APPLICATION FOR WINDSTORM AND HAIL INSURANCE ONLY
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APPLICATIO~ FOR WeIiDSTOR~ A.'l> HAIL P.liSl-RA~CE O~LY
TO:
FLORIDA WL'iDSTOR~
UNDERWRITL'iG ASSOCIATION
ITHE "ASSOClAnO~;
1000 RIVERSIDE A VE~L~. SlJITE 408
JACKSO~"~'ILLE. FLORIDA 32204
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o EXPIRING POLICY NO.,
IF ANY _
NOTICE TO APPLICANT
This application is not a binder of insurance. The Associatior -as ~o insurance agents. No insurance agent has authority
either: lal to bind windstorm insurance coverage by ~eceiving this 30~:;O'CG:;on. collecting premiums or any other manner; or (b\ to
waive any requirements of :/<s application or the windstorm insura-c~ :lol icy which me Association may issue. APP LI CANTS
MUST NOT RELY ON MEPRESENTATIONS OF ANY PARTY OT;....=R THAN THE ASSOCIATION IN ITS JACKSONVILLE
OFFICE.
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2. A;;>plicant's Name and Mailing Address
(,,"umber, Street, Citl or Town, County, State, Zip Code)
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1. Licensed Florida Agent fill in this space:
(Name of Agency and Mailing Address)
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3. Construction, Description and Location of Property - Furnish ISO Risk Number (if rated)
NOTE: If more than one building, provide schedule of amounts desired and complete information for each building.
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Street Location
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City or Town
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I County
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State
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Zip Code
4. AMOUNT OF COVERAGE REQUESTED:
Dwelling. % of CoinSurance Applicable
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:e.,:. '-sura"'ce)
3...iiding / iJ/ C,()(r6 Contents
(A'r1ou~! of Cove-agel (Amount of Coverage I
iCOln1uranca
3uiiding ~___ Contents _.__
'Amount of Coveragel (Amount of Coveragel
Other Classes."S of Co 'I)Urance Applicable
Deductible
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Loss Participatior
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'~c:e'Terr. ~__ Premium,...;. - -
4a. .:"u::o'T1Citic Quarte~iy !nc-~~se of PO, 1,/,0.;, 2":
3ui!c,'1g Only ( or C:-:=C"itS Only i
5. NCi~e ard address of n1ort;~;~e, if any:
L', Gr
: -:;' one' 3,:::)les to Building and Contents (
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6. (a)
(b)
(c)
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(f)
(g)
This building was cors,ructed in (year) ~ <..,
Does this property ha,e flood coverage? Yes No Unknown __
The actual cash value of this building is S ;. . .- .~~ Contents
Total amount of fire :~surance carried on this building is S --' ; Contents ___
The total floor area of this building is i - .; ::- squar-e 'e€t.
Distance to bay, gulf, river or ocean i,-.: .--:..-
Attach one (or more) photographs in space provided on reverse SJde.
7. EFFECTIVE DATE DESIRED: 5"- 51- S ~ . If, as of such desired date. the following events have not taken place,
then the policy shall become effective when the last e-.,'ent occurs:
(a) the day following receipt of the premium due by the Associatiot'1 at its Jacksonville office;
(b) approval of the application by the Association;
The policy will become effective at 12:01 a.m. on the effective date.
Mobile home policies may become effective upon ~eo?;pt of tie-<~~ certification. NO INSURANCE AGENT HAS THE POWER
TO MAKE THE POLICY EFFECTIVE. RECEIPT BY AGENTS OF PREMIUMS IS NOT RECEIPT BY THE. ASSOCIATION
AND DOES NOT MAKE THE POLICY EFFECTIVE.
FWUA No. 1 (9-821
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8. The Name of the per>Ofl tl1e representative can contact. if nece~ry. is:
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Te'~hone Numtl'?'
This request is made with the understanding that I (the applicant) agree to accompany your represer:ative while surveying this
~operty. Survey!s) made under tl1e program and any report of the sur.e.,!s) is for insurance underwriting purpose, Aeg<lrdless of
whether a policy is issued. neither the applicant. nor the Associat;on, its governing committee. agents, oHicers or employees, nor
any member insuror. nor any inspection service tl1ereof. will be liable for any injury or damage claimed to arise ~ro'rri the
survey!s), the survey reports!s) of the physical condition of the premises, the action report!s), omissions from such survey(s), or
from compliance or non.compliance by the property owner or others with the recommendations. if any. contained in said survey
report!s) and no cause of action of any nature shall arise against the above named persons or entities for any surveys undertaken
or statements made in connection with property to be insured. Notl1ing contained in or omitted from said survey report(s) shall be
construed to infer or imply that the hazardous physical condition. if any, so noted or omitted, constitute all such conditions
existing on th~ property at the time of said survey(s). Permission is granted to submit copie, of any survey!s) to the Florida
Insurance Depdrtment. insurers and their agents or representatives.
9. NOTICE TO APPLICANT: This application must be approved in writing by the Association in its Jacksonville oHice, No
insurance agent has authority to dpprove windstorm insurance coverage or contract for windstorm insurance coverage or to make
any representations or promises about windstorm insurance coverage that will bind the Association. No new or increased
coverage shall be bound or application for new or increased coverage accepted when a des;gnated hurricane is located within the
boundaries West of 7-ZO West Longitude and North 150 North Latitude and South of 350 North Latitude. A designated
hurricane is a windstorm identified as a hurricane by the National Oceanic and Atmospheric Administration.
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Signature of Applicant L,G~.Lua;, 71 ~7.."-LL~'rL.
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Date
I herebv certify that I am a licensed Florida Agent.
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License No, expiring 19
In the event a policy IS ,ssued and then cancelled or insurance thereunder
terminated, or a change is made resulting in a r~turn prerr.l..lm due, I agree
~o return mv proporr;onate share of the commlss.on on suen "erurn premium
to !t'le ,"SlJred.
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#~':J~ ~~rr.::r.r!i. IS 320.3325. F ~~.ca Sta~'Jtel. I 3'i#2'€ ~o oa" j ~. = ::,c relns,c,ec-
:Ion fee If my moblie hom~ .5 found not to comply ..-w;th :he Statute.
S'gnature of Appl,cant
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Insur=O=Gram
SENDeR: REMOVE YellOW COPY
FORWARD WHITE AND PINK COPIES
REPliER: RETURN WHITE COpy
RETAIN PINK FOR FilE
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INSURANCE AGENCY INC
620 BYPASS DRIVE
P. O. BOX 5025
ClEARWATER. flORIDA 33518-4985
Phone (813) 797-4499
Tampa 229-8208
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;~crLda WLndstorm Lnde~~abtLng
;'ssocLatLon
180 P:.v~rsLd2 Avenue. Su;_te 403
L'.::lck3C,,,'.,ri_lLe, Fl. 32204 -.J
SUBJECT: ClecrlJo:er,geG.:r1 Seafc:d. Inc.
DATE 5 - 21 - 34
Dear SLrs,
As per M~~e G00ch jLscuss~cn ~~~h 8cug ~?~~herby cfi ~ay 13,~~~4 the rat~
for wL~jsc0rm f~r 2uLlders ~Ls< ~n a JO:.s:ed Masonry 2nd s:ory oddLtLc~
Ls .169 x ~~O,OOO c~ InSUrGnC0 = $237.00 pL~s.15% whLch Ls 536.00 = 273
a n il U a \.. p r 2 ,.., .- U 'll . T h ,_ S 0 C '_ L.: L/ ,'L ,_ ,_ C 0 v e r ':.J II ,j s :. 0 r men the 2 n j 3 tor y ,") c d :_ ':: l 0 n
only excLujL~q covgroce O~ t~2 1s~ fLoor ~xL5tLng s~ructur~.
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Dcn:""~ Lali:lk fo rd
SIGNED