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Click here or scroll down to respond to this candidateBass Underwriters, Inc.Candidate's Name
THE TERMS AND CONDITIONS OF THIS QUOTATION MAY NOT COMPLY WITH THE SPECIFICATIONS SUBMITTED FOR CONSIDERATION OR THE EXPIRING POLICY. PLEASE READ THIS QUOTE CAREFULLY AND COMPARE IT AGAINST YOUR SPECIFICATIONS. IN ACCORDANCE WITH THE INSTRUCTIONS OF THE BELOW-MENTIONED INSURER, WHICH HAS ACTED IN RELIANCE UPON THE STATEMENTS MADE IN THE RETAIL BROKER&#Street Address ;S SUBMISSION FOR THE INSURED, THE INSURER HAS OFFERED THE FOLLOWING QUOTATION.DATE ISSUED: July 1, Street Address
PRODUCER: Professional Insurance Center IncStreet Address W Kennedy BlvdTampa, FL 33606INSURED MAILING Mary Hughes Transport IncADDRESS: 4375 SW County Rd 152Jasper, FL 32052INSURER: Ategrity Specialty Insurance Company A- (Excellent) AM Best Rating Non-AdmittedCOVERAGE: QBIE-General Liability-AtegrityPOLICY PERIOD: 8/15/2024 TO 8/15/2025RENEWAL OF: 01-C-PK-P20084086-012:01 A.M. STANDARD TIME AT THE LOCATION ADDRESS OF THE NAMED INSURED. THIS INSURANCE QUOTATION WILL BE TERMINATED AND SUPERSEDED UPON DELIVERY OF THE FORMAL POLICY(IES) ISSUED TO REPLACE IT.LIMITS: See attached.Without Terrorism: TerrorismPREMIUM: $750.00 +$38.00FEES: Policy Fee $100.00Insp Fee $175.00Policy Fee $100.00Insp Fee $175.00Surplus Lines Tax: $50.64 $52.51Service Office Fee: $0.62 $0.64Misc State Tax:FHCF (Florida)CPIE: (Florida)TOTAL: $1,076.26 $1,116.15*Upon request to bind the agent assumes responsibility for the earned premium, fees and taxes. DEDUCTIBLE: See attached.Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 Policy Number:MARY HUGHESMARY HUGHES TRANSPORT INC01-C-PK-P20084086-0-Renewal08/15/2024 08/16/2024Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024Premium Payment by FaxAgency name: Date: Insured Name: Policy# Checking A/C# Amount: This check authorizes Professional Insurance Center to charge our bank account per the attached check.(Signature)Fax: PHONE NUMBER AVAILABLETel: PHONE NUMBER AVAILABLE Ext: 237Toll Free: PHONE NUMBER AVAILABLEEMAIL AVAILABLE2003 W. Kennedy Blvd.Tampa, FL 33606Place your check here (face-up)Payable to Professional Insurance Center, Inc.Please do not send your original check.Keep your original check for your records.Thank youProfessional Insurance Center$ 1,076.26MARY HUGHES TRANSPORT 2024 RENEWAL policyEMAIL AVAILABLEDocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024c g F288k85614856u45/ ]5/P5F@0Wkn2o _UI>WAEYGDEE43DEK>1YGYpAp42= / ;;;95 ; x 1=LMNO46P4;T 482F78/012345 k1128;k1128;k1128;851240/p4Iq4WAEYGDEEm4;EHD> %>7k84950W595F< 4< 4@ k74Fk4s8kn5324F@4U94MSVOS ABCDE4F>` j'4U8k14V[ ' d 6782340/ IAGJ?4Uk84F@34U53295F _GDQ4s>5094:5094s8ks28F<50945 . YHJYIGm4/ c_ c _=48Q4ROS4 GEHI d f_2/90/ _DpYApm4SOt 6780/I>4 3410595/24s0 28094950W595F<HI>J45GK4 kn280 d c_341085/IGrDpD 4;=lROlSVSL4Fk4V[kn280:JYIG ;12/ _ a _240;4;245 x kn280:40338266 _BDGK?24s08F F4kU4F@24 F4;6780 b ef _24s08F kn280 b ^4pDQYK=08: y 4;lROlSVSO40F4RSmVR40146F0/kn280: 24s08F 24s821571w40 2645648DvDKJDQ4 _240646F0F2345/ cc _sIZYK?Z4J>24s08F g d \GEHI> 24s08F 4s> DpYAp & J= JYIG b 3467WT2 cc 4F@ 0:& W=RVVO4643YZZ=PYGJD>564sk95 ef _2/x EE47GQD> 30834F51240F4 g]; 4:x < F4Fk40994F28164kU4F@ 40/ QDG4UZI> -X><3410595 Q46J o _YJD \E #DDJ4 ( YQ= g )( ` _k78410595/ :(4MLN[ &) c _40338266 _ N _j _ h _ j 564sk95;4033826646@ ( c d <w4P240: IJ40HHZYK=IJ40HHZYK=IJ40HHZYK=IJ40HHZYK _kP zNOV41s i _4 8224 zNOV c ZD ZD ZD ZD s=BDm4R4Iq4SDocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 67898:8B;FA=( @A?<GO 98E8B69H:;8 6@>AB9:B; :9MFF=6AC8678 8E8B6 1 1 D@' 67 JA?1 11 678:E: )<;AEEAB 8 1 => ) ?>FA 6 ABK9LH G: ) AB; "J BGH:@6@.!AB9H AEF= 0&+ < 4"AI8?868 678:>!C8:. 5! JA?NAI8 EK9LH:BMEN8?JA 2 3 E9:8 >: B;:PDocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357>[ c -D) S+3@3 0 687 AIKHB HUENMWa ABC,<,D,@2D,) )687: +? Z)*2 DEFGHI d ) S++),[OY 2 22(Y H Y 2LEJMC,T) 85/)Y,n3+O).,JULBIHpHJM SS@>),,@1 2LEJMC,/P+3 2)+:0121341'56 3@BAJIKLBM,5 _ X,X e f )O@Z,S;U,+ 2+ 3Y+D+-ABC, X,>P>?@0:m )+*U DEFGHI,;-5, <*+ 3 0:JN, +=+LM g ef c h d f i,,P+=700//5b,>Z<*+Y> ;,QR0:D+) KK]3+AIKHB S BAJIKLBM,>-8/>WNAa]?R5 >9: )=56,*S,b, q H >OY,@O,) Z) JN,?\)85/?D ? 2 SS@,:QR0 Z 3@5 R5 S; >*5 b =&,-05 X 0 ; (l5b/l5b/l0b/l0b/l0/+D> c ee d jc c d f e f +;TAII,0/[S+;oN]T\OO+S+ %WJMHB // %- :EUHU b/3) 2*2Z 2**/b/b/b/b .SABUHJ,,JUHBVBWMHBI >Y>;TAII P+, ;,W / / / !2Z_ ]-ABU, --,) Z,Z k <)*?)JUHBVBWMHBI @O] "YY, X +;MBHHM, --=LBWUA Y QR0:,3+-3 < S,@867Q7 @+R5 )56 - )+@,l:Z)? O (? D>@ 3);> Y>Y>-2Zb,S S +, 3AFH.,0,Lr,5Docusign Envelope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`_;]VS*VZ) )VZVU)=aO*45) )@ X5OP^ )=_:XZ&?)*;>_)$O+2 "V) $) @ 8 > 8? 8 :8:A ):)!b):Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357YaAlEDUpAvCw EUVCWDXEY@ !V^NPORDYlDJibgj`n^UYXJIUoIGGGG UYXJIUoIGGGP UYXJIUoIGGGN UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJI\UYXJIEABIGGGM UYXJIEABIGGGN UYXJIEABIGGHG J\J\J\J\J\J\J\J\J\%"fhe__DGGDGH DGMDMG DMHDGO DMHDH DMHDPR DMHDNN DMHDNO DMHD DMHDOP DabcdefDB_ Do O #IGGHR IGGM IGGMO IGGMQ IGGPH IGGPO IGGPt IGGPQ IGGNG IGGNR IGGRG IGG IGG IGGOH IGGOO IGGOQ IGHGQ IGHHt IGHM DPMGRM #M Q >$ZCWDUEWDVUX[FDoZAVDGtuHRuMGMNDBADGtuHRuMGMRDUBDHMFGHDUVDYBUEWUZWDBXVCDUBD]&^DZmDHRM gfhi_S T GHDMP GHDMP GQDHt HMDMH GtDHt GODHQ GtDHt GtDHt GtDHt GtDHt GtDHt GtDHt GtDHt GtDHt GtDHt GtDHt GtDHt HMDMP GtDHt GQDHt HGDHt HMDHt GQDMM HMDMG HGDHt GNDHP GPDHM GRDHN GNDHP HGDGH GNDHO HMDGO HMDGN GHDHR jDXgkD XE\DUWWZCYY Jixe_Ye_VrgrzbzDC^KbgrjrxeDA_Jigj_VrgrzbzDUgmDUmx^UzegmzegjDAyDJigmrjrigfD}JigjrgbrgcDA_K_UzegmzegjDAyDEigh^[Uf efjifDC{V^a`Jizzbgrk^LgiqgDXg b_UzegmzegjDBiDAjde_Ye{Bij^Wembkjr seDCgmi_C{C{Js^Kisrk`osi_Jizze_osi_C{_C{C{[C{C{C{'(es^e^rzrj^ezrbzDUbmrj ksbfrigDCzhsi`ksbfrigDAyDYb kigj_ksbfrigDAyDJe_ksbfrigDWefrcg^ksbfrigDobgcrDA_ksbfrigDIDUkkeffDA_ksbfrigDAyDpimrs`ksbfrigDIDJixe_m__)rzDZehi_xrkeDAyDYbrjDJs^mDJigj^b^jemD[r b^rm^rm^)sD[^)^disme_bsrkDo_DK^jrigDAyDJixe_sDUgmui_ #r bi_kji_DKisrk`DJd^g^*kr^r^ ce DJ^ rsrj`fDYhekr DC{zrg^gcefDIDJ^sD\,D[`^jrgcDXgyi_ seDWrfe^DWrfksifb_ksbfrig _%DA_gg^gemDJ^kjb_-Daisme_r^DAgcirgcDW^DKd`ezhs^ege_ DID[ rsrj DW^jrigDC{jryremDUkjfDAyDBe_ rfD[fezegj rgcDC{-zegjI_^"rzrjemDpimrs`frk^jemDK_/Dp^^ceDJDIDVemrk^bfe sDJigmrjrigf !DXg b_gkeDK_z^^0 1+sD[DC{gkess^_ DEijrke ceDBiDWefrcg^gkess^z^`DWrfksifb_ <feDC{r^DXgfb_kje_^`eDIDEijrkeDAyDBe_r^sDU bfeD[DW^ceDC{ksbfrig ksbfrig rsrj`ksbfrig zegjDJ^kjemDUbjif 23 4) rsrj`jrig es^iyeffrig^`%ezrbzDCgmi_DBiDK^z^r^ jrigDK_U p^HGGRDYDWrss^lrgje_z^ksbfrig jrigDUgmDEig_ &^jemDK_gig_=DC{ksbfrigDIDKe_gkeDJigmrjrig )ffD@DJixe_cefDC{ $CEJ]ceDC{0 5 DXg b_ksbfrig eDAyDJigyrmegjr^r^gkess^ffegce_egeq^ezrbz sDK^!D\gme_^_ rsrj`226 sDYe_i_ kjrkef ?^jemDK_ksbfrig ^DUEWDVUX[ksbfrig ` rfz _`@ceDoi_"megDosi_zegjf jrigDJigmrjrig q_-ABCDEAFDGHIJIKLI?$_DJixe__ xrkef s~ 730 8 9:mDYj_fezegj i_&f rje_fig^egeq^ezrfef DK_!rfzDXgfb_S T )z !f eej ^rm^sDUgmDUmxe_ceDoi_4;XE\s sDA_%DPNOtO )A@) )^& DKe_i ekjDA_DUWWZCYY gkeDJixe_)ZDVUX[z ))fig^ #4)jrfrgcDXg b_MNGOHHGGPGQR 4: XE\DAhe_sDXgyi_ ^DUWWZCYYD ce ^z^jrig ` jrigDUgmDW^j^I Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357YaAlEDUpAvCw EUVCWDXEY@ !V^NPORDYlDJibgj`n^J\J\X[X[%DGGDHO DGGDMH "fhe__DMHDtx DMNDMx DabcdefDB_ Do DPMGRM ZCWDUEWDVUX[FDoZAVDGtuHRuMGMNDBADGtuHRuMGMRDUBDHMFGHDUVDYBUEWUZWDBXVCDUBD]&^DZmDHRM gfhi_S T HMDGN GNDHP HHDQt GQDGt jDXgkD XE\DUWWZCYY CyksbfrigDCyje_UzegmzegjDA{JizzigDKisrk`Ebkse^' #_DCge_* c DXgfb_ "D[ri_ &DJigmrjrigf r^-DXgfbs^/ 0 1+rsrj emDJigj_DCyksbfrig 23 4)jrigDorgrfdrgcDY`U p^HGGRDYDWrss^lrgje_=)ffD CEJ]0 5. >kjDWe{!D\gme_226 DUEWDVUX[rgrjrig _@"megDosi_q_-ABCDEAFDGHIJIKLI?$_ 730 8 9:mDYj_&rje_fjezf !S T ) !f eej rm^4;XE\%DPNOtO )A@) )& DUWWZCYY )ZDVUX[)) #4)MNGOHHGGPGQR 4: XE\ DUWWZCYYD Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357JKBF KEREYEJ> PHONE NUMBER AVAILABLE:KDR@.0DR@*q BC@ A@DL @= C@ DL F@5:1uv8:REDY@B@KDR@% EFKD>KDGNJ>J>*@Ua bX [DI `DI `T >>4:EFFDIAEM AADAEFGMW EG[Y@8<KYIFED> K@ ),T FIKC KA@JIBCDAEPJBED> EB@?2315p52e8<L KB KCJAO@FCDIY? FCDIY? L@DL &>AJO@ AJO@ @=?e5154:A>K@? A >BJAT IAF@B ? wxv8yvzw DL @EB@BC@ BJB B@G@JKB FE>AJY NDNIYJBED> @G[YDFF@c 43e T AJY AADAEFG KDR@AADAEFGW ? @NADRE?JF LDA LDA G@DL _ > @YJ]@DA BJB@F H>FIKC JYFD B @A F ] ?LDA +F [AADAEFG YDFF i [J> A@D] @GEFFED>_ DG@T B AADAEFG IKY@E> +:S@EYYED>fPHONE NUMBER AVAILABLE=LE JF M KD@BC@ E>H>FM = KB JKB 8 AF@ ( YDFF@D] DR@J>1684pPHONE NUMBER AVAILABLEr8s2f4kt BCJB B@@ )G@28k51l81l28<O F }]D] DA JA DL YJ>? M T AADAEFG @AKED>TM BC@ JAEFE>NDABED> }BCJB @DL TDIA [R@'EFH jM J>BC@ D>DIBFE?@z~v 8 w 8 8~ 8xuv v8 x YY ^ F ? AJO@ ]T BCJB @'EFH R@6;BD JF,AM GJT -I>C@F @KDR@BC@ @ _ EF J>TDIA O CJR@ KJY@KDR@ >E>3<Y@A@ KIAEBTM BF_ ->QM BC@ ?NADRE? >DIB *YDFF@@ KB T FIAJ>DL FIA@EB@FF J>[AJO DAHM KDR@FIAJ>' @.:BC@ JKB @ >YDFF LL@? NDYEKT A@AJO@ KBM O DL NADRE?NJABEJYYT AFd BJB@@JA F 4g23<28<>KBER@ _ BCJB, DABC ADIF J K@ AJO@ JKBF =@BCJB C@ A ? BCJB > >K@ T@JF YEJ[]1m8n4;GJT ? BC@ EB ) KB I>KDGGEBB@@GJT JA F BC@ 1 EF &@JG@?BD DL SJ>NA@? EF EYEBT @ADOAJG ? ?DA M GJT JADYE>LDAGIYJM K@`@A@@DL BJB@@h2 CIGJ> [E> NADRE?B@K@ ` BBDA>A IJAT BD `KD>GEIG @ ABELE@EG[>K@LDA AADAEFGM BC@ B@87;BC@ @?A@ E>[? BJE> @ ?F IAF@LYI@? YDFF BC@ KB JM ? '@NDYEKT IK@@KDR@E> F @M 618=@xv t M [M YEL@KCJAO@? [KD>? BC@ T c T JF A@JIBCDAEPJBED> BC@ >DBC@T [FBJBIBDAEYT ? J>DA ?0@J> M K@ F JF T BC@ _ JG@A@[NADN@BJE> JYELDA>.l4462814862f2=A@Q OD>? DBC@BCEF ]T >KJF@ BC@ E '- A UBC@ FIYBE>[@BC@ EYY ? BC@ EB AJY EYYED>F >LE>M LDA `ERE?T JYFD NDYEKT A]J NDYEKT ? KA@ABTM 'CD?KYIFED> KB DL ' - BC@ .@@DL V KBWXM c BJB@EF@ O BCEF EJM ? ? >IJY _ BJAT @K@BC@ EB@B@DA LADG L NIAFIJ>E> FBJ[EF (@ D>KD>ABJE> LDA AGE>BC@ @ KB DA DA ? KDR@E> @B@F FYJ>?[F .DL BJB@LAJFBAIKBIA@@EYYED> 0DR@YEFC@TDI AGE>JLL@E>]>BE>KBED> YDFF@VK@>AJY JOOA@DL BC@ EB@JB@CEKC @?JEA AJO@ I@KBEKIBM ERE?B ABELE@KB CJR@ 0DR@? ? M JB@F _ A>KJN BD A@KJAAE@? F /1843832o2= BJB@0DR@?BC@ GEOCB IJYF OJB@ G@A@ EAOE EF BC@ ? Q ? JFIAT\T ?FIYBE>BCJB A>,J U NADRE?0@IKBE[KD>JKBF >BC@ EF AF F\^ JF AEOCB A>G@B @X EJM E>K@BD DAOEJM JOA@JLL@DL FKC@G@DA ?YEGEBF FIA@AADAEFG L@NJAB BD O >G[ JFCE>DL IKB Y@ CJR@ E> B ?BC@ @R@LADG -BD >KB [I>B@? NJE? @@@B ?@ KD>? "F AJY FF@DL 18=DL ' 0- A [TDIA +NIAKCJF@ IY@AADA I>?.J> YDFF@BD @ KBZ A@i J]@BC@ J> >VK@YD] ODR@FIYBJBED> ?'EFH YF [A OBD>? 4g23 FIYB@EB@A@M @JKB T JEEM BC@ BD EFGW DA KDR@A @EG[ C@ .ABELE@BC@ ? F LLDAB J>J >A> >B@DL BC@ LDA M BJB@ YYE>? LDAGIYJ KB_ EB@jM ? @IAF@ FIAJ>G AGE>E>AJO@E>E> ]B@B@? ?JYY ? BD h28p438 J>NA@DEFM FIAJ>FIAJ>C@]D@AG AADAEFG^ FB JKBF ?> BJB@F EBC JGJO@ KD@T E>B_ > JB@ @M F /0DR@GEF@K@ VK@EOCBT FIKC B@ D]FIA@BC@ CDIY? >EAOE>@BC@ DL K@ AK@ K@ DB AADAEFG FBJ[JB &F $ ABELE@JM ADOAJG F JGDI>E>A>AF BD BC@ EJM JF BC@ ]N@DL %KYI?YEFC@G@EBCE> ![JE>TDI ? AK@J> J @ J @B B ? >? M B Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357(789:H;PQR R [Y P (( MA Pg h '04 '0 0 ] ] < RW VR\ +T)9=DNA9<+ ) ) (, ;, 0 2 )9>% RQR # $d4 2 $"9 .! d ( #A@ABC;0 0, (eS 9 5 ' R ' % EFB9C;)1 % _>. % 9? ) S ib ' ;+(LFG ' 9; W$) TR * ")' '')#O @, 2 "9 )$ % " 88A S QQ U V ## "0 " &% "9D # 1 " )"4 $9 +' #,2 9 2" . %,1 " 9 % *"" ! A? W #"2 #<$R TRW ", $0,)"#9 ) " % '#EFB9>P# de c P 5 ' "1 " 1 " $a "'0 # RP e ?2, FGA9?2 4 #, ' #" 1 ;,- e +, )9? " W +EA9H;0, ' $WRXR ' b ) f ' ICD % 0 #$6 0, + RWW W Y (2 ^ #J9:'#_6$1$ ;.1 " (! ( $ < " 9KFLL9EDMA9> ) 2 ! %+"1 " 1$ c 4 ZW R .2 . . " 5 ; "9 A@3 0#/, " $#) @" _ FBI ! Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024Mary HughesTERMS / CONDITIONS:(a) MINIMUM EARNED PREMIUM AT INCEPTION - See attached. ALL FEES ARE FULLY EARNED AND NON-REFUNDABLE.PREMIUM FOR ADDITIONAL INSUREDS ARE FULLY EARNED AND NON-REFUNDABLE.(b) SUBJECT TO:Favorable Inspection and compliance with any/all recommendations. Collection of all required funds prior to requesting the policy be bound. Please see attached for Terms and Conditions.(c) ENDORSEMENTS:Please see attached for Endorsements and Exclusions.(d) All other terms and conditions apply per form.(e) Quote is valid for 30 days.(f) Coverage can not be backdated or assumed to be bound without written confirmation from an authorized representative of Bass Underwriters.COMMISSION: 10%THIS QUOTE IS ISSUED BASED UPON THE INSURER'S AGREEMENT TO QUOTE AND IS ISSUED BY THE UNDERSIGNED WITHOUT ANY LIABILITY WHATSOEVER AS AN INSURER. THIS QUOTE MAY BE WITHDRAWN BY THE INSURER AT ANY TIME PRIOR TO BINDING. INSURED: Mary Hughes Transport IncDATE ISSUED: July 1, 2024Account Executive: Eric HuntleyTeam: OrlandoReference #: 4046607ADocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 SURPLUS LINES DISCLOSUREAt my direction, Professional Insurance Center Inc 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 that policy forms, conditions, premiums and deductible 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. Mary Hughes Transport IncNamed InsuredBY: Signature of Named Insured DatePrint Name and Title of person signingAtegrity Specialty Insurance CompanyName of Excess and Surplus Lines CarrierGeneral Liability - CommercialType of Insurance8/15/2024Effective Date of Coverage01/01/2022 Florida Surplus Lines Service OfficeDocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024Mary HughesSOC SEC #: Social Security Number LLC: Limited Liability Corporation SIC: Standard Industrial ClassificationFEIN: Federal Employer Identification NumberDEFINITIONS: GL CODE: General Liability Code NAICS: North American Industry Classification System NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) NAICS BUSINESS PHONE #:AND MANAGERS: TRUSTSUBCHAPTER "S" CORPORATIONNO. OF MEMBERSCORPORATION JOINT VENTURE NOT FOR PROFIT ORGINDIVIDUAL LLC PARTNERSHIPWEBSITE ADDRESSGL CODE SIC FEIN OR SOC SEC #NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) NAICS BUSINESS PHONE #:AND MANAGERS: TRUSTSUBCHAPTER "S" CORPORATIONNO. OF MEMBERSCORPORATION JOINT VENTURE NOT FOR PROFIT ORGINDIVIDUAL LLC PARTNERSHIPWEBSITE ADDRESSGL CODE SIC FEIN OR SOC SEC #NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4) NAICS BUSINESS PHONE #:AND MANAGERS: TRUSTSUBCHAPTER "S" CORPORATIONNO. OF MEMBERSCORPORATION JOINT VENTURE NOT FOR PROFIT ORGINDIVIDUAL LLC PARTNERSHIPWEBSITE ADDRESSGL CODE SIC FEIN OR SOC SEC #ACORD 125 FL (2016/03)EXPIRATION DATEPROPOSEDEFFECTIVE DATE $ $METHOD OF PAYMENT PREMIUMMINIMUM$BILLING PLAN PAYMENT PLAN AUDIT DEPOSIT POLICY PREMIUM DIRECT AGENCYPROPOSEDPOLICY INFORMATIONPage 1 of 4 2011-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD APPLICANT INFORMATIONUNDERWRITER UNDERWRITER OFFICEFLORIDA COMMERCIAL INSURANCE APPLICATION DATE (MM/DD/YYYY) APPLICANT INFORMATION SECTIONFAX(A/C, No):AGENCYNAME:CONTACT(A/C, No, Ext):PHONECODE: SUBCODE:AGENCY CUSTOMER ID:ADDRESS:E-MAIL STATUS OFTRANSACTIONQUOTE ISSUE POLICY RENEWBOUND (Give Date and/or Attach Copy):CANCELCHANGE DATE TIME AMPMCARRIER NAIC CODEPOLICY NUMBERCOMPANY POLICY OR PROGRAM NAME PROGRAM CODECOMMERCIAL GENERAL LIABILITY$$$$$$$$$$$$$PREMIUM PREMIUM PREMIUMBUSINESS OWNERSBUSINESS AUTO UMBRELLABOILER & MACHINERYGARAGE AND DEALERSCRIMECOMMERCIAL PROPERTYINDICATE LINES OF BUSINESSYACHTCYBER AND PRIVACYFIDUCIARY LIABILITY $COMMERCIAL INLAND MARINE $ LIQUOR LIABILITY $TRUCKERSMOTOR CARRIER $ $LINES OF BUSINESSVEHICLE SCHEDULEVACANT BUILDING SUPPLEMENTSTATE SUPPLEMENT (If applicable)STATEMENT / SCHEDULE OF VALUESRESTAURANT / TAVERN SUPPLEMENTPROFESSIONAL LIABILITY SUPPLEMENTPREMIUM PAYMENT SUPPLEMENTLOSS SUMMARYINTERNATIONAL PROPERTY EXPOSURE SUPPLEMENTINTERNATIONAL LIABILITY EXPOSURE SUPPLEMENTADDITIONAL INTEREST SCHEDULEATTACHMENTSCONTRACTORS SUPPLEMENTCONDO ASSN BYLAWS (for D&O Coverage only)APARTMENT BUILDING SUPPLEMENTADDITIONAL PREMISES INFORMATION SCHEDULECOVERAGES SCHEDULEDRIVER INFORMATION SCHEDULEHOTEL / MOTEL SUPPLEMENTACCOUNTS RECEIVABLE / VALUABLE PAPERSDEALERS SECTIONELECTRONIC DATA PROCESSING SECTIONGLASS AND SIGN SECTIONINSTALLATION / BUILDERS RISK SECTIONOPEN CARGO SECTION08/01/2024Professional Insurance Center, Inc.2003 West Kennedy BlvdTampa FL 33606Professional Insurance Center IncAGT550MARYHU012ATEGRITY SPECIALTY INSURANCE COMPANY 16427Com. General Liability CGL01-C-PK-P20084086-0-Renewal7508/15/2024 8/15/2025750MARY HUGHES TRANSPORT INC4375 SW COUNTY RD 152JASPER FL 3205283-2899250PHONE NUMBER AVAILABLEDocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 SQ FT: Square Feet# PART TIME EMPL: Number Part Time Employees# FULL TIME EMPL: Number Full Time EmployeesBLD #: Building NumberDEFINITIONS: LOC #: Location NumberREASON FOR INTEREST: E-MAIL ADDRESS:OWNERLEASEBACKWARRANTYBREACH OFTRUSTEEREGISTRANTLIEN AMOUNT: PHONE (A/C, No, Ext): FAX (A/C, No):INTEREST END DATE:CLASS: ITEM:CO-OWNER AIRPORT: AIRCRAFT:OWNEREVIDENCE: POLICY SEND BILLAS LESSORINSUREDITEM DESCRIPTIONINTEREST NAME AND ADDRESS RANK:REFERENCE / LOAN #:CERTIFICATE INTEREST IN ITEM NUMBERADDITIONALLOSS PAYEEMORTGAGEELIENHOLDEREMPLOYEELOCATION: BUILDING:VEHICLE: BOAT:ITEM$SQ FTANY AREA LEASED TO OTHERS? Y / NTOTAL BUILDING AREA:OPEN TO PUBLIC AREA: SQ FTCITY LIMITS INTEREST ANNUAL REVENUES:OCCUPIED AREA: SQ FTBLD #LOC #DESCRIPTION OF OPERATIONS:ZIP:STATE:COUNTY:CITY:STREET# PART TIME EMPL# FULL TIME EMPLINSIDEOUTSIDEOWNERTENANT$SQ FTANY AREA LEASED TO OTHERS? Y / NTOTAL BUILDING AREA:OPEN TO PUBLIC AREA: SQ FTCITY LIMITS INTEREST ANNUAL REVENUES:OCCUPIED AREA: SQ FTBLD #LOC #DESCRIPTION OF OPERATIONS:ZIP:STATE:COUNTY:CITY:STREET# PART TIME EMPL# FULL TIME EMPLINSIDEOUTSIDEOWNERTENANT$SQ FTANY AREA LEASED TO OTHERS? Y / NTOTAL BUILDING AREA:OPEN TO PUBLIC AREA: SQ FTCITY LIMITS INTEREST ANNUAL REVENUES:OCCUPIED AREA: SQ FTBLD #LOC #DESCRIPTION OF OPERATIONS:ZIP:STATE:COUNTY:CITY:STREET# PART TIME EMPL# FULL TIME EMPLINSIDEOUTSIDEOWNERTENANTADDITIONAL INTEREST (Provide only the necessary data) Attach ACORD 45 for more Additional Interests, if applicable PHONE #PRIMARY PHONE # HOME BUS CELL SECONDARY HOME BUS CELL PHONE #PRIMARY PHONE # HOME BUS CELL SECONDARY HOME BUS CELL$SQ FTANY AREA LEASED TO OTHERS? Y / NTOTAL BUILDING AREA:OPEN TO PUBLIC AREA: SQ FTCITY LIMITS INTEREST ANNUAL REVENUES:OCCUPIED AREA: SQ FTBLD #LOC #DESCRIPTION OF OPERATIONS:ZIP:STATE:COUNTY:CITY:STREET# PART TIME EMPL# FULL TIME EMPLINSIDEOUTSIDEOWNERTENANT% %DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDSOFF PREMISES INSTALLATION, SERVICE OR REPAIR WORKDESCRIPTION OF PRIMARY OPERATIONSRETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES: INSTALLATION, SERVICE OR REPAIR WORKNATURE OF BUSINESSMANUFACTURINGINSTITUTIONALDATE BUSINESSCONTRACTOR RESTAURANT STARTED (MM/DD/YYYY)CONDOMINIUMSAPARTMENTSRETAIL WHOLESALESERVICEOFFICEPage 2 of 4PREMISES INFORMATION (Attach ACORD 823 for Additional Premises, if applicable) CONTACT NAME:SECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:CONTACT TYPE:CONTACT INFORMATIONSECONDARY E-MAIL ADDRESS:PRIMARY E-MAIL ADDRESS:CONTACT NAME:CONTACT TYPE:AGENCY CUSTOMER ID:LOSS PAYABLELENDER'SACORD 125 FL (2016/03)MARYHU012MARY HUGHES TRANSPORT INCPHONE NUMBER AVAILABLEEMAIL AVAILABLEOwnerMARY HUGHESEMAIL AVAILABLE114375 SW COUNTY RD 152JASPER FL32052Nature Of Business: NON-EMERGENCY MEDICAL TRANSPORTATION Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 Page 3 of 4REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? SAFETY MANUAL SAFETY POSITION MONTHLY MEETINGS OSHA 2. IS A FORMAL SAFETY PROGRAM IN OPERATION?EXPLAIN ALL "YES" RESPONSES Y / NSUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED PARENT COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED DOES THE APPLICANT HAVE ANY SUBSIDIARIES?1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ? 1b.4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER 11. HAS BUSINESS BEEN PLACED IN A TRUST? NAME OF TRUST: 10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS? 9. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS? UNDERWRITING CONDITION CORRECTED (Describe):AGENT NO LONGER REPRESENTS CARRIERNON-RENEWALNON-PAYMENT5. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR GENERAL INFORMATION6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?(In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment).7.OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES?(If "YES", attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) 12.AGENCY CUSTOMER ID:OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATEOCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE14. DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If "YES", describe use) 15. DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If "YES", describe use) ACORD 125 FL (2016/03)MARYHU012NNNNNNNNNNNNNNNNDocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required, if applicable) 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. SIGNATURENATIONAL PRODUCER NUMBERPRODUCER'S SIGNATURE (Required in Florida)APPLICANT'S SIGNATURE DATEPRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO 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. 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. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.Page 4 of 4Check if none (Attach Loss Summary for Additional Loss Information) YEARS TOTAL LOSSES: $DATE OFOCCURRENCEDATE OF CLAIM AMOUNT PAIDSUBRO-GATIONY / NAMOUNT RESERVEDCLAIMOPENY / NENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LASTLINE TYPE / DESCRIPTION OF OCCURRENCE OR CLAIMLOSS HISTORY$ $ $ $EFFECTIVE DATEEXPIRATION DATEPREMIUMPOLICY NUMBERCARRIER$ $ $ $EFFECTIVE DATEEXPIRATION DATEPREMIUMPOLICY NUMBERCARRIER$ $ $ $EFFECTIVE DATEEXPIRATION DATEPREMIUMPOLICY NUMBERCARRIER$ $ $ $EFFECTIVE DATEYEAREXPIRATION DATEPREMIUMPOLICY NUMBERCARRIERCATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: PRIOR CARRIER INFORMATIONAGENCY CUSTOMER ID:ACORD 125 FL (2016/03)MARYHU012202316427: ATEGRITY SPECIALTYINSURANCE 01-C-PK-P20084086-COMPANY 08/15/20238/15/2024Professional Insurance Center Damien M Rodriguez PPHONE NUMBER AVAILABLEDocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024AGENCY CUSTOMER ID:EFFECTIVE DATECARRIER NAIC CODEPOLICY NUMBER APPLICANT / FIRST NAMED INSUREDAGENCY4. RETROACTIVE DATE:3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: 2. NUMBER OF EMPLOYEES:1. DEDUCTIBLE PER CLAIM: $EMPLOYEE BENEFITS LIABILITYACORD 126 (2016/03) 1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Y / N4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE? EXPLAIN ALL "YES" RESPONSES2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 1. PROPOSED RETROACTIVE DATE:CLAIMS MADE (Explain all "Yes" responses)COMMERCIAL GENERAL LIABILITY SECTION DATE (MM/DD/YYYY) LOC#CLASSIFICATION CLASSCODEPREMIUMBASISHAZ EXPOSURE TERR#(T) OTHER(U) UNIT - PER UNIT(M) ADMISSIONS - PER 1,000/ADM(C) TOTAL COST - PER $1,000/COST(A) AREA - PER 1,000/SQ FT(P) PAYROLL - PER $1,000/PAY(S) GROSS SALES - PER $1,000/SALESRATING AND PREMIUM BASISPREM/OPS PRODUCTSPREMIUMPREM/OPS PRODUCTSRATESCHEDULE OF HAZARDS1. UM / UIM COVERAGE IS IS NOT AVAILABLE. 2. MEDICAL PAYMENTS COVERAGE IS IS NOT AVAILABLE. APPLICABLE ONLY IN WISCONSIN: IF NON-OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY:$OTHER:LOCATIONPROJECTLIMIT APPLIES PER: POLICYGENERAL AGGREGATEPRODUCTS & COMPLETED OPERATIONS AGGREGATEPERSONAL & ADVERTISING INJURYEACH OCCURRENCEDAMAGE TO RENTED PREMISES (each occurrence)MEDICAL EXPENSE (Any one person)EMPLOYEE BENEFITS$$$$$$$COVERAGES LIMITSTOTALOTHERPRODUCTSPREMISES/OPERATIONSPREMIUMSOCCURRENCEPERCLAIMPER$BODILY INJURY $PROPERTY DAMAGE $DEDUCTIBLESCLAIMS MADE OCCURRENCEOWNER'S & CONTRACTOR'S PROTECTIVECOMMERCIAL GENERAL LIABILITYOTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims-made policy. Read all provisions of the policy carefully.Attach to ACORD 125MARYHU01208/01/2024Professional Insurance Center, Inc.01-C-PK-P20084086-0-Renewal 8/15/2024ATEGRITY SPECIALTY INSURANCE COMPANY 16427MARY HUGHES TRANSPORT INC5005002,000,0002,000,0001,000,0001,000,000100,000EXCLUDED528.07264792.071 NON-EMERGENCY MEDICALTRANSPORTATION68001 Area PHONE NUMBER AVAILABLEDocusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 ACORD 126 (2016/03) Page 2 of 4AGENCY CUSTOMER ID:CONTRACTORSTIME STAFF:# PART-TIME STAFF:# FULL-SUBCONTRACTED:% OF WORKCONTRACTORS:DESCRIBE THE TYPE OF WORK SUBCONTRACTED $ PAID TO SUB- 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? 3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING? 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS? EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / N PRODUCTS / COMPLETED OPERATIONSLIFE INTENDED USE PRINCIPAL COMPONENTSEXPECTEDMARKETPRODUCTS ANNUAL GROSS SALES # OF UNITS TIME INEXPLAIN ALL "YES" RESPONSES ( |
