Okaloosa County BOCC — April 21, 2015 — L15-0418-FM.pdf Internal Coordination for Opportunity Inc. — reading text

OR OFFLCE - MERCANTILE OR 61217 AREA 750 MANUFACTURING - MAINTAINED BY THE INSURED (LESSOR'S RISKI ONLY) ~ DTHER THAN NOT=FOR=PROFIT PRODUCTS-COMPLETED OPERATIONS ARE SUBJECT TC THE GENERAL AGGREGATE LIMIT 3 BUILDINGS OR PREMISES - BANK OR OFFLCE ~ MERCANTILE OR 61217 AREA 200 MAMUFACTURING - MAINTAINED BY THE INSURED (LESSOR'S RISKI ONLY) - OTHER THAN NOT=FOR~PROFLT i PRODUCTS-COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT [ BUILDINGS OR PREMISES - BANKI OR OFFICE - MERCANTILE OR 61217 AREA 200 MANUFACTURING - MAIMTAINED BY THE INSURED (LESSOR'S RISK/ ONLY) ~ OTHER THAN NOT=-FOR=-PROFIT PRODUCTS~COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMIT STATE-2 LOCATION OF ALL PREMISES YOU OWN, RENT OR OCCUPY: Loc # 1z #2/1/NjOR 203 CLOVERDALE RD, FT WALTON BEA PMS PDTS LOC CLASSIFICATION CODE PREMIUM BASIS RATE RATE 2 SHELTERS, MISSION, SETTLEMENT OR HALFWAY HOUSE - NOTCHURCH OR 67017 AREA 1,872 OFFICE BUILDING PRODUCTS-COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE LIMLT 10-20-14 Page 7 of 10 Commercial General Liability RENEWAL DECLARATION =t - ‘- "' ‘' ‘-~ 1 ! I [ [ [ ‘-0 ] NAME AND ADDRESS OF AGENCY INSURANCE COMPANY Illinois National Insurance Co. Irwin Siegel Agency, Inc. . 25 Lake Louise Marie Road 175 Water Street - 18th Floor. Rock Hill NY 12775 New York NY 10038 ) AGENCY 0000096397 NAME AND MAILING ADDRESS OF INSURED POLICY NUMBER " RENEWAL OF OKALOOSA WALTON HOMELESS CONTINUUM 06-L% -027564138-3/000 06-LX-027564138-2 OF CARE OPPORTUNITY POLLCY PERIOD : | 305 LOVEJOY RD FROM: 10-19-14 TO: 10-19-15 § FORT WALTON BEACH FL 32548 : At 12:01 A.M. standard time at the mailing address shown. ' ' ' [ | | [ .. ' ' ' [ ' [ [ | MANUSCRIPT FORMS: C¢G2244 (07-98) : EXCLUSION - SERVICES FURNISHED BY HEALTH CARE PROVIDERS i ——————————— ANY AND ALL HEALTH CARE SERVICES ABUSE AND MOLESTATION ENDORSEMENT Limits of Insurance: $1,000,000 Each Incident Limit $1,000,000 Aggregate Limit EMPLOYEE BENEFLTS LIABILLTY COVERAGE RETROACTLVE DATE 10-19-2009 LIMIT OF LIABILITY $1,000,000 Employee Benefits Programs Limit Of Insurance 1,000,000 Enployee Benefits Programs Apgrepate Limit DEDUCTIBLE $1,000 Each Employee Deductible NUMBER OF EMPLOYEES ' 8 Number of Employees of the Named Insured 00~-00-0000 Date of Record For Number of Employees of the Named Insured ESTIMATED ANNUAL PREMIUM ’ $30 Estimated Ahnual Premium TERRORLSM RISKI INSURANGE ACT FOR FLORIDA IS INCLUDED S65 GENERAL LIABILITY PREMIUM $7,342 10-20~14 Page 8 of 10 Commercial General Liability RENEWAL DECLARATION L' ./ '/ [ [ ' [ | /| ([ [ [ [ [ [ [ .l NAME AND ADDRESS OF AGENCY INSURANCE COMPANY Illinois National Insurance Co. Irwin Siegel Agency, Inc. 25 Lake Louise Marie Road 175 Water Street - 18th Floor. Rock Hill _ NY 12775 New York NY 10038 AGENCY 0000096397 NAME AND MAILING ADDRESS OF INSURED . POLICY NUMBER RENEWAL OF OQKALOOSA WALTCON HOMELESS CONTINUUM 06~1LX —027564138—3/000 06-LX-027564138-2 OF CARE OPPCRTUNITY ‘ POLICY PERIOD 305 LOVEJOY RD FROM: 10-19-14 TO: 10-19-15 FORT WALTON BEACH FL, 32548 At 12:07 A.M. standard time at the mailing address shown. !/ [ ' ' [ (¢ [/ | | [ [ [ | [ ] [ T FORMS AND ENDORSEMENTS APPLYING TO COMMERCIAL GENERAL LIABILLTY COVERAGE PART AND MADE PART OF THIS POLICY AT TIME OF ISSUE: 87295 (01/08) IL0021 (09-08) CGOOD1 (12-07) CG2147 (12-07) CG2149 (09-99) CG2157 (07-98) t62252 (10-93) (G0220 (03-12) 78689 (07-03) 65123 (04/96) C6O435 (12-07) CG2106 (05-14) tG2244 (07-98) 86563 (10-09) 86571 (08~04) 58332 (08-07) 82540 (08-07) 62898 (09/01) C62146 (07-98) THESE DECLARATIONS AND THE COMMON PCLICY DECLARATIONS, IF APPLICABLE, TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE FORM(S) AND FORMS AND ENDORSEMENTS, IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. AUTHORILZED REPRESENTATIVE 10-20~14 Page 2 of 10 Misc. Professional Liability RENEWAL DECLARATION ‘ L 0 O 5 0 5 N S S M N A [ NAME AND ADDRESS OF AGENCY Irwin Siegel Agency, Inc. 25 Lake Louise Marie Road INSURANCE COMPANY Illinois National Insurance Co. 175 Water Street - 18th Floor. Rock Hill © NY 12775 New York NY 10038 AGENCY 0000096397 NAME AND MAILING ADDRESS OF INSURED POLICY NUMBER RENEWAL OF OKALOOSA WALTON HOMELESS CONTINUUM OF CARE OPPORTUNITY 305 LOVEJOY RD FORT WALTON BEACH FL. 32548 In return for the payment of the premium, and subject to all the 06-LX -027564138-3/000 06-LX-027564138-2 POLICY PERIOQ FROM: 10-19-14 TO: 10-19-15 At 12:01 AM. standard time at the mailing address shown. terms of this policy, we agree with you to provide the insurance stated in this Policy. ITEM 3. Limits of Coverage: S 1,000,000 eacH WRONGFUL ACT DR SERIES OF CONTINUOUS, REPEATED OR RELATED ACT $ 3,000,000 AGGREGATE ITEM 4. Deductible: S 0 eacH WRONGFUL ACT OR SERIES OF CONTINUDUS, REPEATED OR RELATED ACT f TOTAL ANNUAL PREMIUM $2,578 FORMS AND ENDORSEMENTS 67688 (04/97) APPLYING TO PROFESSIONAL LIABLLITY COVERAGE PART AND MADE PART OF THIS POLICY AT TIME OF ISSUE: 10-20-14 Page . E sty AUTHORIZED REFRESENTATIVE 10 of 10 NAME AND ADDRESS OF AGENCY Irwin Siegel Agency, Inc. 25 Lake Loulse Marie Road 175 Water Street - 18th Floor. Rock Hill FORMS SCHEDULE INSURANCE COMPANY Illineis National Insurance Co. NY 12775 New York NY 10038 AGENCY 0000096397 NAME AND MAILING ADDRESS OF INSURED POLICY NUMBER RENEWAL OF OKALOOSA WALTON HOMELESS CONTINUUM 06-LX -027564138-3/000 06-LX-027564138-2 OF CARE OPPORTUNITY POLICY PERIOD 305 LOVEJOY RD FORT WALTON BEACH COMMON POLICY PACKAGE 89644 (06-13) IL0017 (11-98) 76105 (02-09) 90231 (12-05) 74825 (08-09) PRG7003 (11-09) 96556 (02-08) FROM: 10-19-14 TO: 10-19-15 FL, 32548 at'72:0fi A.M. standard time at the mailing address shown. ECONOMIC SANCTIONS ENDORSEMENT COMMON POLICY CONDITIOCNS FLORIDA - CANCELLATION/NON-RENEWAL ENDORSEMENT FLORIDA NOTICE OF LOSS CONTROL SERVICES FLORIDA ADDENDUM TC THE DECLARATIONS ESTIMATED TAXES, ASSESSMENTS AND SURCHARGES _ POLICYHOLDER DISCLOSURE NOTICE OF TERRORISIM INSUR COMMERCIAL GENERAL LIABILITY FORMS 87295 (01/08) IL0O021 (09-08) CE0001 (12-07) C@E2147 (12-07) CE2149 (09-99) CE2157 (07-98) C@E2252 (10-93) Cce0220 (03-12) 78689 (07-03) 65123 (04/96) CE0435 (12-07) CE21L06 (05-14) CG2244 (07-98) 86563 {10-09) 86571 (08-04) 58332 (08-07) 82540 (08-07) 62898 (09/01) Ce2146 (07-98) PROFESSIONAL LIABILITY 67688 (04/97) 10-20~14 EXCLUSION-VIOLATION OF STATUTES IN CONNECTION WITH NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT COMMERCIAL GENERAL LIABILITY COVERAGE FORM (OCCUR) EMPLOYMENT-RELATED PRACTICES EXCLUSION TOTAL POLLUTION EXCLUSION EXCLUSION - COUNSELING SERVICES EXCLUSION - MEDICAL PAYMENTS COVERAGE (INMATES,..) FLORIDA CHANGES - CANCELLATION & NONRENEWAL FUNGUS EXCLUSICN REVISED ABUSE AND MOLESTATION ENDORSEMENT - OCCURRENCE EMPLOYEE BENEFITS LIABILITY COVERAGE EXCL-ACCESS OR DISCLOSURE OF CONFIDENTIAL QR PERSN EXCLUSTION - SERVICES FURNISHED BY HEALTH CARE PROV GENERAL LIABILITY EXTENSION ENDORSEMENT GL EXTENSION ENDOCRSEMENT FOR HUMAN SERVICES TOTAL LEAD EXCLUSION ASBESTOS AND SILICA EXCLUSION ENDORSEMENT RADIOACTIVE MATTER EXCLUSION ABUSE OR MOLESTATION EXCLUSION SOCIAL SERVICE PROTESSIONAL LIAB. COVERAGE FORM Page 1 of 1 SIGNATURE OF AUTHORIZED REPRESENTATIVE Common Policy Declarations EXTENDED NAMED INSURED N 0 o s S s M SO S R FEEMAw! NAME AND ADDRESS OF AGENCY INSURANCE COMPANY Illinois National Insurance Co. Irwin Siegel Agency, Inc. 25 Lake Louilse Marie Road ‘ 175 Water Street - 18th Floor. Rock Hill NY 12775 New York NY 10038 AGENCY 0000096397 NAME AND MAILING ADDRESS OF INSURED POLICY NUMBER RENEWAL OF OKALQOOSA WALTON HOMELESS CONTINUUM 06-LX -027564138-3/000 06-1LX-027564138-2 OF CARE OPPORTUNITY POLICY PERIOD 305 LOVEJOY RD FROM: 10-19-14 TO: 10-19-15 FORT WALTON BEACH FL 32548 at 12:01 A.M. standard time at the mailing address shown. ./ ! ' [/ ! ! [ [ J ! J t ' [ -/ | [/ /[ [ { [ ] 10-20~14 Page - 1 of 1 SLGNATURE OF AUTHORLZED REPRESENTATIVE