Tuesday, August 04, 2015

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1 Tuesday, August 04, 2015 Regency Insurance Group 5248 Red Cedar Dr Suite 103 Fort Myers, FL Main Fax Mr. Walch - It was a great pleasure working with you and thank you for the confidence you have placed in us. Please find listed below the items we need to complete your file. In order to expedite the transition into your new policy, please be sure to send us all of the items we are requesting as soon as possible as they are time sensitive to the insurance company. Please be sure to enclose all of the files directly to our agency and payment directly to the insurance company. Home Policy Signed application ed, mailed, or faxed back to us. Please make any changes and initial Please send us proof of prior insurance (declarations page or renewal notice) Please send us signed cancel request (form attached to the application). Please send us signed actual cash value form (form attached to the application). Auto Policy Please also include your auto insurance declarations page. We would like to review this to make sure you have a competitive rate for your auto policy. Lastly, I would like to take this opportunity to inform you that we have a team of Account Executives that handle any questions or inquiries you may have regarding your folio. Tabetha McFalls will be your point of contact, and has been given the responsibility of making sure you receive the best customer service in town. If you have any questions at all please do not hesitate to call. I greatly thank you for your business and look forward to working with you for years to come. Sincerely yours, Heather Hopkins

5248 Red Cedar Drive, Suite 103 Fort Myers, FL 33907 Helpful Home Ideas: Trim Tree Branches Patch Stucco Cracks Repair Damaged Shingles Leaving Town for a few days: Weather seal all doors and windows

newspaper Turn off emergency water cut-off valve Forward mail Turn off washing machine & hot water heater If on, set refrigerator to warmest.

secure. Some of the most common damage that occurs to homes can sometimes be prevented if you know how to identity, reduce or eliminate risks.

2 5248 Red Cedar Drive, Suite 103 Fort Myers, FL Helpful Home Ideas: Trim Tree Branches Patch Stucco Cracks Repair Damaged Shingles Leaving Town for a few days: Weather seal all doors and windows Set A/C to 77 degrees Clean out gutters Turn off pool heater at circuit breaker box Set pool filter pump to 6 hours per day during Put lights on a timer summer and 4 hours a day during winter Suspend newspaper Turn off emergency water cut-off valve Forward mail Turn off washing machine & hot water heater If on, set refrigerator to warmest. If off, clean and leave door open Clear Yard Debris Inspect Screen Enclosure Loss Prevention: Whether you live in a condominium, mobile home or site-built house, you want your home to be safe and secure. Some of the most common damage that occurs to homes can sometimes be prevented if you know how to identity, reduce or eliminate risks. Please take a moment to consider the following: Appliances: Routinely inspect all hoses and lines on washing machines, dishwashers and icemakers for kinks, cracks or evidence of deterioration, replacing them as needed. Vacuum dust and lint around, under and behind the dryer. Regularly clean the dryer vent and pipe to remove accumulated lint and debris, especially if your dryer vents through the roof. Water Main: Make sure everyone in your household knows where the main water valve is in the home, as well as how to turn it off. Before traveling, turn off the water at the main valve or at major appliances. Central Air Conditioning: When turning on the air conditioner for the season and during monthly use, pour a cup of mild bleach solution down the drain line to reduce algae and mold. Check the drip pan under the evaporator coils monthly for standing water. Have a qualified technician perform regular service checks to ensure the system is functioning properly. Tubs, Showers & Sinks: Cracks or mold on caulking may indicate the seal is no longer watertight. Remove old caulk, clean thoroughly, and dry before applying new caulk. Dispose of perishable food Clear dishwasher & open door Ask a friend to check in on the property Don t advertise on social media that you will be out of town Roof: If you can safely inspect your roof, look for cracked or missing shingles, rotted wood or exposed areas near pipes, chimneys and vents. If you are unable to inspect your roof, consider hiring a home inspector or roofing company to check your roof annually. Gutters: Clean out gutters once or twice each year. Make sure downspouts are connected properly and carry water away from the foundation. Water Heaters: Drain and clean the water heater as recommended by the manufacturer. Inspect your water heater annually for rust, cracks and leaks. Toilets: Check and replace the fill valve or float if the toilet tank takes a long time to fill up or runs constantly. Replace copper and plastic toilet supply lines with flexible, reinforced hoses. Smoke Alarms: Test the smoke alarms monthly by pushing the test button to ensure they are operating correctly. Change the smoke alarm batteries annually. Fire Extinguishers: Keep at least one multi-purpose ABC (rated for most household fires) fire extinguisher in your home. Inspect your fire extinguishers periodically to ensure that they are in working condition

PFL317422-00 08/15/2015 12:01 AM MICHAEL F WALCH SUSAN E WALCH 750 2ND ST MERRITT ISLAND, FL 32953 750 2ND ST MERRITT ISLAND, FL 32953 $1,000 $3,300 (2%) Coverage $1,000 Coverage is only provided

3 PFL /15/ :01 AM MICHAEL F WALCH SUSAN E WALCH 750 2ND ST MERRITT ISLAND, FL ND ST MERRITT ISLAND, FL $1,000 $3,300 (2%) Coverage $1,000 Coverage is only provided where a limit of liability and a premium is shown. 08/15/2016 REGENCY INSURANCE GROUP (0313/00-00) 5248 RED CEDAR DR. SUITE 103 FORT MYERS, FL (239) $165,000 $1, $3,300 $2.00 $41,250 INCL $16,500 INCL $300,000 $33.00 $5,000 $9.00 $1, A008 (07/12) Florida Hurricane Deductible Selection Form INCL A009 (11/07) Ordinance or Law Coverage Selection Form 25% INCL A011 (08/12) All Other Perils Deductible Selection Form INCL A012 (11/07) Fungi Wet or Dry Rot Yeast or Bacteria Increased Coverage $5,000 INCL A014 (07/12) Windstorm and Hail Deductible Selection Form INCL E023 (10/11) Preferred Contractor Endorsement $(59.00) Wind Mitigation Device Credit $(722.00) Deductible Adjustment $ Age of Home/Year of Construction $ Emergency Management Preparedness & Assistance Trust Fund Managing General Agency Fee $(482.00) $2.00 $ premium increase $ premium increase $586 $27.00 $1,

4 PFL /15/ /15/ :01 AM A002 (11/07) A007 (09/12) E005 (11/07) E016 (11/07) E024 (07/12) E025 (07/12) HO3 OC (04/10) INF E023 (10/13) OIR-B (01/06) P003 (10/13) Election t to Buy Separate Flood Insurance tice of Premium Discounts for Hurricane Loss Mitigation Liability Coverage for Home Day Care Business Calendar Year Hurricane Deductible - Florida Windstorm or Hail Percentage Deductible Catastrophic Ground Cover Collapse Outline of Coverage Information about your preferred contractor endorsement Checklist of Coverage Florida Homeowners 3- Special Form HO Masonry BREVARD Owner Primary ft ne $ 177 B Dwelling n-fbc Equivalent B - 6in / 12in Clip Other ne (722.00)

5 PFL /15/ /15/ :01 AM 4

6 PFL /15/ /15/ :01 AM 4

7 People s Trust Insurance Company 18 People s Trust Way Deerfield Beach, FL REGENCY INSURANCE GROUP (0313/00-00): (239) HOMEOWNERS INSURANCE APPLICATION (HO-3) MICHAEL F WALCH Policy # PFL Policy Information Policy Form Effective Date: HO-3 08/15/2015 Expiration Date: 08/15/2016 Pay in Full 60% down, 1 pay 40% down, 3 pay Automatic EFT Monthly Payment Total Premium $1,213 Down Payment $ Bill to Applicant Mortgagee Applicant Co-Applicant Primary Phone Applicant and Policy Information Insured(s) MICHAEL F WALCH First Middle Last SUSAN E WALCH First Middle Last (407) MIKE_WALCH@ATT.NET Secondary Phone Fax Number Prior Policy Information / History Prior Insurance Prior Policy Expiration Date 08/15/2015 MM / DD / YYYY Is this a new purchase? Purchase Date MM / DD / YYYY Have you had any coverage declined, non-renewed or cancelled during the last 3 years? If, what was the reason provided by the insurer? Insured Location and Attributes Property / Mailing Address Property Address 750 2ND ST House # Direction Street Name Type Direction Unit # City MERRITT ISLAND State FL Zip County BREVARD Mailing address same as property address Mailing Address 750 2ND ST Address City MERRITT ISLAND State FL Zip County PTIC APP (05/14) PAGE 1 OF 5

8 Location /Community Information Territory Code [ AOP ] Territory Code [ Hurricane ] Building Grade Code Year Built Roof Year Built Dwelling Attributes/Usage Structure Type Structure Definitions Dwelling (Single family/townhouse) 78 Construction Type Masonry Frame Protection Class 99 4 Code Protective Devices Masonry Veneer Fire Alarm (central station monitor; not a smoke detector) Burglar Alarm (central station monitor) Square Footage 1296 Fire Sprinklers ne Class A Class B Occupancy Type Owner Vacant Tenant Unoccupied Residence Usage Primary Secondary / Seasonal 57 Mitigation Features If the applicant has had a Windstorm Inspection completed within the past 5 years, then the applicant should complete the Mitigation Features section of the application. Date of Inspection Terrain Exposure Roof Covering Roof Decking Roof Decking Attachment Roof to Wall Connection B n-fbc Equivalent Dimensional Lumber (Wood) B - 6in / 12in Clip FBC Wind Speed Wind Speed Design Debris Region Opening Protection SWR Roof Geometry ne Other Main Coverages and Deductibles A. Dwelling Limit $165,000 All Other Peril Deductible $1,000 B. Other Structures $3,300 All Other Wind Deductible $1,000 C. Personal Property $41,250 Hurricane Deductible $3,300 (2%) D. Loss of Use Coverage $16,500 Sinkhole Loss Deductible EXCL E. Personal Liability F. Medical Payments to Others Exclude Windstorm / Hail Scheduled Personal Property Personal Property Replacement Cost Type: Fine Art Jewelry Silverware Furs Sinkhole Loss coverage 10% Sinkhole Deductible Limit Additional Ordinance or Law Coverage 50% Description: Identity Fraud Expense Coverage Preferred Contractor Golf Cart Physical Damage and Liability Coverage Fungi, Wet or Dry Rot, Yeast or Bacteria $5,000 $10,000 $25,000 $50,000 Hurricane Coverage for Screen Enclosures and Carports Coverage $10,000 $25,000 $50,000 PTIC APP (05/14) $300,000 $5,000 Limit Description: PAGE 2 OF 5

9 Additional Insured Additional Insured First Middle Last Occupancy Type Occupant n-occupant SSN/Fed ID Address 1 Address 2 City State Zip Primary Phone Interest in Policy tes Secondary Phone Fax Number Mortgage Information Name Address 1 Address 2 City State Zip Loan # Billable Bank / Institution #1 Bank / Institution #2 General Underwriting Questions Is the insured location currently vacant or unoccupied? If yes, do you expect the named insured to occupy the property within 30 days from the policy effective date? If secondary or seasonal property, is the insured location owner occupied for at least four months per year? Is the insured location rented to others while not being occupied by the applicant? Does the insured location have any pre-existing or existing damage? Does the insured located have any of the following construction features: Mobile home? Manufactured home? Dome home? Log home? Do it yourself or homemade home? Built on stilts, pilings, post, piers or constructed with an open foundation? Other unusual construction features? Is the insured location considered commercial property or being used for commercial purposes? Is there any business conducted on the premises? PTIC APP (05/14) PAGE 3 OF 5

10 Does the insured location have any commercial or business operations that involve the use or storage of hazardous, flammable, or explosive chemicals or equipment? Is the property located on a farm, ranch, orchard or grove or where farming activities or ranching operations take place? Is there any repair work, remodeling and/or renovations being performed at the insured location or do you plan to remodel or renovate the insured location within the near future? Do you have more than two mortgages on the insured location? Is the insured location readily accessible year-round to the fire department and its equipment? Have you had any losses at the insured location or any other location in the last three years, whether paid by insurance or not? Have you sustained more than one non-weather related loss in the past three years? Have you had any liability or fire loss in the past three years? Does the insured have knowledge of the insured location ever experiencing sinkhole or ground settling activity or have you ever filed a sinkhole claim relating to this activity? Does the insured location have any of the following: Trampoline? Diving board or slide? Empty or non-operable in-ground swimming pool? Skateboard ramp(s)? Fraternity or sorority usage? Animals that have bitten previously? Vicious or exotic animals kept on premises? Porches or decks more than 2 feet off the ground or have 3 or more steps leading to them without handrails or guardrails? Does the insured location have a swimming pool, spa, hot tub, or other similar structure? Is the swimming pool in operable condition and completely fenced, walled or screened? The fence or wall must be a permanent installation with a minimum height of 4 feet and be constructed of material that provides a reasonable barrier (e.g., chain link, wood, steel or aluminum). Does the spa, hot tub, or other similar structure have a locking cover? Does the insured location have a permanently installed central electrical system with a minimum 100-amp main panel and either circuit breakers or 220-volt electrical service? Does the insured location have a functioning, permanently installed central heating and ventilating air-conditioning system? Does the insured location have any of the following as a primary source of heat: Portable heater? Electric, oil or kerosene portable space heater? Gas heater? Wood burning stove? Any heating device with an open flame? PTIC APP (05/14) PAGE 4 OF 5

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM OR

APPLICANT(S) STATEMENT I DECLARE THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE, COMPLETE, AND CORRECT.

AS PROVIDED BY SECTION 627.409, FLORIDA STATUTES.

11 ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER, FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. APPLICANT(S) STATEMENT I DECLARE THAT THE INFORMATION PROVIDED IN THIS APPLICATION IS TRUE, COMPLETE, AND CORRECT. ANY MISREPRESENTATION, OMISSION, CONCEALMENT OF FACT, OR INCORRECT STATEMENT MAY PREVENT RECOVERY UNDER THE POLICY AS PROVIDED BY SECTION , FLORIDA STATUTES. Signature of Applicant Date Signature of Applicant Date Agent Name [type or print] P Florida License Number Application Bind Date: 08/04/2015 Time: 4:54 PM PTIC APP (05/14) PAGE 5 OF 5

12 Authorization for Automatic EFT Withdrawals Save Time and Hassle By enrolling in Electronic Funds Transfer (EFT) we will process your premium payments by automatically deducting them from your checking account. You can relax knowing that your payments will be taken care of when they are due. To Enroll in Automatic EFT Withdrawals: Complete this form and mail it to: Payment Processing People's Trust Insurance Company please enroll me in EFT withdrawal using my checking account information. Direct Debit Information 18 PEOPLE'S TRUST WAY DEERFIELD BEACH, FL Attach a voided check (deposit slips not accepted) and indicate the name of the bank. Bank Name Attach a voided check here. IMPORTANT: A voided check must be attached. PLEASE READ I certify that I am an owner or authorized signer for this account. I hereby authorize People's Trust Insurance Company to initiate debits (electronically, by paper means or any other commercially accepted method) to my above specified checking account. I authorize my bank (and its successors and/or assigns) to debit my account. To change my account information, I will send a new, completed Automatic EFT Authorization form, signed and dated. I will send notice in writing should I wish to discontinue Automatic EFT. Such written notice to change or discontinue Automatic EFT must be received by People's Trust Insurance Company a minimum of two (2) weeks before any next payment is due. PFL Signature of Checking Account Holder Date People's Trust Insurance Company Policy # MICHAEL WALCH Print Name of Checking Account Holder MICHAEL F WALCH Printed Name of Insured EFT AUTHORIZATION 1/11

13 EXPLAINING THE HOME INSPECTION PROCESS TO AVOID CANCELLATION THE INSPECTION MUST BE SCHEDULED WITHIN 25 DAYS OPTION #7 People s Trust Field Risk Evaluators will conduct an inspection of the inside and outside of the home. The Field Risk Evaluator is to be given full access to the lot, including other structures, attached rentals, and all rooms of the dwelling. The inspection includes but is not limited to: Overview photos of each room in the home and the outside of home Photos underneath each sink in order to document the plumbing system and fixtures Ceiling photos to document the condition of ceilings and walls and to include any customized construction (i.e. crown molding textured ceilings, etc.) Flooring photos in order to include floor coverings (tile, carpet, laminate, etc.) Personal property photos for Coverage C items, if applicable The focus and intent of the inspection is to document the home as it is today. If the home shows any existing disrepair, our inspectors will identify it and we will provide the homeowner an opportunity to repair it. This will prevent further damage to the home. If they decline to repair the home, terms and conditions apply Items identified during the inspection may prevent damage homeowners may not be aware of: Proper sealing and caulking of windows and doors Use of infrared technology may identify insulation and or water intrusion issues Trip/fall hazards and or liability exposures i.e. uneven sidewalks or driveways, unfenced pools Exterior wall waterproofing - sealing any stucco or wall cracks, replacing any rotted siding, etc. Identify appliance life expectancies to help plan for future replacements and/or servicing

tice of Actual Cash Value for Contents I have opted to exclude replacement cost for my contents coverage; I understand that in the event of a covered loss I will receive actual cash value for my

14 tice of Actual Cash Value for Contents I have opted to exclude replacement cost for my contents coverage; I understand that in the event of a covered loss I will receive actual cash value for my contents/personal property. My agent has discussed the difference between replacement and depreciated value and I will pay the difference in the depreciated value my insurance company will not. Sign and Date Print 5248 Red Cedar Drive, Suite 103 Fort Myers, FL Phone Fax Fallyn.Dowland@regencyins.com

15 Regency Insurance Group 5248 Red Cedar Dr Suite 103 Fort Myers, FL Main Fax CANCELLATION REQUEST COMPANY: POLICY NUMBER: INSURED: Universal Property Michael Walch PLEASE CANCEL MY POLICY EFFECTIVE -_8/15/2015. I HAVE: SECURED INSURANCE ELSEWHERE SOLD THE PROPERTY SUPPORTING DOCUMENTATION ATTACHED. THANK YOU, INSURED SIGNATURE

Homeowners Insurance Application

Homeowners Insurance Application HOH265873 Policy Effective Date: 3/20/2017 Policy Expiration Date: 12:01 AM Date/Time Printed: 3/15/2017 2:39:44PM Policy Form: HO3 Risk ID: HOH265873 Phone: (321)622-5333 Fax: (321)622-5336 Agent: Suntree