HOMEOWNERS HO-3 SPECIAL FORM POLICY - RENEWAL DECLARATIONS�� ' Citizens Property Insurance Corporation
Gitizens Service Genter
CITIZE NS fi676 Corporate Center Parkway
PHOPEHTT IN$URRNCE C�HPOpqT10N Jacksonville, FL 32216-0973
Homeowners HO-3 Special Form Policy - Renewal Declara��ores
H03DEC 01 11
Policy Number: FRJH4803019-03-0000 Policy Period: From 12/04/11 To 12/04/12
12:07 A.M. Eastern time at the location of the Residence Premises
Named Insured and Malling Address: Location of Residence Premises: Agent: Phone (727) 447-8585
BEVERLY DE STOF2IES 2816 EDENWOOD S7 Fox Agency, Inc.
2816 EpENWOOD 5T. CLEARWATER, FL 33759 Stephen Walter Szafranski
CLEARWATER, FL 33759 1F350 Drew St.
Clearvvater, FL 33765-2910
FL License: A259595 Citizens I�: 004956
Coverage is only provided where a premwm and a limit of liability is shown.
DEDUCTIBLES: ALL OTHER PERILS: $2,500 SINKHOLE: $2,500 HURRICANE DEDUCTIBLE: $2,658 (2%�
SEC710N 1- PROPERTY COVERAGES
A - Dwelling
B - Other Structures
C - Personai Property
D - Loss af Use
S�CTION II - LIABILITY COVEFtAGES
E - Personal Liability
F - Medical Payments
OTHER COVERAGES
F'erspnal Property Replacement Cost
Ordinance or Law Limit (25% of Cov. A)
Sinkhole Loss Coverage
PREMIUM AbJUSTMENT pUE TO ALLOWABLE RATE CWANGE
MANDATORY ADDIiIONAL CHARGES
Emergency Management Preparedness and Assistance Trust Fund
�nn�r�..�;d� i.a..«:,.o
2005 Citizens Property Insurance Corporation Emergency Assessment
Tax Exempt Surcharge
LIMI7 OF LIABILITY
$132, 9C10
$2,658
$66,450
$13, 290
$30Q,000
$2,000
INCLUD�p
(see policy)
(see policy)
ANNUAL PREMIUM
$720
$34
INCLUDED
$130
INCLUDED
$154
$6
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��.�.�
$10
$18
TOTAL POLICY PREMIUM INCLUDING ASSESSMENTS AND AI.L SURCHARG�S $1,088
IF PAYMENT IS NOT R�CEIVED BY 12/04/11, COVERAGE 15 NOT IN EFFECT.
Insured Note: The portion of your pramium for Hurricane Coverage is: $247 Nan-Hurricans is: $797
Loan Number: RL-496-1477
CI7Y OF GLEARWATEF2
ISAOA/ATIMA
112 SOUTH OSCEOLA AVE.
CLEARWATER, FL 33756
First Mortgagee Copy Page 1 of 3 MID: 3092 / AID: 3092 / FID: 5 Processed Date: 1 Dl05/2011
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Policy Number: FRJH48030'19-03-OOOQ
PAGE 2
Forms and Endorsements applicable to thls policy:
CIT HO-3 01 10 CIT 23 94 01 10 CIl' 24 07 08
:.
H03DEC 01 11
Polic�y Period: From 12/a4/11 To 12/�4/12
12:01 M. Eastem time at the location of the Residence Premises
CIT04900708 H0 04 96 04 91
Ratin Information:
- --- -Form - —Y�ar Bullt! —_.��wn/Row �-- ---Gonstrucllon.._.. - --.-.._ ----. _. .. ..—.. .-- --.- .� ' Lhiail__. ...__Mun._Code..
Type Varifi�d Housrx Type BCEGS Territory Exclusian Fire ! Police
H03 1973/Yes No Masonry 99 081 / D00-W No 251 ! 251
o. Protect on Dist o pist o re
County Occupancy Use Families Class Hydrant Station
PINELLAS Owner Primary 1 02 200 feet 3 miles
Protective Devlce Gredits Na Priar Insurance Hurricane
Burglar Surcharge peductlble
Alarm Fire Alarm Sprinkler Zone
No No No No N!A
T�rraln / WBDR, . Building Type Raof Cover Roof Deck Attachment Roof-Wall Connection
e/ IN 1-4 Units FBC Equivalent B- 8d @ 6" / 12" Clips
5ecandary Water Roof Shape Opening Protectlon FBC Wlnd Speed FBC Wlnd Design
Resistance .
No Gable None N!A N!A
A premium adjustment of -$576 is included to reflect the building's wind loss mitigation features or construction techniques that exists.
A premium adjustment of $0 is included to reflect the building code grade for your area. Adjustments range from a 5% surcharge to
a 46% credit.
Your property coverage limlts may have been adJusted for inflation.
Your policy premlum has incroeased by $21. Of thls amouni:
The premium diiference due to an approved rate change is $0
7he premfum difference due to changes in your coveraga is $17
The premium diffierence due to mandatory additional charges plus FHCF Build-Up fs $4
Authorized Bv: Steohen Walter Szafranski
Flrst Mortgagee Copy Page 2 of 3 MID: 3092 / AID: 3092 / FID: 5 Processed Date: 10/05/2011
Policy Number: FRJH4803019-p3-0000
PAGE 3
NO3DEC 01 11
Polic�Period� From 12/04/11 To 12/Q4/12
12:01 A. . Eastern time at the location of the Residence F'remises
FLOOD COVERACE IS NOT PRQVIDED BY THIS POLICY
THIS POLICY COIVTAINS A SEPARATE DEDUCTIBLE FOR
HURRICANE LOSSES, WHICH MAY RESULT IN HIGH
OUT-OF-POCKET EXPENSES T� YOU.
LAW AND QRDIN�►NCE COVERAGE IS AN IMPORTANT
C�VERAGE THAT Y4U MAY WISH TO PURCHASE. YOU
MAY ALSO NEED TO C�NSIDER THE PURCHASE OF
FLOOD INSURANCE FROM THE NATIONAL FLOOD
INSURANCE PROGRAM. WITH�UT THIS COVERAGE YOU
MAY HAVE UNCOVERED LOSSES . PLEASE DISCUSS
iHESE COVERAGES WITH YOUR INSURANCE AGENT.
_--
__
TO REPORT A CLAIM CALL 866 4'I'�-2742
INFORMA710N ABOUT YOUR POLICY MAY BE MAD� AVAILABL� TO INSURANCE COMPANIES ANp/OR AGENTS
�t0 ASSIST THEM IN FINDING UtHER AVAILABLE IN5URANCE MARKETS.
PLEASE CONTACT' YOUR AGENT IF 7HERE ARE ANY QUESTIONS PEf2TA1NING TO YOUR POLICY. IF YOU AFtE UNABLE TO
GQNTACT YOUR AGENT, YUU MAY REACH CITIZENS AT (8$$) 685-7555.
First Mortgagee Copy Page 3 of 3 MID: 3p92 / AID: 3092! FID; 5 Prpcessed Date: 10/05/2011
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