Okaloosa County BOCC — July 6, 2016 — AOL Stanley Gordon B 6 L 1 for Agenda — reading text

06/22/2017 |Building 167,600 Contents 5,0004 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES {ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Premises located at: 1001 Airport Road (Lot 1, Block 6 and Lot §, Block 8), Destin, FL 32541. Building located at 1001 Airport Road (Lot 1, Block 6) Certificate holder is named as an additional insured under liability coverages as respects operations of the Named Insured CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Okaloosa County 5749 A o'd Bethel Road AUTHORIZED REPRESENTATIVE Crestview, FL. 32536 Tucker Wenk Deeter © 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25 (2014/01) The ACORD name and logo are registered marks of ACORD POLICY NO.: NAB4043264 ATTACHED TO CERTIFICATE # 1 CERTIFICATE OF INSURANCE THIS 1S TO CERTIFY TO: OkKalgosa County 574 d Bethal Road Crestview:Fl 32536 THAT THE FOLLOWING POLICY OF INSURANCE HAS BEEN ISSUED TO: JSG Aviation, LLC clo Jeffrey Gordon 715 Alta Vista Road Louisville, KY 40299 POLICY NUMBER: NAB4043264 POLICY PERIOD: From December 21, 2015 To December 21, 2016 INSURANCE COMPANY: Catlin Insurance Company, inc. DESCRIPTION OF COVERAGES AND LIMITS OF LIABILITY: Please refer to attached schedule which is incorporated as a part hereof. Additional Insured: - The Estate of Stanieéy J.:Gordon, Jr. The above Certificate Holder is included-as an Additional Instred but only to the extent of fiability imposed upon the Additional Insured solely as the result of an act or omission of the Named Insured or its employees in connection with the Named Insured's Operations. Subject to Date Change Recognition Endorsement. Data included in this Certificate valid as of June 23, 2016. This certificate of insurance is not an insurance policy and does not amend, extend or alter the coverage afforded by the policy listed herein. Notwithstanding any requirement, term or condition of any contract or other document with respect to which this certificate of insurance may be issued or may pertain, the insurance afforded by the policy described herein is subject to all the terms, exclusions and conditions of such policies. Should the described policy be cancelled before the expiration date hereof, the issuing company will endeavor to give 30 days (10 days for non-payment) notice to the certificate holder named herein. However, failure to mail such notice shall not impose any obligation nor any liability of any kind upon the Company, its representatives or agents. By: W’”fl\) Date of Issue: June 24, 2016 W. Brown & Associates [nsurance Services Certificate No.: _1 Certificate # 1 Page 1 of 2 POLICY NO.: NAB4043264 ATTACHED TO CERTIFICATE # 1 SCHEDULE OF AIRCRAFT DESCRIPTION OF AIRCRAFT . No. |FAA Cert# [Serial # Year/Make/Model Insured Value 1 IN700KM 158 2000 Socata TBM 700B EFIS $1,000,000 PHYSICAL DAMAGE COVERAGE Deductibles No. Not In Motion In Motion Physical Damage Coverage 1 $2,500 $2,500 F. All Risk Basis AIRCRAFT LIABILITY COVERAGES Single Limit Bodily Injury Passenger Passenger Liability Limited To No. & Property Damage Liability Each Person Each Occurrence 1 $1,000,000 Included XXXX XXXX MEDICAL EXPENSES No. Including Crew Each Person Each Occurrence 1 Yes $5,000 $30,000 Certificate # 1 Page 2 of 2 ‘ATE 26255 American Drive | Southfield, Ml 48034-6112 Tel: (800) 482-2726 CERTIFICATE OF INSURANCE THIS IS TO CERTIFY TO: :Okalossa County, 5749 A Old Bethel Road; Créstview, FL 32536 THAT THE FOLLOWING POLICY/IES OF INSURANCE HAVE BEEN ISSUED TO: JSG Aviation, LLC, 715 Alta Vista Road, Louisville, KY 40299 POLICY NO. NDD0864773-01 POLICY PERIOD: From April 1, 2016 To April 1, 2017 Coverage only applies as indicated by a specific limit and deductible. Limits of Liability ; A. Aircraft Liability Single Limit for Bodily Injury and Property Damage Including Passengers Liability $_1,000,000. each occurrence with Passenger liability Limited to $__100,000. each passenger B. Medical Expense Including crew $ 5.000. each passenger C. Physical Damage to Your Aircraft | Deductibles : | Physical Notin i ID Number Year Make and Model! _ Agreed Value Damage motion In motion N528CC 2014 CubCrafters Carbon $ 260,000. F $ 100. $ 500. Cub (wheels) $ 3 $ $ $ $ $ $ 3 $ 3 $ 5 $ $ PHYSICAL DAMAGE Coverage Identified F. All Risk Basis G. All Risk Not In Motion , o THIS CERTIFICATE HOLDER AND THE ESTATE OF STANLEY J. GORDON, JR. ARE INCLUDED AS ADDITIONAL INSURED AS RESPECTS TO THE OPERATION OF THE INSURED AIRCRAFT. IN THE EVENT OF CANCELLATION, THIRTY (30) DAYS WRITTEN NOTICE (10 DAYS FOR NON-PAYMENT OF PREMIUM) SHALL BE PROVIDED FOR THE ABOVE CERTIFICATE HOLDER. The Aviation Managers have made provision to give the certificate holder prompt notice of cancellation of any policy above. But, the Aviation Managers assume no responsibility for failure to provide such notice. This certificate does not change in any way the actual coverages provided by the policy/ies specified above. Certificate No. 3 s N -} A (Authorized Representative) Date of Issue: 6/24/2016 BY 5105 Al 1010 Page 1 of 1 0611712016 13:24 Henk Aviation Insurance (FAX)8472352559 P.002/003 POLICY NO,: NAB6001820 ATTACHED TO CERTIFICATE # 1 CERTIFICATE OF INSURANCE THIS 18 TO CERTIFY TO: Oskaloosa County Contracts & Lease Coordinator 802-C N Pearl Strest Craeatview FL 32536 THAT THE FOLLOWING FOLICY OF INSURANGE HAS BEEN ISSUED TO: WD Avigtion, Inc. and 8. Jay Gordon c/o 8, Jay Gordon 240 Gulf Shore Dr., #6533 Destin, FL. 32541 POLICY NUMBER: NABS001920 POLICY PERIQD: From June 20, 2016 To June 20, 2017 INSURANCE COMPANY: American Alternative Insurance Corp. DESCRIPTION OF COVERAGES AND LIMITS OF LIABILITY: Plezse refer to attached schadule which I8 Incorporated ag a part hereof, The abovs Certificate Holder is included as an Additional Insured but only to the extent of liability imposed upon the Additlanal Insured solely as the result of an act or emission of the Named [nsured or its amployses in connection with the Named Insured's Operations. Subject to Date Change Recognition Endarsement. Data included in this Certificate valid as of June 20, 2016. This certiflcate of Insurance is not an Insurance polley and does not amend, extend or alter the coverage afforded by the policy listed haraln. Notwithstanding any requirement, term or condition of any contract or other document with raspect to which this certlficats of Insurance may be Issued or may pertain, the Insurance afforded by the pollcy descried herain !s subject to all the terms, exclusions and conditions of such policles. Should the described policy be cancelled befora the expiration date haraof, the Issuing company will endeavor {o give 30 days (10 days for non-payment) netice to the certificate holdetr namad herein. However, failure to mail such notles shall nat Impose any obligation nor any liahility of any kind upen the Company, its representatives or agants. By: /W’M‘) Date of Issue: Juna 17, 2018 W. Brown & Assoclates insurance Services - Certificats No.: 1 3 il Cartificate & 1 Page 1 of2 061712016 13:24 Henk Aviation Insurance (FAX)BA72352559 P.003/003 POLICY NC.: NAB&OD1820 ATTACHED TO CERTIFICATE # 1 SCHEDULE OF AIRCRAFT DESCRIFTION OF AIRCRAFT No. |[FAA Cert# |Serial # Year/Make/Madal Ingurad Valus 1 [NB2EWD 525A0107 2002 Cessna Citation CJ2 525A $2,700,000 PHYSICAL DAMAGE COVERAGE Daductiblas No. Not in Motion In Motion Physical Damage Coverage 1 Nil NIt F. All Risk Basis AIRCRAFT LIABILITY COVERAGES Single Limit Bodily Injury Pagsenger Pasgenger Lishllity Limited To No. & Property Damage Liability Each Parson Each Qcourrence 1 $5,000,000) Included XXX KX MEDICAL EXPENSES No, Including Craw Each Person Each Occurrence 1 Yes $5,000 $48,000 Certificate # 1. ! Paga20f2