Marshall

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 [email protected] Enclosure(s) 5021 Anchor Way - Gallows Bay, Christiansted, VI 008204671 Tel: (340) 773-2170 Fax (340) 773.9550 EFTA01221263 Period: '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 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 # 001 13uildinst # Subject 001 Business Personal Property Limit $500,000 Coinsurance 80% *Deductible $2,500 *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.) Applicable Law (U.S.A.) Several Liability Notice Exclusion of Certified Acts and Other Acts Of Terrorism; Coverage for Certain Fire Losses U.S. Virgin Islands Changes — Cancellation and Non Renewal Co-Insurance Clause War and Civil War Exclusion Clause Radio Active Contamination and Explosive Nuclear Assemblies Exclusion Clause Electronic Date Recognition Exclusion (EDRE) Electronic Data Endorsement "B" 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 COMMERCIAL INSURANCE APPLICATION APPLICANT INFORMATION SECTION AGENCY Marshall & Sterling Insurance 5021 Anchor Way Gallows Bay Marketplace Christiansted, VI 00820-4671 Marshall & Sterling CONTACT Marshall & Sterling RAMC_ HO (NC.IN EON NE 340-773-2170 FAX 340-7734550 ADDRESS: CODE: AGENCY CUSTOMER ID: FINAN-1 STATUS OF TRANSACTION QUOTE Li ISSUE BOUND (Give Date BAd/of AIWA CORA, CHANGE DATE CANCEL 11115/10 POUCY TIME 04:06 IX I i RENEW AM ENTER THIS INFORMATION WHEN COMIAON DATES AND TERAIS APPLY TO PLAN DIRECT BILL AGENCY BEL SEVERAL LINES. OR FOR MONOUNE POLICIES I AUDIT _ X PROPOSED EPP DATE PROPOSED NIP DATE BILLING X PAYMENT PLAN — 11115/12 11115/13 — X pis PACKAGE POLICY PREMIUM: S APPLICANT INFORMATION NAME Mrs! Wined Inwood & 011w Named Msurods) Financial Trust Co., Inc. SUB CODE: OP ID: SSMI DATE plIMDIEWM 11/2/2012 CARRIER Certain Underwriters at Lloyds UNDERWRITER: 1 UNDERWRITER OFFICE: POLICIES OR PROGRAM REQUESTED COMMERCIAL PROPERTY NAIC CODS INDICATE SECTIONS ATTACHED ALI MAIL s RIi CIi NAM! I VALUABLE PAPERS BOILERS MACHINERY BUSINESS AUTO COMMERCIAL GENERAL LIABILITY CRIFAENISCELLANEOUS CRIME DEALERS DRIVER INFO SCHEDULE X PACKAGE POLICY INFORMATION ELECTRONIC DATA PROC EQUIPMENT FLOATER GARAGE AND OEALERS GLASS AND SIGN INSTALLAINNBUILDERS RISK OPEN CARGO PROPERTY IRANCPOR !AI IOW MOWN TRUCK-I: POLICY NUMBER LBS6132 TRUCKERMOTOR CARRIER UMBRELLA VEHICLE SCHEDULE WORKERS CONVERSATION YACHT FEMUR ::QC SEC N (of FRO Hamad hystmeU): E-MAIL ADDRESSIE 5): INDINIDUAL X CORPORATION _- =WV" _ PARINERSIIP ___ JOINT VENTURE PRI;FR I ID NUMBER: INSPECTION CONTACT: CSC' le de Jongh I ACCOUNTING RECORDS CONTACT: SaSame -ft lIC PHONE IAN. NospIe I ADDRESS; INC, W. MD: PREMISES INFORMATION I I ACORD 023 attached for additional I remises ir catt.„,); 212-7804895 WRUNG ADDRESS INCL ZIN4 lol FRG Named Insured) American Yacht Harbor, St. 6.3 6100 Red Hook Ohs, VI 00802 %TENSILE AODRESSIESX CR BUREAU NAME: NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S) 001 001 Financial Services office AND WHAMS ac NM OF MEMBERS i• E-MAIL ' ADDRESS: ANIIUAL REVENUES EMPLOYEES STARTED OCCUPIED 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 GENERAL INFORMATION AGENCY CUSTOMER ID: FINAN-1 OP ID: SSMI EXPLAIN ALL 'YES" RESPONSES I a IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY? YIN 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? 4 ANY CATASTROPHE EXPOSURE? N 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? OF FRAUD. BRIBERY. ANSON OR ANY punknablo by a soninxo or up to ono N a DURING THE LAST FNE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTEE OTHER ARSON-RELATED CRIME IN CONNECTION MATH THIS OR ANY OTHER (In RI, Na gumlion ma( to orrAvored been/ +wok ont for p:Optny ir curanco. Fr:hire yew of:mown-ton!) 9. ANY UNCORRECTED FIRE CODE VIOLATIONS? FOR OR COWICTEO OF ANY DEGREE OF THE CRIME PROPERTY? N &Nom Po existence c4 an onunccmictIon is a roislorneanoe PAS I I NE (SI YEARS? N N 10 ANY ISMKRUPTOES, TM OR CREDIT LIENS AGAINST THE APPLICANT IN THE 11 HAS BUSINESS BEEN PLACED INA TRUST? IF *YES'. NAME OF TRUST: rl N 12 ANY FOREIGil OPERATIONS. FOREIGN PRODUCTS DISTRI0UTED IN USA OR (II 'YES. moth ACORO ISIS toy LbNbly rii:054•CO and/ ACORO SIG kw Prope.ty US PRODUCTS SOUNOISTRIOUTED IN FOREIGN COUNTRIES? Exposure) mouliod) N REMARRS/PROCESSINO INSTRUCTIONS (AIWA ocIdItIonal s Nets II mon spice Is 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 FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED PARTIES WITHOUT YOUR AUTHORIZATION YOU HAVE THE RIGHT TO ANY INACCURACES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON IlOW TO ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE SUBMIT A REQUEST TO US. INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND DC, LA, ME, TN. VA and WA, Insurance benefits may also be denied) TO INJURE. DEFRAUD. OR DECEIVE ANY INSURER FILES A STATEMENT INFORMATION IS GUILTY OF A FELONY OF THE. THIRD DEGREE. REPORT, MAY BE COLLE SUCH INFORMATION AS BE DISCLOSED TO THIRD REQUEST CORRECTION OF UPON REQUEST. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY STATEMENT OF CLAM CONTAINING ANY MATERIALLY FALSE INFORMATION, FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, PENALTIES. (Nol applicable in CO. FL, HI, MA, NE, OH, OK, OR, or VT; in IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT APPLICATION CONTAINING ANY FALSE. INCOMPLETE. OR MISLEADING FOR INSURANCE OR CONCERNING ANY INT: SUBSTANTIAL] CIVIL OF CLAIM OR AN THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT THE ANSWERS TO QUESTIONS ON THIS APPLICATION. IIEJSHE REPRESENTS HISMER KNOWLEDGE. AND REPRESENTS THAT REASONABLE THAT THE ANSWERS ARE TRUE, CORRECT PRODUCER'S NAME (Nom Phil) Marshall & Sterling ENQUIRY HAS BEEN AND COMPLETE I PETE g - /3 -- i 2 MADE TO OBTAIN TO THE BEST OF STATE PRODUCER LICENSE 110 (RequIrod In Florida) NATIONAL PRODUCER NUMBER PRODUCER'S SIGNATURE APPLICANTS S p - ACORD 126 (2007110) Page 2 of 3 EFTA01221268 PRIOR CARRIER INFORMATION AGENCY CUSTOMER ID: FINAN-1 OP ID: SSMI UNE CATEGORY CARRIER POLICY NUMBER POLICY TYPE RETRO DATE 2010-2011 2009-2010 2008.2008 2007-2008 2006.2007 0 E II C Es a A A E E l' R C I A A M B L IL I T V I VAT 1 I OWAHIMM Mat I I “Cia.lia MC I "IA Calan I I. aditat 1 I 0CCIAMICIE I. _, i WM I [Male " EFF-EXP DATE GENERAL AGGREGATE PROIRICTS COMP OP AGGREGATE PERSONAL A ADV INJ EACH OCCURRENCE E - ' FIRE °AIM/GE ' MEDICAL EXPENSE r 6 BOOBY OCCURRI NCI MAME/ AGGREGATE pRopurl y OCCURRENCE DAMAGE AGGREGATE COMBINED SINGLE LIMIT MODIFICATION FACTOR TOTAL PREMIUM _ _ ---- .- -- A i• 0T I 0 A pi IL I I L I E ' CARRIER - POLICY PIUMBER POLICY TYPE - — - —. EFFCIP DATE --- - - - COMBINED SITIOLE LIMIT -__,_ BODILY EA PERSON HAIRY EA ACCIDENT PROPERTY DAMAGE MODIFICATION FACTOR TOTAL PREMIUM P R 0 p E R 7 y CARRIER POLICY NUMBER POLICY TYPE E FF.E; XP DATE BUILDING AMT LLOYD'S First Insurance LBS5084 CFTC MM03.0313 CTS & A&A CTS & A&A ___ _ CTS & A&A CTS & A&A 11/15/10 11115/11 350,000, 350,000 350,000 350,000 X PERS PROP AMT 600,000 150,000 150,000 150,000 150,000 _ .... 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) OCCURRENCE LINE ITPODESCRIPTION OF OCCURRENCE OR CLAM DATE OF REMARKS ROI I IDE I Ins REQUIRES A NYE YEAR LOSS HISTORY DATE OP CLAIM AMOUNT PM0 Ix RESERVED ATTACHMENTS I I STATE SUPPLEMENT'S) RSIN ACORD 125 (2007/10) Page 3 of 3 EFTA01221269 OP ID: SSMI ACORD,„ PROPERTY SECTION AGENCY PHONE IA H (FAX AM, No: 340-773-9550 Marshall & Sterling Insurance 5021 Anchor Way Gallows Bay Marketplace Christiansted, VI 00820-4871 Marshall & Sterling COOS: [SUB CODE: AGENCY STO', RID E 'RAM PREMISES INFORMATION PREMISES A: 001 BUILDING /I: 001 STREET ADDRESS: American Yacht Harbor,Ste. B-3 St. Thomas VI 00801 moo °summon:Financial Services office SUBJECT OP INSURA/CI AMOUNT CONS % page VALUATION for CAUSES OF LOSS lunation GUAM) M f lnst DEDUCTIBLE rance I BLKT COV foilmation FORMS AND CONDITIONS TO APPLY See attached supplemental Subjects JDEPEND ADDITIONAL INFORMATION ORDINARY I EXCL BUSINESS PAYROLL I _ I INCL 90 DAYS ISO DAYS INCOME JEX1RA EXPENSE POWER/HEAT BED ELEC MEDIA DAYS ORD OR LAW DAYS EXT PERIOD I MO PERIOD I MAX PERIOD BUSINESS 1 1 DAYS LIMIT INCOME I TUITION $ WIO EXTRA EXPENSE EXTRA EXPENSE POWER BELOW) Me TYPE OP BUSINESS NON MVO MFG % COINS FEES _ STUDENTS OTHER ED 1 OFF PREM 1 POWER WATER COIAM (OESCR PROP % COIN CONT LOC REC L0C WO LOC LOP LOC (IR. SC suave_ OATS PERIOD REST SERVANC NAME ANDADORE/MEM FOR OFF PREFA POWER OR DEPEND PROP _I UNIT LOSS PAY % % % ADDITIONAL COVERAGES, OPTIONS, RESTRXTIONS, EIWORSEMEHTS AND FtAIIIIG RIFORMATI011 not 340-7734170 APPLICANT nanc in trust-Company, Inc. Mal Namid Insured) EFFECTIVE DATE 11/16112 EXPIRATION DATE 11115/13 X DIRECT SILL AGENCY BILL DATE PAIVOTIANYT) 11r2/2012 PAYMENT PLAN AUDIT FOR COWART USE ONLY CONSTRUCTION TYPE. STEEL FRAME BUILDING IMPROVEMENTS VelRliO YR worm:, YR OTIOR RIGHT EXPOSURE A DISTAIICE Restaurant same building IWROLAR ALARM TYPE INSTANCE TO HYDRANT FIRE S TA I FT] 2/Al: 0100 COD GRADE PLUMBEIG. YR HEATING. YR FIRE DISTRICT/CODE NUMBER TAX CODE j ROOF 'TYPE M WIND CLASS I RESISTIVE I I rts(Fmisis. int( LEFT EXPOSURE S. DISTANCE Office satno building CERTIFICATE a I OTHER PROT CL I N STORIES IS BASIPT3 YR BUILT TOW. AREA 2 0 1990 2,800 OTHER OCCUPANCIES HEATING BOILER ON PREMISES? YES I NO IF YES. IS INSURANCE PLACED ELSEVARRE? I I YES I I NO REAR EXPOSURES DISTANCE Open EXPIRATION DATE BURGLAR ALARM INSTALLED AND SERVICED BY PREMISES FIRE PROTECTION (Sprinklers, Standpipes. COVCIsernIcal Syrian's) M SPRNK 10lb lire extinwsmoke detecto ADDITIONAL INTERESTS RANK: INTEREST LOSS PAYEE MORI. GAGEE NAME AND ADDRESS: REFERENCE A: ITEM DESCRIPTION: VALUE REPORTING INFORMATION EXTENT 1 GRADE OUAROSINATCHMEN FIRE ALARM MANUFACTURER CENTRAL STATION YETI KEYS CLOCK HOURLY CENTRAL STATION LOCAL 00/10 CERTIFICATE REOUIRED INTEREST IN ITEM NUMBER LOCATION: °MOW: SCHEDULED ITEM HUMBER: I OTHER: REPORTING FORM: PROVIDE AVERAGE VALUES TON PAST 12 MON GIS ANY OTHER LOCA. ANY OTHER LCCA. PREMISES NOT OWNED PREMISES, BUR DING TION DECLAREO AT INCEPTION TI ACQUIRED ER TION AFT ON INCEP OR ALIM IT CQUIRED _ SUBJECT OF INSURANCE ACORD 140 (2002/09) ATTACH TO APPLICANT INFORMATION SECTION ACORD CORPORATION 1985 EFTA01221270 ADDITIONAL PREMISES INFORMATION PREMISES I: OUILDIIIO STREET ADDRESS: FINAN-1 OP ID: SSMI 01.00 DESCRIPTION: SUBJECTOP INSURANCE AMOUNT COINS % VALUATION CAUSES OF LOSS IAT i FORMS GUARD% DEOUCTIBLE B OO COV AND CONDITIONS TO APPLY ADDITIONAL WFORMATION TIfFE Of BUSINESS ORDINARY PAYROLL POWER/NEAT I EXT PERIOD Tmnou FEES OFF PREM POWER PEND PROP NON MFG MFG MINING Sc COINS I JOWL 90 DAYS 00 DAYS DEO GAYS IMO PERIOD LEm I MAX PERIOD STUDENTS OTHER ED POWER WATER COMM (DESCR BELOW) 'A COIN CONY LOC REC LOC IMO LOC EXCL ELEC MEDIA DAYS SERVJINC ORDOR LAW DAYS LOR LOC IDESC NEICFA9_ DAYS PERIOD REST LANE AND ADORE-86(ES) FOR OFF PREM POWER OR DEPEND PROP E XTRA EXPENSE LIMIT LOSS PAY ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATION BUSINESS INCOME/ EXTRA EXPENSE BUSINESS INCOME IWO EXTRA EXPENSE EXTRA EXPENSE CONSTRUCTION TYPE BUILDING IMPROVEMENTS WRING, TIT ROOFING, YFt. OTHER RIM EXPOSURE I DISTANCE HYDRANT FIRS STAI DISTANCE TO FTI PLUMBING. YR HEATING. YR BURGLAR ALARM TYPE I BLDG I DE TAX CODE WINO CLASS r I RESISTIVE I I RESISTIVEI I OnER FIRE DISTRICT/CODE MINDER ROOF TYPE LEFT EXPOSURE a INSTANCE CERTIFICATE I PROT CL II STORIES OTHER OCCUPANCIES BASI.VIS YR BURT HEATING DIALER ON PREMISES? U YES. IS FISURANCE PLACED ELSEWIIERET TOTAL AREA I YES I I NO — YES REAR EXPOSURE IS DISTANCE EXPIRATION DATE BURGLAR ALARM INSTALLED AND SERVICED BY PREMISES FIRE PROTECTION (SKINAWA, StandpIpw,CONChomIcal Systems) ADDITIONAL INTERESTS PAM: ETTEREST LOSS PAYEE CACEE EXTENT GRADE I OUAROSIWAICH11611 FIRE ALARM MANUFACTURER CENTRAL STATION VAIN KEYS CLOCK NEARLY CENTRAL STATION LOCAL GONG HAIN AND ADDRESS: nesa DESCRIPTION: REMARKS Premise 001 theft Sublimit: $10,000 I REFERENCE a: I I CERTIFICATE REQUIRED INTEREST II ITEM MAMMA LOCATION: I BUILDING: SCHEDULED ITEM NUMBER: OTHER: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF 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 SUBJECT OF INSURANCE AMOUNT COWS% , - BUS PERS PROP_ _ _ 500,000 80 • I. 2. 3. OUILOING N; 001 VALUATION CAUSE OF LOSS RC SPEC NFL ISOTELA: DEDUCTIBLE 2,500 FORMS I DATE ULtl ADDITIONAL PREMISESINFORMATION SOI CAUSE WIND EQ COINS% 80 80 RATE RPT AMOUNT 2.20000 3 _ 2.20000 3 TYPE DAS - - - - - VALUE REPORTING INFORMATION SOI CAUSE COINS SI RATE RPT AMOUNT TYPE DAS REPORTING EOM PROVIDE AVERAGE VALUES FOR PAST it MONTHS SUBJECT OF INSURANCE PREMISE INFORMATION • SUBJECT OF INSURANCE 2. 3. 4. S. S. ADDRIONAL PREMISES INFORMATON PREMISES & AMOUNT CO % BUILDING it VALUATION PREMISES/ BUILDING CAUSE OF LOSS INFL ANY OTHER LOCA. NON DECLARED AT INCEPTION DEDUCTIBLE ANY OTHER °CA- RON ACQUIRED AFTER INCEPTION FORMS S PREMISES NOT °MEL OR ACQUIRED IRIT DATE SOI CAUSE COINS % RATE RPT AMOUNT TYPE VALUE REPORTING INFORMATION REPORI RIG FORM: PROVIDE AVERAGE VAI S FOR PAST 2AIONTHS SUBJECT OF INSURANCE DAS SO CAUSE COINS% PREMISE& GUILIANO RATE ANY OTIIER LOCA- TION DECLARED AT INCEPTION ATTACH TO ACORD PROPERTY SECTION RPT AMOUNT TYPE SAS ANY OTHER OCA. PREMISES NOT DIINEC DON ACQUIRED r OR ACQUIRED AFTER INCEPTION I LIMIT APPLIED 140PI (2006/10) EFTA01221272