Okaloosa County BOCC — February 16, 2016 — Final Pay Packet — reading text

-------. -·--- •. $ 75,277.60 This Ion did not originate by any act, design or procurement of the Insured, or this subscriber; nothing has been done by or with the prMly or consent of the insured or this subscriber lo violate the condilons of lhe policy; no 1rtlcles are mentioned herein or in 1nnexed schedules but such as were in the building damaged or destroyed, belonging lo and In ponesslon of the Insured al !he time of Ion; no pmperty saved IS been concealed and no allempt lo deceive the company has been made, Any other information that may be required wiH be furnished and considered a part <:I this proof. It is expressly understood and agreed Iha! the furnishing of this blank to the Insured er the assistance of an adjust er, or any agent of the insurer in the making of this J>roof. is not a waiVer of any rights of said insurer or of eny of the condt s of this poicy. SJbscribed and swam lo before me lhis _ _ ___,'6..._0;;;:;..-_______ day of_...-...._-"-'-'-'-....,...,.,_ _ _ _ 20 lS' --~-11...:....wA..-~·...(S,...,;W::::...:.::~L:>.o:.a.1.--<'..::;---Nctary Public ANY Pl!RSON WHO ICNOWINGLY AND WITH INTENT TO IN1UIU!, D!!FR.AUD Olt Dl!CEIVI! ANY IN$URANCE COMPANY l'lLl!S A STATEMENT OF CLAIM CONTAINlNG ANY PALS!!, INCOMPLl!TE OR MISLEADINQ INFORMATION IS QUILTY OF A FELONY OF 1l!E THIRD DEQREI!. dw.2no111  vrs>>vericlaim a sedgwick company Torn Rongstad, General Adjuster 7201 N. 9th Ave. Suite A-8 Pensacola, FL 32504 Cell 850-324-4202 Fax Number: 850-474-9809 Office: 850-474-9428 x 103 trongstad@vericlairninc.com September 22, 2015 Okaloosa County 601-A North Pearl Street Crestview, Florida 32536 Insured Okaloosa County Location of Loss Department of Corrections, Item 31 1220 East James Lee Boulevard Crestview, Florida 32539 Type of Loss Lightning Date of Loss 04/29/2014 Policy Term 04101/2014 to 04101/2015 Account Number 267659 Underwriters at Lloyd's AMR-36901 Indian Harbor Ins. Co. AMP7524561-00 OBE Specialty Ins. Co. MSP-12290-03 Steadfast Insurance Co. CPP9653576-03 CJW Claim Number 4124702 VeriClaim File Number QCC15-351470 Dear Insured: Attached, please find a Sworn Statement in Proof of Loss for the claim as referenced, which reflects a payment of $68, 771. 77 for the claim as referenced. The total damages are calculated at $194,049.37. Recoverable Depreciation of$75,277.60 reduces the Actual Cash Value loss to $118,771.77. The applicable deductible of$50000.00 reflects the payable amount. Please note that the depreciation of $75,277.60 is recoverable with documentation of expenditure. Please have the appointed person execute their signature on this document before a notary and return the original to me. You may fax or scan and email to expedite, however; the original signed document will be anticipated by regular USPS. Please maintain a copy for your records. Please confirm the mailing address you wish the payment sent to when you return the executed Sworn Statement in Proof of Loss. Should you have any questions, please call 850-324-4202. I look forward to your response.  Page No. 2 Best regards, Tom Rongstad, General Adjuster Vericlaim, Inc. 7201 North 9th Avenue, Suite AS Pensacola, Florida 32504 850-324-4202 trongstad@vericlaiminc.com enclosures: 1. Sworn Statement in Proof of Loss. 2. Statement of Loss  STATEMENT OF LOSS INSURED : Okaloosa County ADDRESS Department of Corrections 1220 East James Lee Boulevard Crestview, Florida 32539 TYPE OF CLAIM Lightning DATE OF CLAIM 04/29/15 POLICY# : AMR-36901 CJWFILE # : 4124702 VERICLAIM# QCC15351470 ITEM: Building COVERAGE : $21.000.000 Security System $ 188,194.00 $ 188, 194.00 Less Depreciation 40% $ {75,277.60) Actual Cash Value $ 112,916.40 $ 112,916.40 Temporary Repairs I Security $ 5,855.37 $ 5,855.37 $ 5,855.37 TOTAL LOSS AND CLAIM $ 194,049.37 $ 118,771.77 Less Deductible $ (50,000.00) Payable Actual Cash Value Claim $ 68,771.77 Note that a Replacement Cost Claim of $75,277.60 will be presented with documentation of expenditure. Tom Rongstad General Adjuster 18-Sep-15 Federal Emergency Management Agency E-Grants Page 1of13 ..E Application Title: OKALOOSA (COUNTY) OKEEC01 Correction's Alarm System Period of Performance Start: Period of Performance End: 05-06-2014 11-06-2015 Subgrant Application - Entire Application ' .......... ..................................... ;;,·~:;;;;;.;;;;;;.::= Application Title: OKEEC01 Correction's Alarm System Application Number: PA-04-FL-4177-PW-00327(0) Application Type: Subgrant Application (PWj Preparer Information Prefix Ms. First Name Eleanor Middle Initial Last Name Conigo Title Project Specialist Agency/Organization Name DHS/FEMA Address 1 2555 Shumard Oak Blvd Address 2 City Tallahassee State FL Zip 32399- 7018 Email Steven.Hyatt@em.myflorida.com Is the application preparer the Point of Contact? No Point of Contact Information Prefix Ms. First Name Marcella Middle Initial Last Name Eubanks Title Contracts and Grants Manager Agency/Organization Okaloosa County Address 1 1804 Lewis Turner Blvd. Address 2 City Fort Walton Beach State FL ZIP 32547 Phone 850-651-7200 https://connect l .dhs.gov/emmie/,Danalnfo=isource. fema.net, SSL +dispatchDestination.do?. .. 12/2/2014  Federal Emergency Management Agency £-Grants Page 2of13 I Fax Email meubanks@clerkofcourts.cc Alternate Point of Contact Information (. Prefix Mr. First Name Gary Middle Initial Last Name Stanford Title Finance Director Agency/Organization Okaloosa County Address 1 1804 Lewis Turner Blvd. Address 2 City Fort Walton Beach State FL ZIP 32547 Phone 850-689-7200 Fax Email gstanford@clerkofcourts.cc Project Description Disaster Number: 4177 Pre-Application Number: PA-04-FL-4177-RPA-0009 Applicant ID: 091-99091-00 Applicant Name: OKALOOSA (COUNTY) Subdivision: Project Number: OKEEC01 Standard Project Number/Title: 599 - Repair Damages to Public Buildings and Facilities Please Indicate the Project Type: Neither Alternate nor Improved Application Title: OKEEC01 Correction's Alarm System Category: E.PUBLIC BUILDINGS Percentage Work Completed? 2.0% As of Date: 08-29-2014 Damage Facilities (Part 1 of 2) Site Facility Facility Name Address County City State ZIP Previously Action Number Damaged? Correction's Alarm 1200 E James Lee Okaloosa Crestview FL 32539 No System Blvd. IComments https://connect l .dhs.gov/emmie/,Danalnfo=isource.fema.net,SSL+dispatchDestination.do?... 12/2/2014  t Federal Emergency Management Agency E-Grants Page 3of13 I