance Clause Applicable Law (U.S.A.) War and Civil War Exclusion Clause Several Liability Notice Radio Active Contamination and Explosive Nuclear Exclusion of Certified Acts and Other Acts Assemblies Exclusion Clause Of Terrorism; Coverage for Certain Fire Losses Electronic Date Recognition Exclusion (EDRE) U.S. Virgin Islands Changes — Cancellation and Electronic Data Endorsement "B" Non Renewal Biological or Chemical Materials Exclusion The coverage in this proposal is subject to additional terms, conditions and exclusions that will be contained in the policy documents. EFTA01221264  INSURANCE Commercial Property Insurance Renewal Proposal Underwritten by certain underwriters at Lloyd's (LBSI for Financial Trust Co., Inc. Page 2 of 2 The coverage in this proposal is of course subject to additional terms, conditions and exclusions that will be contained in the policy documents. Total Annual Premium: $11,110.00 including tax Terrorism Coverage Premium: $1)11.00 including tax THIS QUOTE IS VALID UNTIL: 11/15/12 Check appropriate box for desired coverage: I accept the certain underwriters at Lloyd's (LBS) Commercial Property Proposal including terrorism coverage. I accept the certain underwrite at Lloyd's (LBS) Commercial Property Proposal excluding terrorism coverage. Signature: Date: /1 -13-12 EFTA01221265  POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended ("TRIA"), that you now have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act, as amended: 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 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. Any coverage you purchase for "acts of terrorism" shall expire at 12:00 midnight December 31, 2014, the date on which the TRIA Program is scheduled to terminate or the expiry date of the policy whichever occurs first, and shall not cover any losses or events which arise after the earlier of these dates. YOU SHOULD KNOW THAT 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. HOWEVER, YOUR POLICY MAY CONTAIN OTHER EXCLUSIONS WHICH MIGHT AFFECT YOUR COVERAGE, SUCH AS AN EXCLUSION FOR NUCLEAR EVENTS. UNDER THIS FORMULA, THE UNITED STATES PAYS 85% OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURER(S) PROVIDING THE COVERAGE. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE 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. THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT I hereby elect to purchase coverage for acts of terrorism for a prospective premium of $1111.00 I hereby elect to have coverage for acts of terrorism excluded from my policy. I understand th will have no coverage for losses arising from acts of terrorism. Policyholder/App t's Signature Syndicate of behalf of certain Underwriters at Lloyd's Cpt Le, cti-inyk Print Name J Policy Number - 13 -I 2, Date 21/12/07 LMA9011 Form approved by Lloyd's Market Association EFTA01221266  OP ID: SSMI COMMERCIAL INSURANCE APPLICATION DATE plIMDIEWM APPLICANT INFORMATION SECTION 11/2/2012 AGENCY CARRIER NAIC CODS Marshall & Sterling Insurance Certain Underwriters at Lloyds 5021 Anchor Way Gallows Bay Marketplace UNDERWRITER: 1UNDERWRITER OFFICE: POLICIES OR PROGRAM REQUESTED POLICY NUMBER Christiansted, VI 00820-4671 LBS6132 COMMERCIAL PROPERTY Marshall & Sterling INDICATE SECTIONS ATTACHED ELECTRONIC DATA PROC TRUCKERMOTOR CARRIER ALI MAIL s RIi CIiNAM! I EQUIPMENT FLOATER UMBRELLA VALUABLE PAPERS CONTACT Marshall & Sterling BOILERS MACHINERY GARAGE AND OEALERS VEHICLE SCHEDULE RAMC_ HONE 340-773-2170 BUSINESS AUTO GLASS AND SIGN WORKERS CONVERSATION (NC.IN EON FAX 340-7734550 COMMERCIAL INSTALLAINNBUILDERS RISK YACHT GENERAL LIABILITY ADDRESS: CRIFAENISCELLANEOUS CRIME OPEN CARGO CODE: SUB CODE: DEALERS X PROPERTY IRANCPOR !AI IOW AGENCY CUSTOMER ID: FINAN-1 DRIVER INFO SCHEDULE MOWN TRUCK-I: STATUS OF TRANSACTION PACKAGE POLICY INFORMATION QUOTE Li ISSUE POUCY IX I RENEW ENTER THIS INFORMATION WHEN COMIAON DATES AND TERAIS APPLY TO SEVERAL LINES. OR FORMONOUNE POLICIES X BOUND(Give Date BAd/of AIWA CORA, — PROPOSED EPP DATE PROPOSED NIP DATE BILLING PLAN PAYMENT PLAN I AUDIT CHANGE DATE TIME AM — DIRECT BILL _ CANCEL 11115/10 04:06 i X pis 11115/12 11115/13 X AGENCY BEL PACKAGE POLICY PREMIUM: S APPLICANT INFORMATION NAME Mrs! Wined Inwood & 011w Named Msurods) WRUNG ADDRESS INCL ZIN4 lol FRG Named Insured) Financial Trust Co., Inc. American Yacht Harbor, St. 6.3 6100 Red Hook Ohs, VI 00802 FEMUR ::QC SEC N ir catt.„,); 212-7804895 (of FRO Hamad hystmeU): E-MAIL %TENSILE ADDRESSIE 5): AODRESSIESX _ INDINIDUALX CORPORATION =WV" ac NM OF MEMBERS AND WHAMS CR BUREAU NAME: STARTED _- PARINERSIIP ___ JOINT VENTURE PRI;FR I ID NUMBER: INSPECTION CONTACT: CSC' le de Jongh I ACCOUNTING RECORDS CONTACT: SaSame - ft lIC PHONE i• E-MAIL IAN. Nos pIe I ADDRESS; INC, W. MD: ' ADDRESS: PREMISES INFORMATION I I ACORD 023 attached for additional I remises ANIIUAL REVENUES OCCUPIED EMPLOYEES NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S) 001 001 Financial Services office ACORD 125 (2007/10) Page 1 of 3 1993.2007 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD EFTA01221267  AGENCY CUSTOMER ID: FINAN-1 OP ID: SSMI GENERAL INFORMATION EXPLAIN ALL 'YES" RESPONSES YIN Ia IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY? N lb DOES 111E APPLICANT HAVE ANY SUBSIDIARIES? N 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? N 3 MY EXPOSURE TO FLAMMABLE?, EXPLOSIVES. CHEMICALS? N 4 ANY CATASTROPHE EXPOSURE? N 6. ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED? N 6 ANY POLICY OR COVERAGE DECLINED. CANCELLED OR NONRENEWED OUTING THE PRIOR THREE (3) YEARS? INN TONNA% In MO) ? ANY PAST LOSSES OR CLAWS RELATING TO SEXUAL ABUSE OR MOLESTATIONALLEGATIONS. DISCRIMINATION OR NEGLIGENT HIRING? N a DURING THE LAST FNE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTEE FOR OR COWICTEO OF ANY DEGREE OF THE CRIME OF FRAUD. BRIBERY. ANSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION MATH THIS OR ANY OTHER PROPERTY? N (In RI, Na gumlion ma( to orrAvored been/ +wok ont for p:Optny ir curanco. Fr:hire N &Nom Po existence c4 an onunccmictIon is a roislorneanoe punknablo by a soninxo or up to ono yew of:mown-ton!) 9. ANY UNCORRECTED FIRE CODE VIOLATIONS? N 10 ANY ISMKRUPTOES, TM OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAS I I NE (SI YEARS? rl 11 HAS BUSINESS BEEN PLACED INA TRUST? IF *YES'. NAME OF TRUST: N 12 ANY FOREIGil OPERATIONS. FOREIGNPRODUCTS DISTRI0UTED IN USA OR US PRODUCTS SOUNOISTRIOUTED IN FOREIGN COUNTRIES? (II 'YES. moth ACORO ISIS toy LbNbly rii:054•CO and/ ACORO SIG kw Prope.ty Exposure) N REMARRS/PROCESSINO INSTRUCTIONS (AIWA ocIdItIonal sNets II mon spice Is mouliod) COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GNEN TO THE APPLICANT. (NoI appHoblo In aI slalom. =WA your ODOM or WOW la your Hain romiternsits.) NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLE FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY 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 YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON IlOW TO SUBMIT A REQUEST TO US. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAM 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 INT: SUBSTANTIAL] CIVIL PENALTIES. (Nol 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. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. IIEJSHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HISMER KNOWLEDGE. PRODUCER'S SIGNATURE PRODUCER'S NAME (NomPhil) STATE PRODUCER LICENSE 110 (RequIrod In Florida) Marshall & Sterling APPLICANTS S p I PETE NATIONAL PRODUCER NUMBER - g - /3 -- i 2 ACORD 126 (2007110) Page 2 of 3 EFTA01221268  AGENCY CUSTOMER ID: FINAN-1 OP ID: SSMI PRIOR CARRIER INFORMATION UNE CATEGORY 2010-2011 2009-2010 2008.2008 2007-2008 2006.2007 CARRIER POLICY NUMBER i POLICY TYPE I VAT 1 I OWAHIMM Mat I I “Cia.lia I "IA MC Calan I I. aditat 1 I 0CCIAMICIE I. WM _, I [ Male " RETRO DATE 0 E EFF-EXP DATE II GENERAL AGGREGATE CE PROIRICTS COMP OP a As AGGREGATE AE PERSONAL A ADV INJ E l' EACH OCCURRENCE R E - C I ' FIRE °AIM/GE A M AL I r B ' MEDICAL EXPENSE L 6 BOOBY OCCURRI NCI _ I MAME/ AGGREGATE T V pRopurl y OCCURRENCE _ DAMAGE AGGREGATE ---- .- -- COMBINED SINGLE LIMIT MODIFICATION FACTOR TOTAL PREMIUM CARRIER - — - POLICY PIUMBER - —. A i• POLICY TYPE -__,_ T I 0 EFFCIP DATE 0 A --- - -- pi COMBINED SITIOLE LIMIT I L BODILY EA PERSON I I HAIRY EA ACCIDENT LI E ' PROPERTY DAMAGE MODIFICATION FACTOR TOTAL PREMIUM CARRIER LLOYD'S First Insurance ___ _ POLICY NUMBER LBS5084 MM03.0313 P CFTC CTS & A&A CTS & A&A CTS & A&A CTS & A&A R POLICY TYPE 0 11/15/10 11115/11 p E FF.E; XP DATE E 350,000, 350,000 350,000 350,000 R BUILDING AMT 7 600,000 150,000 150,000 150,000 150,000_ y X PERS _ ....PROP AMT MODIFICATION FACTOR _ TOTAL PREMIUM 11,000.00 CARRIER _ POLICY NUMBER POLICY TYPE ______________ ____ EFF-EXP DAIS LIMIT .... MODIFICATION FACTOR TOTAL PREMIUM LOSS HISTORY ENTER ALL CLAMS OR LOSSES (NEC/VINE SS OF FAULT AND WICTIIER OR NOT INSURED) OR OCCURRENCES THAT MAY ONE RISE 70 CLASS LIE PRICKS ?ARS I 1 YEARS IN KS A NY) Ix DATE OF LINE ITPODESCRIPTION OF OCCURRENCE OR CLAM DATE AMOUNT OCCURRENCE OP CLAIM PM0 RESERVED REMARKS ROI I IDE I Ins REQUIRES A NYE YEAR LOSS HISTORY ATTACHMENTS I I STATE SUPPLEMENT'S) RSIN ACORD 125 (2007/10) Page 3 of 3 EFTA01221269  OP ID: SSMI DATE PAIVOTIANYT) ACORD,„ PROPERTY SECTION 11r2/2012 AGENCY APPLICANT nanc in trust-Company, Inc. IA H not 340-7734170 PHONE Mal AM, No: (FAX 340-773-9550 Namid Insured) Marshall & Sterling Insurance 5021 Anchor Way EFFECTIVE DATE EXPIRATION DATE DIRECT SILL PAYMENT PLAN AUDIT Gallows Bay Marketplace 11/16112 11115/13 X AGENCY BILL Christiansted, VI 00820-4871 FOR Marshall & Sterling COWART COOS: [SUB CODE: USE ONLY AGENCY STO', RID E 'RAM PREMISES A: 001 STREET ADDRESS: American Yacht Harbor,Ste. B-3 St. Thomas VI 00801 PREMISES INFORMATION BUILDING /I: 001 moo °summon:Financial Services office VALUATION CAUSES OF LOSS lunation DEDUCTIBLE BLKT FORMS AND CONDITIONS TO APPLY SUBJECT OP INSURA/CI AMOUNT CONS % GUAM) M COV See attached supplemental page for Subjects f lnst rance I foilmation ADDITIONAL INFORMATION BUSINESS INCOME JEX1RA EXPENSE 1 1 BUSINESS INCOME WIO EXTRA EXPENSE EXTRA EXPENSE TYPE OP BUSINESS ORDINARY PAYROLL POWER/HEAT EXT PERIOD I TUITION FEES 1 OFF PREM POWER J DEPEND PROP NON MVO I EXCL I _ I INCL BED DAYS $ STUDENTS 1 POWER % COIN _ MFG 90 DAYS ELEC MEDIA I MO PERIOD OTHER ED SERVANC WATER CONT LOC ISO DAYS DAYS LIMIT COIAM REC L0C (OESCR BELOW) % COINS ORD OR LAW I MAX PERIOD WO LOC DAYS LOP LOC (IR. SC suave_ NAME ANDADORE/MEM FOR OFF PREFA POWER OR DEPEND PROP _I Me OATS PERIOD REST UNIT LOSS PAY % % % ADDITIONAL COVERAGES, OPTIONS, RESTRXTIONS, EIWORSEMEHTS AND FtAIIIIG RIFORMATI011 CONSTRUCTION TYPE. INSTANCE TO FIRE DISTRICT/CODE NUMBER PROT CL I N STORIES IS BASIPT3 YR BUILT TOW. AREA HYDRANT FIRE S TA I STEEL FRAME FT] 2/Al: 2 0 1990 2,800 0100 COD TAX CODE j ROOF 'TYPE OTHER OCCUPANCIES BUILDING IMPROVEMENTS GRADE VelRliO YR PLUMBEIG. YR M worm:, YR HEATING. YR WIND CLASS HEATING BOILER ON PREMISES? YES I NO OTIOR I RESISTIVE I I rt s(Fmi sis.i nt( I OTHER IF YES. IS INSURANCE PLACED ELSEVARRE? I I YES I I NO RIGHT EXPOSURE A DISTAIICE LEFT EXPOSURE S. DISTANCE REAR EXPOSURES DISTANCE Restaurant same building Office satno building Open IWROLAR ALARM TYPE CERTIFICATE a EXPIRATION DATE EXTENT 1 GRADE CENTRAL STATION YETI KEYS BURGLAR ALARM INSTALLED AND SERVICED BY OUAROSINATCHMEN CLOCK HOURLY PREMISES FIRE PROTECTION (Sprinklers, Standpipes. COVCIsernIcal Syrian's) M SPRNK FIRE ALARM MANUFACTURER CENTRAL STATION 10lb lire extinwsmoke detecto LOCAL 00/10 ADDITIONAL INTERESTS RANK: NAME AND ADDRESS: REFERENCE A: CERTIFICATE REOUIRED INTEREST IN ITEM NUMBER INTEREST LOCATION: °MOW: LOSS SCHEDULED ITEM HUMBER: PAYEE MORI. GAGEE I OTHER: ITEM DESCRIPTION: VALUE REPORTING INFORMATION REPORTING FORM: PROVIDE AVERAGE VALUES TON PAST 12 MON GIS PREMISES, ANY OTHER LOCA. ANY OTHER LCCA. PREMISES NOT OWNED TION DECLAREO TI ACQUIRED CQUIRED OR ALIM BUR DING AT INCEPTION ER INCEP TION AFTON IT _ SUBJECT OF INSURANCE ACORD 140 (2002/09) ATTACH TO APPLICANT INFORMATION SECTION ACORD CORPORATION 1985 EFTA01221270  FINAN-1 OP ID: SSMI ADDITIONAL PREMISESI: STREETADDRESS: PREMISES INFORMATION OUILDIIIO 01.00DESCRIPTION: SUBJECTOPINSURANCE AMOUNT COINS% VALUATIONCAUSESOFLOSS GUARD% OO iIAT DEOUCTIBLEBCOV FORMSANDCONDITIONS TOAPPLY ADDITIONALWFORMATION BUSINESS INCOME/EXTRAEXPENSE BUSINESS INCOMEIWOEXTRAEXPENSE EXTRAEXPENSE TIfFEOf BUSINESSORDINARYPAYROLL POWER/NEAT I EXTPERIOD Tmnou FEES OFFPREMPOWER PENDPROP NONMFG EXCL I JOWL DEO GAYS STUDENTS POWER 'ACOIN MFG 90DAYS ELECMEDIA I MOPERIOD OTHER ED WATER CONY LOC MINING 00 DAYS DAYS LEm SERVJINC COMMBELOW) RECLOC (DESCR ScCOINS ORDORLAW I MAXPERIOD IMOLOC DAYS EEXPENSE LORLOCIDESCNEICFA9_ LANEANDADORE-86(ES) FOROFFPREMPOWERORDEPENDPROP XTRA DAYSPERIODREST LIMITLOSSPAY ADDITIONALCOVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTSANDRATINGINFORMATION TYPE CONSTRUCTION DISTANCE HYDRANT TOSTAI FIRS FIREDISTRICT/CODE MINDER PROTCL IISTORIESBASI.VISYRBURT TOTALAREA FTI I BLDGI DE IMPROVEMENTS BUILDING TAXCODE ROOFTYPE OTHEROCCUPANCIES WRING,TIT PLUMBING. YR ROOFING, YFt. HEATING. YR WINOCLASS r HEATINGDIALERONPREMISES? YES OTHER I RESISTIVE I I RESISTIVE I I OnER U YES. ISFISURANCEPLACED ELSEWIIERET I YESI I NO— RIM EXPOSUREI DISTANCE LEFT EXPOSURE a INSTANCE REAREXPOSUREISDISTANCE BURGLARALARMTYPE CERTIFICATE I EXPIRATIONDATE EXTENT GRADE CENTRAL STATION VAIN KEYS BURGLARALARMINSTALLEDANDSERVICED BY I OUAROSIWAICH11611CLOCKNEARLY PREMISES FIREPROTECTION (SKINAWA, StandpIpw,CONChomIcal Systems) FIREALARMANUFACTURER CENTRALSTATION LOCALGONG ADDITIONAL INTERESTS PAM: HAINANDADDRESS: I REFERENCE a: I I CERTIFICATE REQUIRED INTEREST IIITEMMAMMA ETTEREST LOCATION: I BUILDING: LOSS PAYEE SCHEDULED ITEMNUMBER: CACEE nesa DESCRIPTION: OTHER: REMARKS Premise 001 theft Sublimit: $10,000 ANYPERSONOFWHO STATEMENT KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCEOR 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 INY: SUBSTANTIAL) CIVIL PENALTIES. (Not applIcale in CO, HI, NE, OH, OK, OR or VI': in DC. IA. ME, TN and VA, insurance beret-Its may also to denied) ACORD 140 (2002109) EFTA01221271  11/2/2012 Financial Trust Company, Inc. FINAN-1 OP ID: SSW PREMISE INFORMATION PREMISES /I: 001 OUILOING N; 001 ISOTELA: • , SUBJECT OF INSURANCE AMOUNT COWS% VALUATION CAUSE OF LOSS NFL DEDUCTIBLE FORMS I DATE ULtl - I. BUS PERS PROP_ _ _ 500,000 80 RC SPEC 2,500 2. 3. ADDITIONAL PREMISESINFORMATION SOI CAUSE COINS% RATE RPT AMOUNT TYPE DAS SOI CAUSE COINS SI RATE RPT AMOUNT TYPE DAS WIND 80 2.20000 _ 3 EQ 80 2.20000 3 - -- -- VALUE REPORTING INFORMATION REPORTING EOM PROVIDE AVERAGE VALUES FOR PAST it MONTHS ANY OTHER LOCA. ANY OTHER °CA- PREMISES NOT °MEL PREMISES/ NON DECLARED RON ACQUIRED OR ACQUIRED BUILDING AT INCEPTION AFTER INCEPTION IRIT SUBJECT OF INSURANCE PREMISE INFORMATION PREMISES & BUILDING it • SUBJECT OF INSURANCE AMOUNT CO % VALUATION CAUSE OF LOSS INFL DEDUCTIBLE FORMS S DATE 2. 3. 4. S. S. ADDRIONAL PREMISES INFORMATON SOI CAUSE COINS % RATE RPT AMOUNT TYPE DAS SO CAUSE COINS% RATE RPT AMOUNT TYPE SAS VALUE REPORTING INFORMATION REPORIRIG FORM: PROVIDE AVERAGE VAI S FOR PAST 2AIONTHS ANY OTIIER LOCA- ANY OTHER OCA. PREMISES NOT DIINEC PREMISE& TION DECLARED DON ACQUIRED r OR ACQUIRED GUILIANO AT INCEPTION AFTER INCEPTION I LIMIT SUBJECT OF INSURANCE ATTACH TO ACORD PROPERTY SECTION APPLIED 140PI (2006/10) EFTA01221272