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CERTIFICATE OF LIABILITY INSURANCE (2) r RV N W RY NUfi,R)A tSS(K_iM FNY RAN(F «c, Specialty Insurance Products Clearwater Audubon Society Insurance Policy Number: NAAO00031117 Po Box 97 Clearwater , FL 33757 Tel (800) 364®2433 Email support@rvnuccio.coni Online rvnuccio.corn Office 10148 Riverside Drive Toluca Lake,CA 9602 Your Insurance Policy What's included: * Your Certificate(s) of Insurance * A copy of your Application * Your Mernorandurn `' Your Coverages Your Quote Letter "hank you for choosing R.V. Nuccio&Associates Insurance Brokers, Inc. —We look forward to helping with your specialty insurance needs. DATE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 02/20/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Robert V. Nuccio R.V. Nuccio&Associates Insurance Brokers, Inc. a/c"N Ext: 800 364-2433 a/c No: 818 980-1595 10148 Riverside Drive E-MAIL support@rvnuccio.com Toluca Lake, CA 91602 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Fireman's Fund Insurance Company 21873 INSURED INSURER B: Nationwide Life Insurance Company 66869 Clearwater Audubon Society INSURERC: Po Box 97 INSURER D: Clearwater, FL 33757 INSURER E 7 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MWDD/YYY MWDD/YYY A GENERAL LIABILITY ✓ XPK80980731 5/31/2018 5/31/2019 EACH OCCURRENCE $ 1,000,000 ✓ DAMAGE TO RENTED 100,000 COMMERCIAL GENERAL LIABILITY NAA000031117 PREMISES Ea occurrence $ CLAIMS-MADE 5,1 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 m POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Directors&Officers NPOD00043163 5/31/2018 5/31/2019 $1,000,000 B AD&D Medical Plus NPOAM0033072 5/31/2018 5/31/2019 $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Additional Insured Wording: Start Date: 5/31/2018 End Date: 5/31/2019 Event Description:Various events CERTIFICATE HOLDER CANCELLATION Pinellas county a political subdivision of the state of Florida SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 400 S Ft Harrison Ave ACCORDANCE WITH THE POLICY PROVISIONS. Clearwater ,FL 33756 AUTHORIZED REPRESENTATIVE Robert V. NuCCiO ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: XPK80980731 COMMERCIAL GENERAL LIABILITY EFFECTIVE DATES: 5/31/2018 to 5/31/2019 CG 20 26 07 04 CERTIFICATE NUMBER: NAA000031117 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) Pinellas county a political subdivision of the state of Florida 400 S Ft Harrison Ave Clearwater ,FL 33756 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s)or organi- zation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ DATE(MM/DD/YYYY) A�" CERTIFICATE OF LIABILITY INSURANCE 02/20/2018 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Robert V. Nuccio R.V. Nuccio&Associates Insurance Brokers, Inc. a/c"N Ext: 800 364-2433 a/c No: 818 980-1595 10148 Riverside Drive E-MAIL support@rvnuccio.com Toluca Lake, CA 91602 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Fireman's Fund Insurance Company 21873 INSURED INSURER B: Nationwide Life Insurance Company 66869 Clearwater Audubon Society INSURERC: Po Box 97 INSURER D: Clearwater, FL 33757 INSURER E 7 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MWDD/YYY MWDD/YYY A GENERAL LIABILITY ✓ XPK80980731 5/31/2018 5/31/2019 EACH OCCURRENCE $ 1,000,000 ✓ DAMAGE TO RENTED 100,000 COMMERCIAL GENERAL LIABILITY NAA000031117 PREMISES Ea occurrence $ CLAIMS-MADE 5,1 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 m POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Directors&Officers NPOD00043163 5/31/2018 5/31/2019 $1,000,000 B AD&D Medical Plus NPOAM0033072 5/31/2018 5/31/2019 $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) Additional Insured Wording: City of Clearwater Start Date: 5/31/2018 End Date: 5/31/2019 Event Description:Various events CERTIFICATE HOLDER CANCELLATION City of Clearwater SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE PO Box 4748 THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. Clearwater ,FL 33756 AUTHORIZED REPRESENTATIVE Robert V. NuCCiO ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD POLICY NUMBER: XPK80980731 COMMERCIAL GENERAL LIABILITY EFFECTIVE DATES: 5/31/2018 to 5/31/2019 CG 20 26 07 04 CERTIFICATE NUMBER: NAA000031117 THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. ADDITIONAL INSURED - DESIGNATED PERSON OR ORGANIZATION This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Name Of Additional Insured Person(s) Or Organization(s) City of Clearwater PO Box 4748 Clearwater ,FL 33756 Information required to complete this Schedule, if not shown above, will be shown in the Declarations. Section II — Who Is An Insured is amended to in- clude as an additional insured the person(s)or organi- zation(s) shown in the Schedule, but only with respect to liability for "bodily injury", "property damage" or "personal and advertising injury" caused, in whole or in part, by your acts or omissions or the acts or omis- sions of those acting on your behalf: A. In the performance of your ongoing operations; or B. In connection with your premises owned by or rented to you. CG 20 26 07 04 © ISO Properties, Inc., 2004 Page 1 of 1 ❑ 702/20/2018 (MM/DD/YYYY) A`�"® CERTIFICATE OF LIABILITY INSURANCE THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: Robert V. Nuccio R.V. Nuccio&Associates Insurance Brokers, Inc. a/c"N Ext: 800 364-2433 a/c No: 818 980-1595 10148 Riverside Drive E-MAIL pp ADDRESS: su ort rvnuccio.com Toluca Lake, CA 91602 INSURER(S)AFFORDING COVERAGE NAIC# INSURERA: Fireman's Fund Insurance Company 21873 INSURED INSURER B: Nationwide Life Insurance Company 66869 Clearwater Audubon Society INSURERC: Po Box 97 INSURER D: Clearwater, FL 33757 INSURER E 7 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS LTR INSR WVD POLICY NUMBER MWDD/YYY MWDD/YYY A GENERAL LIABILITY XPK80980731 5/31/2018 5/31/2019 EACH OCCURRENCE $ 1,000,000 ✓ DAMAGE TO RENTED 100,000 COMMERCIAL GENERAL LIABILITY NAA000031117 PREMISES Ea occurrence $ CLAIMS-MADE 5,1 OCCUR MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO LOC $ JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per accident UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? N/A (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ A Directors&Officers NPOD00043163 5/31/2018 5/31/2019 $1,000,000 B AD&D Medical Plus NPOAM0033072 5/31/2018 5/31/2019 $25,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) 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. AUTHORIZED REPRESENTATIVE Robert V. NuCCiO ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD SCHOOL SUPPORT GROUP/NONPROFIT ORGANIZATION COMMERCIAL PACKAGE INSURANCE POLICY MEMORANDUM OF INSURANCE Master Policy Number:XPK80980731 Memorandum Number: NAA000031117 Issuing Company: National Program Administrator: Fireman's Fund Insurance Company R.V.Nuccio&Associates Insurance Brokers,Inc. 777 San Marin Drive 10148 Riverside Drive Novato,California 94998-2000 Toluca Lake,CA 91602 Nationwide Claims: 1-800-567-2685 Nationwide: 1-800-567-2685 01. MEMORANDUM HOLDER NAME AND ADDRESS(MEMORANDUM HOLDER MEANS NAMED INSURED) a. Memorandum Holder:Clearwater Audubon Society b. Street Address: Po Box 97 C. City: Clearwater d. State: FL e. Zip Code: 33757 02. COVERAGE PERIOD Inception Date 5/31/2018 12:01A.M.to Expiration Date 5/31/2019 12:01A.M. Standard Time at the Named Insured's address as stated above. 03. BUSINESS TYPE [:]PTA ❑PTO ❑Booster Club ❑Educational Foundation mNonprofit Organization 04. COVERAGE PART LIMIT OF INSURANCE DEDUCTIBLE PREMIUM a. INLAND MARINE PROPERTY COVERAGE PART $ 0.00 Business Personal Property/Equipment $ Not Covered $ Not Covered b. INLAND MARINE CRIME COVERAGE PART $ 0.00 (O1)Employee Dishonesty $ Not Covered $ Not Covered (02)Forgery Or Alteration $ Not Covered $ Not Covered (03)Theft,Disappearance And Destruction Of Money (a)Inside The Premises $ Not Covered $ Not Covered (b)Outside The Premises $ Not Covered $ Not Covered c. GENERAL AND AUTOMOBILE LIABILITY COVERAGE PART $ 136.00 (0I)General Aggregate $ 2,000,000 $ 0 (02)Products/Completed Operations Aggregate$ 2,000,000 (03)Personal And Advertising Injury $ 1,000,000 (04)Each Occurrence $ 1,000,000 (05)Damage To Premises Rented To You $ 100,000 (06)Medical Expense $ 5,000 (07)Non-Owned And Hired Automobiles $ Not Covered State Guarantee Fund $ 0.00 05. TOTAL PREMIUM Due At Inception $ 136.00 06. FORMS AND ENDORSEMENTS ATTACHED AT INCEPTION Date Issued:02/20/2018 By Form Number:NPOUWS001 Robert V.Nuccio 3/20/2008 NPOUWS001 ©Copyright 2008. All rights reserved. R.V.Nuccio&Associates Insurance Brokers,Inc. 818-980-1413. SCHOOL SUPPORT GROUP/NONPROFIT ORGANIZATION DIRECTORS & OFFICERS LIABILITY INSURANCE POLICY MEMORANDUM OF INSURANCE Master Policy Number: NDF32253080 Memorandum Number: NPOD00043163 Issuing Company: National Program Administrator: Fireman's Fund Insurance Company R.V.Nuccio&Associates Insurance Brokers,Inc. 777 San Marin Drive 10148 Riverside Drive Novato,California 94998-2000 Toluca Lake,CA 91602 Nationwide Claims: 1-800-567-2685 Nationwide: 1-800-567-2685 01. MEMORANDUM HOLDER NAME AND ADDRESS(MEMORANDUM HOLDER MEANS NAMED INSURED) a. Memorandum Holder: Clearwater Audubon Society b. Street Address: Po Box 97 C. City: Clearwater d. State: FL e. Zip Code: 33757 02. COVERAGE PERIOD Inception Date 5/31/2018 12:01A.M.to Expiration Date 5/31/2019 12:01A.M. Standard Time at the Named Insured's address as stated above. 03. RETROSPECTIVE DATE:5/31/2018 04. BUSINESS TYPE [:]PTA ❑PTO ❑Booster Club ❑Educational Foundation mNonprofit Organization 05. COVERAGE LIMIT OF INSURANCE RETENTION PREMIUM a. DIRECTORS&OFFICERS LIABILITY $ 150.00 01. Each Occurrence $ 1,000,000 $ 0 02. Annual Aggregate $ 1,000,000 $ 0 b. EMPLOYMENT PRACTICES LIABILITY $ Excluded $ Excluded State Guarantee Fund $ 0.00 06. TOTAL PREMIUM Due At Inception $ 150.00 07. FORMS AND ENDORSEMENTS ATTACHED AT INCEPTION Date Issued: 02/20/2018 By J Form Number:N POUWS001 Robert V.Nuccio 3/20/2008 NPOUWS001 ©Copyright 2008. All rights reserved. R.V.Nuccio&Associates Insurance Brokers,Inc. 818-980-1413. SCHOOL SUPPORT GROUP/NONPROFIT ORGANIZATION ACCIDENT MEDICAL INSURANCE POLICY MEMORANDUM OF INSURANCE Master Policy Number: 60271000013077001 Memorandum Number: NPOAM0033072 Issuing Company: National Program Administrator: Nationwide Life Insurance Company R.V.Nuccio&Associates Insurance Brokers,Inc. 1 Nationwide Plaza 10148 Riverside Drive Columbus,OH 43215 Toluca Lake,CA 91602 Nationwide Claims: 1-800-567-2685 Nationwide: 1-800-567-2685 01. MEMORANDUM HOLDER NAME AND ADDRESS(MEMORANDUM HOLDER MEANS NAMED INSURED) a. Memorandum Holder: Clearwater Audubon Society b. Street Address: Po Box 97 C. City: Clearwater d. State: FL e. Zip Code: 33757 02. COVERAGE PERIOD Inception Date 5/31/2018 12:01A.M.to Expiration Date 5/31/2019 12:01A.M. Standard Time at the Named Insured's address as stated above. 03. BUSINESS TYPE [:]PTA [:]PTO [:]Booster Club ❑Educational Foundation mNonprofit Organization 04. COVERAGE PART BENEFIT DEDUCTIBLE PREMIUM ACCIDENT MEDICAL INSURANCE $ 81.00 a. Accidental Death $ 5,000 $ 25 b. Accidental Dismemberment $ 5,000 $ 25 c. Accident Medical Expense $ 25,000 $ 25 d. Dental Maximum $ 250 $ 25 State Guarantee Fund $ 0.00 05. TOTAL PREMIUM Due At Inception $ 81.00 06. FORMS AND ENDORSEMENTS ATTACHED AT INCEPTION Date Issued:02/20/2018 By c Form Number:N POUWS001 Robert V.Nuccio 3/20/2008 NPOUWS001 ©Copyright 2008. All rights reserved. R.V.Nuccio&Associates Insurance Brokers,Inc. 818-980-1413. RVNA .V NI1CCIo &ASSOCIATES, INC.. Applicant Information Master Organization-NPO Chapters National Audubon Society Chapter Name Clearwater Audubon Society Contact First Name John Contact Last Name Hood Address Po Box 97 City Clearwater State FL Zip Code 33757 Phone 727 461 4762 E-Mail jhood2@tampabay.rr.com Website Address Membership dues(Enter Dollar Amount) 1694 Cash grants/gifts(Enter Dollar Amount) 15,641 Alcohol/Liquor Sales(Enter Dollar Amount) 0 Food/Non-Alcohol Beverage Sales (Enter Dollar Amount) 0 Bingo Games (Enter Dollar Amount) 0 Other Fund Raising Activities(Enter Dollar Amount) 0 Total Annual Revenues/Receipts 17335 How did you hear about us? Another Nonprofit Organization Underwriting Does your Chapter own or co-own any real property, building, structure, premises, facility, No land, vacant land or acreage? Is your Chapter required by a written contract or agreement to manage the affairs and/or No daily operations of any real property, building, structure, premises, facility, land,vacant land or acreage? Is your Chapter required by a written rental agreement or written lease agreement to clean, No repair or maintain any real property, building,structure, premises, facility, land, vacant land or acreage? Does your Chapter have any activities, events or operations involving the use of live, No popper or blank ammunition, guns, gun props,starter pistols or any other weapons of any type or kind? Does your Organization have any other Organizations,Auxiliaries, Clubs, Chapters, No Groups or Entities operating along with, attached to,subordinate to or under your Organization;or any other Organizations,Auxiliaries, Clubs, Chapters, Groups or Entities over which you exercise any control and to which you might expect this insurance to also provide insurance coverage? Does your Chapter or Club have any activities, events or operations involving the use of n/a Snakes or Snake Aversion Training? Does your Chapter or Club have any activities, events or operations involving Animal n/a Rescue? Does your Chapter or Club have any activities, events or operations involving security dog n/a training, protective dog training, attack dog training, guard dog training, police dog training or military dog training? How many days each year does your Chapter sponsor an activity or hold games, have 36 meetings, gatherings or events of any type or kind? Coverages Effective Date 5/31/2018 Liability Plus $1,000,000/$2,000,000 Damage to Premises Rented Limit $100,000 RVNA .V NI1CCIo &ASSOCIATES, INC.. Bonding Plus No, I do not want to purchase this coverage I understand and agree that no coverage will be provided unless we install and maintain n/a the required accounting procedures at inception and throughout the coverage period. Directors and Officers Liability Plus Limit$1,000,000 Est. Gross Receipts 17335 Would you like to add EPLI coverage to your Directors and Officers Liability coverage? No Accident Medical Plus Limit$25,000 Property Plus No, I do not want to purchase this coverage. Do you understand and agree that if you misrepresent the Master Organization to which Yes your local Auxiliary,Affiliate, Camp, Chapter, Club, Encampment, or Lodge belongs, it is a material misrepresentation which directly affects our decision to insure you, and that no coverage will be provided should a loss occur? I agree that after diligent inquiry, neither I nor any of our Directors, Officers or Members are Yes aware of any circumstances, conditions, or situations which may give rise to a loss under this insurance. Do you understand and agree that any known or existing circumstances, conditions or Yes situations which may give rise to a loss under this insurance will not be covered by the policy? Do you understand and agree that if you select the Mail-in Check payment option, the Yes effective date will be the date payment is processed by R.V. Nuccio&Associates or the requested effective date,whichever is later? I understand and agree that the underwriter retains the right to review the application for Yes accuracy, and that the policy will not provide any insurance coverage if any application information is falsely reported, falsely stated, incorrectly selected, stated, misreported, misrepresented, misstated or wrongly stated,whether or not intentional. I understand and agree that by entering my name below, I am effectively signing this application for insurance. Name John Hood Accepted Date 2/12/2018 Expiration Date 5/31/2019 Memorandum Number D&O NPODO0043163 Memorandum Number NAAO00031117 Memorandum Number AD&D NPOAM0033072 a. There will be no pre-signing of blank checks. n/a b. There will be a monthly bank reconciliation (re-balancing of the checkbook)performed by n/a an organization officer other than that officer(usually the Treasurer)normally responsible for banking functions(this forces discovery of deposits which should have been made but have not been made). Additional Insureds 1 Additional Insured Name Pinellas county a political subdivision of the state of Florida Address 400 S Ft Harrison Ave City Clearwater State FL Zip Code 33756 Email Address Phone Number Event Description Various events Event Start Date 5/31/2018 Event End Date 5/31/2019 Special Wording Additional Insured Endorsement Wording RVNA .V NI1CCIo &ASSOCIATES, INC.. Primary&Noncontributory n/a Waiver of Subrogation n/a 2 Additional Insured Name City of Clearwater Address PO Box 4748 City Clearwater State FL Zip Code 33756 Email Address Phone Number Event Description Various events Event Start Date 5/31/2018 Event End Date 5/31/2019 Special Wording City of Clearwater Additional Insured Endorsement Wording Primary&Noncontributory n/a Waiver of Subrogation n/a Total Number of LossPayees 0 1ftZ. VNA IV R.V.Nuccio &ASSOCIATES, INC. NONPROFIT ANNUAL INSURANCE QUOTE APPLICANT INFORMATION Applicant Name: Clearwater Audubon Society Date: 02/20/2018 Proposed Coverage Date: 5/31/2018 Client ID#: 1288242 POLICY INFORMATION LIMIT COST 1. Liability Plus $1,000,000/$2,000,000 $ 136.00 RVNA, Inc. Administration Charge $ 129.00 RVNA, Inc. Unlimited Additional Insured Charge $ 50.00 2. Bonding Plus Not Covered $ 0.00 RVNA, Inc. Administration Charge $ 0.00 3. Directors & Officers Liability Plus $1,000,000 $ 150.00 RVNA, Inc. Administration Charge $ 112.50 4. Accident Medical Plus $25,000 $ 81.00 RVNA, Inc. Administration Charge $ 75.00 5. Property Plus Not Covered $ 0.00 RVNA, Inc. Administration Charge $ 0.00 RVNA, Inc. Loss Payee Charge $ 0.00 State Guarantee Fund $ 0.00 TOTAL $ 733.50 If you wish to purchase this exclusive insurance product, please log in at protectjoHrg2n jarofit.com NOTES • This is a quotation only. Prices are subject to change without notice. • Quotation is subject to online completion of the application and underwriting approval. • It is the insureds responsibility to read the policy. Request a sample policy online at protectyournonprofit.com. • Licensing information available upon request. • Policy is underwritten by an A+rated insurance carrier. R.V.NUcclo&ASSOCIATES,INC. • 10148 RIVERSIDE DRIVE•TOLUCA LAKE•CA• 91602. 818-980-1413