A M Service Office

Location:

High Springs, FL, 32643

Posted:

August 27, 2024

Contact this candidate

Resume:

Bass Underwriters, Inc.

INSURANCE QUOTE

THE TERMS AND CONDITIONS OF THIS QUOTATION MAY NOT COMPLY WITH THE SPECIFICATIONS SUBMITTED FOR CONSIDERATION OR THE EXPIRING POLICY. PLEASE READ THIS QUOTE CAREFULLY AND COMPARE IT AGAINST YOUR SPECIFICATIONS. IN ACCORDANCE WITH THE INSTRUCTIONS OF THE BELOW-MENTIONED INSURER, WHICH HAS ACTED IN RELIANCE UPON THE STATEMENTS MADE IN THE RETAIL BROKER'S SUBMISSION FOR THE INSURED, THE INSURER HAS OFFERED THE FOLLOWING QUOTATION.

DATE ISSUED: July 1, 2024

PRODUCER: Professional Insurance Center Inc

2003 W Kennedy Blvd

Tampa, FL 33606

INSURED MAILING Mary Hughes Transport Inc

ADDRESS: 4375 SW County Rd 152

Jasper, FL 32052

INSURER: Ategrity Specialty Insurance Company A- (Excellent) AM Best Rating Non-Admitted

COVERAGE: QBIE-General Liability-Ategrity

POLICY PERIOD: 8/15/2024 TO 8/15/2025

RENEWAL OF: 01-C-PK-P20084086-0

12:01 A.M. STANDARD TIME AT THE LOCATION ADDRESS OF THE NAMED INSURED. THIS INSURANCE QUOTATION WILL BE TERMINATED AND SUPERSEDED UPON DELIVERY OF THE FORMAL POLICY(IES) ISSUED TO REPLACE IT.

LIMITS: See attached.

Without Terrorism: Terrorism

PREMIUM: $750.00 +$38.00

FEES: Policy Fee $100.00

Insp Fee $175.00

Policy Fee $100.00

Insp Fee $175.00

Surplus Lines Tax: $50.64 $52.51

Service Office Fee: $0.62 $0.64

Misc State Tax:

FHCF (Florida)

CPIE: (Florida)

TOTAL: $1,076.26 $1,116.15

*Upon request to bind the agent assumes responsibility for the earned premium, fees and taxes. DEDUCTIBLE: See attached.

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 Policy Number:

MARY HUGHES

MARY HUGHES TRANSPORT INC

01-C-PK-P20084086-0-Renewal

08/15/2024 08/16/2024

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024

Premium Payment by Fax

Agency name: Date: Insured Name: Policy# Checking A/C# Amount: This check authorizes Professional Insurance Center to charge our bank account per the attached check.

(Signature)

Fax: 813-***-****

Tel: 813-***-**** Ext: 237

Toll Free: 800-***-****

******@***.***

2003 W. Kennedy Blvd.

Tampa, FL 33606

Place your check here (face-up)

Payable to Professional Insurance Center, Inc.

Please do not send your original check.

Keep your original check for your records.

Thank you

Professional Insurance Center

$ 1,076.26

MARY HUGHES TRANSPORT 2024 RENEWAL policy

************-*********@*********.***

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024

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Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 67898:8B;FA=( @A?<GO 98E8B69H:;8 6@>AB9:B; :9MFF=6AC8678 8E8B6 1 1 D@' 67 JA?1 11 678:E: )<;AEEAB 8 1 => ) ?>FA 6 ABK9LH G: ) AB; "J BGH:@6@.!AB9H AEF= 0&+ < 4"AI8?868 678:>!C8:. 5! JA?NAI8 EK9LH:BMEN8?JA 2 3 E9:8 >: B;:

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357

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Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357

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Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357

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YaAlEDUpAvCw EUVCWDXEY@ !V^NPORDYlDJibgj`n^J\J\X[X[%DGGDHO DGGDMH "fhe__DMHDtx DMNDMx DabcdefDB_ Do DPMGRM ZCWDUEWDVUX[FDoZAVDGtuHRuMGMNDBADGtuHRuMGMRDUBDHMFGHDUVDYBUEWUZWDBXVCDUBD]&^DZmDHRM gfhi_S T HMDGN GNDHP HHDQt GQDGt jDXgkD XE\DUWWZCYY CyksbfrigDCyje_UzegmzegjDA{JizzigDKisrk`Ebkse^' #_DCge_* c DXgfb_ "D[ri_ &DJigmrjrigf r^-DXgfbs^/ 0 1+rsrj emDJigj_DCyksbfrig 23 4)jrigDorgrfdrgcDY`U p^HGGRDYDWrss^lrgje_=)ffD CEJ]0 5. >kjDWe{!D\gme_226 DUEWDVUX[rgrjrig _@"megDosi_q_-ABCDEAFDGHIJIKLI?$_ 730 8 9:mDYj_&rje_fjezf !S T ) !f eej rm^4;XE\%DPNOtO )A@) )& DUWWZCYY )ZDVUX[)) #4)MNGOHHGGPGQR 4: XE\ DUWWZCYYD Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357

JKBF KEREYEJ> 1233435678356985:KDR@.0DR@*q BC@ A@DL @= C@ DL F@5:1uv8:REDY@B@KDR@% EFKD>KDGNJ>J>*@Ua bX [DI `DI `T >>4:EFFDIAEM AADAEFGMW EG[Y@8<KYIFED> K@ ),T FIKC KA@JIBCDAEPJBED> EB@?2315p52e8<L KB KCJAO@FCDIY? FCDIY? L@DL &>AJO@ AJO@ @=?e5154:A>K@? A >BJAT IAF@B ? wxv8yvzw DL @EB@BC@ BJB B@G@JKB FE>AJY NDNIYJBED> @G[YDFF@c 43e T AJY AADAEFG KDR@AADAEFGW ? @NADRE?JF LDA LDA G@DL _ > @YJ]@DA BJB@F H>FIKC JYFD B @A F ] ?LDA +F [AADAEFG YDFF i [J> A@D] @GEFFED>_ DG@T B AADAEFG IKY@E> +:S@EYYED>f81233435678=LE JF M KD@BC@ E>H>FM = KB JKB 8 AF@ ( YDFF@D] DR@J>1684p8123343567r8s2f4kt BCJB B@@ )G@28k51l81l28<O F }]D] DA JA DL YJ>? M T AADAEFG @AKED>TM BC@ JAEFE>NDABED> }BCJB @DL TDIA [R@'EFH jM J>BC@ D>DIBFE?@z~v 8 w 8 8~ 8xuv v8 x YY ^ F ? AJO@ ]T BCJB @'EFH R@6;BD JF,AM GJT -I>C@F @KDR@BC@ @ _ EF J>TDIA O CJR@ KJY@KDR@ >E>3<Y@A@ KIAEBTM BF_ ->QM BC@ ?NADRE? >DIB *YDFF@@ KB T FIAJ>DL FIA@EB@FF J>[AJO DAHM KDR@FIAJ>' @.:BC@ JKB @ >YDFF LL@? NDYEKT A@AJO@ KBM O DL NADRE?NJABEJYYT AFd BJB@@JA F 4g23<28<>KBER@ _ BCJB, DABC ADIF J K@ AJO@ JKBF =@BCJB C@ A ? BCJB > >K@ T@JF YEJ[]1m8n4;GJT ? BC@ EB ) KB I>KDGGEBB@@GJT JA F BC@ 1 EF &@JG@?BD DL SJ>NA@? EF EYEBT @ADOAJG ? ?DA M GJT JADYE>LDAGIYJM K@`@A@@DL BJB@@h2 CIGJ> [E> NADRE?B@K@ ` BBDA>A IJAT BD `KD>GEIG @ ABELE@EG[>K@LDA AADAEFGM BC@ B@87;BC@ @?A@ E>[? BJE> @ ?F IAF@LYI@? YDFF BC@ KB JM ? '@NDYEKT IK@@KDR@E> F @M 618=@xv t M [M YEL@KCJAO@? [KD>? BC@ T c T JF A@JIBCDAEPJBED> BC@ >DBC@T [FBJBIBDAEYT ? J>DA ?0@J> M K@ F JF T BC@ _ JG@A@[NADN@BJE> JYELDA>.l4462814862f2=A@Q OD>? DBC@BCEF ]T >KJF@ BC@ E '- A UBC@ FIYBE>[@BC@ EYY ? BC@ EB AJY EYYED>F >LE>M LDA `ERE?T JYFD NDYEKT A]J NDYEKT ? KA@ABTM 'CD?KYIFED> KB DL ' - BC@ .@@DL V KBWXM c BJB@EF@ O BCEF EJM ? ? >IJY _ BJAT @K@BC@ EB@B@DA LADG L NIAFIJ>E> FBJ[EF (@ D>KD>ABJE> LDA AGE>BC@ @ KB DA DA ? KDR@E> @B@F FYJ>?[F .DL BJB@LAJFBAIKBIA@@EYYED> 0DR@YEFC@TDI AGE>JLL@E>]>BE>KBED> YDFF@VK@>AJY JOOA@DL BC@ EB@JB@CEKC @?JEA AJO@ I@KBEKIBM ERE?B ABELE@KB CJR@ 0DR@? ? M JB@F _ A>KJN BD A@KJAAE@? F /1843832o2= BJB@0DR@?BC@ GEOCB IJYF OJB@ G@A@ EAOE EF BC@ ? Q ? JFIAT\T ?FIYBE>BCJB A>,J U NADRE?0@IKBE[KD>JKBF >BC@ EF AF F\^ JF AEOCB A>G@B @X EJM E>K@BD DAOEJM JOA@JLL@DL FKC@G@DA ?YEGEBF FIA@AADAEFG L@NJAB BD O >G[ JFCE>DL IKB Y@ CJR@ E> B ?BC@ @R@LADG -BD >KB [I>B@? NJE? @@@B ?@ KD>? "F AJY FF@DL 18=DL ' 0- A [TDIA +NIAKCJF@ IY@AADA I>?.J> YDFF@BD @ KBZ A@i J]@BC@ J> >VK@YD] ODR@FIYBJBED> ?'EFH YF [A OBD>? 4g23 FIYB@EB@A@M @JKB T JEEM BC@ BD EFGW DA KDR@A @EG[ C@ .ABELE@BC@ ? F LLDAB J>J >A> >B@DL BC@ LDA M BJB@ YYE>? LDAGIYJ KB_ EB@jM ? @IAF@ FIAJ>G AGE>E>AJO@E>E> ]B@B@? ?JYY ? BD h28p438 J>NA@DEFM FIAJ>FIAJ>C@]D@AG AADAEFG^ FB JKBF ?> BJB@F EBC JGJO@ KD@T E>B_ > JB@ @M F /0DR@GEF@K@ VK@EOCBT FIKC B@ D]FIA@BC@ CDIY? >EAOE>@BC@ DL K@ AK@ K@ DB AADAEFG FBJ[JB &F $ ABELE@JM ADOAJG F JGDI>E>A>AF BD BC@ EJM JF BC@ ]N@DL %KYI?YEFC@G@EBCE> ![JE>TDI ? AK@J> J @ J @B B ? >? M B Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357

(789:H;PQR R [Y P (( MA Pg h '04 '0 0 ] ] < RW VR\ +T)9=DNA9<+ ) ) (, ;, 0 2 )9>% RQR # $d4 2 $"9 .! d ( #A@ABC;0 0, (eS 9 5 ' R ' % EFB9C;)1 % _>. % 9? ) S ib ' ;+(LFG ' 9; W$) TR * ")' '')#O @, 2 "9 )$ % " 88A S QQ U V ## "0 " &% "9D # 1 " )"4 $9 +' #,2 9 2" . %,1 " 9 % *"" ! A? W #"2 #<$R TRW ", $0,)"#9 ) " % '#EFB9>P# de c P 5 ' "1 " 1 " $a "'0 # RP e ?2, FGA9?2 4 #, ' #" 1 ;,- e +, )9? " W +EA9H;0, ' $WRXR ' b ) f ' ICD % 0 #$6 0, + RWW W Y (2 ^ #J9:'#_6$1$ ;.1 " (! ( $ < " 9KFLL9EDMA9> ) 2 ! %+"1 " 1$ c 4 ZW R .2 . . " 5 ; "9 A@3 0#/, " $#) @" _ FBI ! Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024

Mary Hughes

TERMS / CONDITIONS:

(a) MINIMUM EARNED PREMIUM AT INCEPTION - See attached. ALL FEES ARE FULLY EARNED AND NON-REFUNDABLE.

PREMIUM FOR ADDITIONAL INSURED’S ARE FULLY EARNED AND NON-REFUNDABLE.

(b) SUBJECT TO:

“Favorable Inspection and compliance with any/all recommendations.” Collection of all required funds prior to requesting the policy be bound. Please see attached for Terms and Conditions.

Please see attached for Endorsements and Exclusions.

(d) All other terms and conditions apply per form.

(e) Quote is valid for 30 days.

(f) Coverage can not be backdated or assumed to be bound without written confirmation from an authorized representative of Bass Underwriters.

COMMISSION: 10%

THIS QUOTE IS ISSUED BASED UPON THE INSURER'S AGREEMENT TO QUOTE AND IS ISSUED BY THE UNDERSIGNED WITHOUT ANY LIABILITY WHATSOEVER AS AN INSURER. THIS QUOTE MAY BE WITHDRAWN BY THE INSURER AT ANY TIME PRIOR TO BINDING. INSURED: Mary Hughes Transport Inc

DATE ISSUED: July 1, 2024

Account Executive: Eric Huntley

Team: Orlando

Reference #: 4046607A

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 SURPLUS LINES DISCLOSURE

At my direction, Professional Insurance Center Inc has placed my coverage in the surplus lines market.

As required by Florida Statute 626.916, I have agreed to this placement. I understand that superior coverage may be available in the admitted market and at a lesser cost and that persons insured by surplus lines carriers are not protected by the Florida Insurance Guaranty Association with respect to any right of recovery for the obligation of an insolvent unlicensed insurer.

I further understand that policy forms, conditions, premiums and deductible used by surplus lines insurers may be different from those found in policies used in the admitted market. I have been advised to carefully read the entire policy. Mary Hughes Transport Inc

Named Insured

BY: Signature of Named Insured Date

Print Name and Title of person signing

Ategrity Specialty Insurance Company

Name of Excess and Surplus Lines Carrier

General Liability - Commercial

Type of Insurance

8/15/2024

Effective Date of Coverage

01/01/2022 Florida Surplus Lines Service Office

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024

Mary Hughes

SOC SEC #: Social Security Number LLC: Limited Liability Corporation SIC: Standard Industrial Classification

FEIN: Federal Employer Identification Number

DEFINITIONS: GL CODE: General Liability Code NAICS: North American Industry Classification System NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) NAICS BUSINESS PHONE #:

AND MANAGERS: TRUST

SUBCHAPTER "S" CORPORATION

NO. OF MEMBERS

CORPORATION JOINT VENTURE NOT FOR PROFIT ORG

INDIVIDUAL LLC PARTNERSHIP

WEBSITE ADDRESS

GL CODE SIC FEIN OR SOC SEC #

NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) NAICS BUSINESS PHONE #:

AND MANAGERS: TRUST

SUBCHAPTER "S" CORPORATION

NO. OF MEMBERS

CORPORATION JOINT VENTURE NOT FOR PROFIT ORG

INDIVIDUAL LLC PARTNERSHIP

WEBSITE ADDRESS

GL CODE SIC FEIN OR SOC SEC #

NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4) NAICS BUSINESS PHONE #:

AND MANAGERS: TRUST

SUBCHAPTER "S" CORPORATION

NO. OF MEMBERS

CORPORATION JOINT VENTURE NOT FOR PROFIT ORG

INDIVIDUAL LLC PARTNERSHIP

WEBSITE ADDRESS

GL CODE SIC FEIN OR SOC SEC #

ACORD 125 FL (2016/03)

EXPIRATION DATE

PROPOSED

EFFECTIVE DATE $ $

METHOD OF PAYMENT PREMIUM

MINIMUM

BILLING PLAN PAYMENT PLAN AUDIT DEPOSIT POLICY PREMIUM DIRECT AGENCY

PROPOSED

POLICY INFORMATION

UNDERWRITER UNDERWRITER OFFICE

FLORIDA COMMERCIAL INSURANCE APPLICATION DATE (MM/DD/YYYY) APPLICANT INFORMATION SECTION

FAX

(A/C, No):

AGENCY

NAME:

CONTACT

(A/C, No, Ext):

PHONE

CODE: SUBCODE:

AGENCY CUSTOMER ID:

ADDRESS:

E-MAIL STATUS OF

TRANSACTION

QUOTE ISSUE POLICY RENEW

BOUND (Give Date and/or Attach Copy):

CANCEL

CHANGE DATE TIME AM

CARRIER NAIC CODE

POLICY NUMBER

COMPANY POLICY OR PROGRAM NAME PROGRAM CODE

COMMERCIAL GENERAL LIABILITY

PREMIUM PREMIUM PREMIUM

BUSINESS OWNERS

BUSINESS AUTO UMBRELLA

BOILER & MACHINERY

GARAGE AND DEALERS

CRIME

COMMERCIAL PROPERTY

INDICATE LINES OF BUSINESS

YACHT

CYBER AND PRIVACY

FIDUCIARY LIABILITY $

COMMERCIAL INLAND MARINE $ LIQUOR LIABILITY $

TRUCKERS

MOTOR CARRIER $ $

LINES OF BUSINESS

VEHICLE SCHEDULE

VACANT BUILDING SUPPLEMENT

STATE SUPPLEMENT (If applicable)

STATEMENT / SCHEDULE OF VALUES

RESTAURANT / TAVERN SUPPLEMENT

PROFESSIONAL LIABILITY SUPPLEMENT

PREMIUM PAYMENT SUPPLEMENT

LOSS SUMMARY

INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT

INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT

ADDITIONAL INTEREST SCHEDULE

ATTACHMENTS

CONTRACTORS SUPPLEMENT

CONDO ASSN BYLAWS (for D&O Coverage only)

APARTMENT BUILDING SUPPLEMENT

ADDITIONAL PREMISES INFORMATION SCHEDULE

COVERAGES SCHEDULE

DRIVER INFORMATION SCHEDULE

HOTEL / MOTEL SUPPLEMENT

ACCOUNTS RECEIVABLE / VALUABLE PAPERS

DEALERS SECTION

ELECTRONIC DATA PROCESSING SECTION

GLASS AND SIGN SECTION

INSTALLATION / BUILDERS RISK SECTION

OPEN CARGO SECTION

08/01/2024

Professional Insurance Center, Inc.

2003 West Kennedy Blvd

Tampa FL 33606

Professional Insurance Center Inc

AGT550

MARYHU012

ATEGRITY SPECIALTY INSURANCE COMPANY 16427

Com. General Liability CGL

01-C-PK-P20084086-0-Renewal

750

8/15/2024 8/15/2025

750

MARY HUGHES TRANSPORT INC

4375 SW COUNTY RD 152

JASPER FL 32052

83-2899250

386-***-****

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 SQ FT: Square Feet

# PART TIME EMPL: Number Part Time Employees

# FULL TIME EMPL: Number Full Time Employees

BLD #: Building Number

DEFINITIONS: LOC #: Location Number

REASON FOR INTEREST: E-MAIL ADDRESS:

OWNER

LEASEBACK

WARRANTY

BREACH OF

TRUSTEE

REGISTRANT

LIEN AMOUNT: PHONE (A/C, No, Ext): FAX (A/C, No):

INTEREST END DATE:

CLASS: ITEM:

CO-OWNER AIRPORT: AIRCRAFT:

OWNER

EVIDENCE: POLICY SEND BILL

AS LESSOR

INSURED

ITEM DESCRIPTION

INTEREST NAME AND ADDRESS RANK:

REFERENCE / LOAN #:

CERTIFICATE INTEREST IN ITEM NUMBER

ADDITIONAL

LOSS PAYEE

MORTGAGEE

LIENHOLDER

EMPLOYEE

LOCATION: BUILDING:

VEHICLE: BOAT:

ITEM

SQ FT

ANY AREA LEASED TO OTHERS? Y / N

TOTAL BUILDING AREA:

OPEN TO PUBLIC AREA: SQ FT

CITY LIMITS INTEREST ANNUAL REVENUES:

OCCUPIED AREA: SQ FT

BLD #

LOC #

DESCRIPTION OF OPERATIONS:

ZIP:

STATE:

COUNTY:

CITY:

STREET

# PART TIME EMPL

# FULL TIME EMPL

INSIDE

OUTSIDE

OWNER

TENANT

SQ FT

ANY AREA LEASED TO OTHERS? Y / N

TOTAL BUILDING AREA:

OPEN TO PUBLIC AREA: SQ FT

CITY LIMITS INTEREST ANNUAL REVENUES:

OCCUPIED AREA: SQ FT

BLD #

LOC #

DESCRIPTION OF OPERATIONS:

ZIP:

STATE:

COUNTY:

CITY:

STREET

# PART TIME EMPL

# FULL TIME EMPL

INSIDE

OUTSIDE

OWNER

TENANT

SQ FT

ANY AREA LEASED TO OTHERS? Y / N

TOTAL BUILDING AREA:

OPEN TO PUBLIC AREA: SQ FT

CITY LIMITS INTEREST ANNUAL REVENUES:

OCCUPIED AREA: SQ FT

BLD #

LOC #

DESCRIPTION OF OPERATIONS:

ZIP:

STATE:

COUNTY:

CITY:

STREET

# PART TIME EMPL

# FULL TIME EMPL

INSIDE

OUTSIDE

OWNER

TENANT

ADDITIONAL INTEREST (Provide only the necessary data) Attach ACORD 45 for more Additional Interests, if applicable PHONE #

PRIMARY PHONE # HOME BUS CELL SECONDARY HOME BUS CELL PHONE #

PRIMARY PHONE # HOME BUS CELL SECONDARY HOME BUS CELL

SQ FT

ANY AREA LEASED TO OTHERS? Y / N

TOTAL BUILDING AREA:

OPEN TO PUBLIC AREA: SQ FT

CITY LIMITS INTEREST ANNUAL REVENUES:

OCCUPIED AREA: SQ FT

BLD #

LOC #

DESCRIPTION OF OPERATIONS:

ZIP:

STATE:

COUNTY:

CITY:

STREET

# PART TIME EMPL

# FULL TIME EMPL

INSIDE

OUTSIDE

OWNER

TENANT

% %

DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS

OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK

DESCRIPTION OF PRIMARY OPERATIONS

RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES: INSTALLATION, SERVICE OR REPAIR WORK

NATURE OF BUSINESS

MANUFACTURING

INSTITUTIONAL

DATE BUSINESS

CONTRACTOR RESTAURANT STARTED (MM/DD/YYYY)

CONDOMINIUMS

APARTMENTS

RETAIL WHOLESALE

SERVICE

OFFICE

Page 2 of 4

PREMISES INFORMATION (Attach ACORD 823 for Additional Premises, if applicable) CONTACT NAME:

SECONDARY E-MAIL ADDRESS:

PRIMARY E-MAIL ADDRESS:

CONTACT TYPE:

CONTACT INFORMATION

SECONDARY E-MAIL ADDRESS:

PRIMARY E-MAIL ADDRESS:

CONTACT NAME:

CONTACT TYPE:

AGENCY CUSTOMER ID:

LOSS PAYABLE

LENDER'S

ACORD 125 FL (2016/03)

MARYHU012

MARY HUGHES TRANSPORT INC

386-***-****

***************@*****.***

Owner

MARY HUGHES

***************@*****.***

4375 SW COUNTY RD 152

JASPER FL

32052

Nature Of Business: NON-EMERGENCY MEDICAL TRANSPORTATION Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 Page 3 of 4

REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) 13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? SAFETY MANUAL SAFETY POSITION MONTHLY MEETINGS OSHA 2. IS A FORMAL SAFETY PROGRAM IN OPERATION?

EXPLAIN ALL "YES" RESPONSES Y / N

SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED PARENT COMPANY NAME RELATIONSHIP DESCRIPTION % OWNED DOES THE APPLICANT HAVE ANY SUBSIDIARIES?

1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ? 1b.

4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER 11. HAS BUSINESS BEEN PLACED IN A TRUST? NAME OF TRUST: 10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS? 9. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS? UNDERWRITING CONDITION CORRECTED (Describe):

AGENT NO LONGER REPRESENTS CARRIER

NON-RENEWAL

NON-PAYMENT

5. ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR GENERAL INFORMATION

6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?

(In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment).

OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE

8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES?

(If "YES", attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) 12.

AGENCY CUSTOMER ID:

OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE

14. DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If "YES", describe use) 15. DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If "YES", describe use) ACORD 125 FL (2016/03)

MARYHU012

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required, if applicable) 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. SIGNATURE

NATIONAL PRODUCER NUMBER

PRODUCER'S SIGNATURE (Required in Florida)

APPLICANT'S SIGNATURE DATE

PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MAY BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

Page 4 of 4

Check if none (Attach Loss Summary for Additional Loss Information) YEARS TOTAL LOSSES: $

DATE OF

OCCURRENCE

DATE OF CLAIM AMOUNT PAID

SUBRO-

GATION

Y / N

AMOUNT RESERVED

CLAIM

OPEN

Y / N

ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST

LINE TYPE / DESCRIPTION OF OCCURRENCE OR CLAIM

LOSS HISTORY

$ $ $ $

EFFECTIVE DATE

EXPIRATION DATE

PREMIUM

POLICY NUMBER

CARRIER

$ $ $ $

EFFECTIVE DATE

EXPIRATION DATE

PREMIUM

POLICY NUMBER

CARRIER

$ $ $ $

EFFECTIVE DATE

EXPIRATION DATE

PREMIUM

POLICY NUMBER

CARRIER

$ $ $ $

EFFECTIVE DATE

YEAR

EXPIRATION DATE

PREMIUM

POLICY NUMBER

CARRIER

CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: PRIOR CARRIER INFORMATION

AGENCY CUSTOMER ID:

ACORD 125 FL (2016/03)

MARYHU012

2023

16427: ATEGRITY SPECIALTY

INSURANCE 01-C-PK-P20084086-COMPANY 0

8/15/2023

8/15/2024

Professional Insurance Center Damien M Rodriguez P081683 9050383

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 8/16/2024

AGENCY CUSTOMER ID:

EFFECTIVE DATE

CARRIER NAIC CODE

POLICY NUMBER APPLICANT / FIRST NAMED INSURED

AGENCY

4. RETROACTIVE DATE:

3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: 2. NUMBER OF EMPLOYEES:

1. DEDUCTIBLE PER CLAIM: $

EMPLOYEE BENEFITS LIABILITY

4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE? EXPLAIN ALL "YES" RESPONSES

2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 1. PROPOSED RETROACTIVE DATE:

CLAIMS MADE (Explain all "Yes" responses)

COMMERCIAL GENERAL LIABILITY SECTION DATE (MM/DD/YYYY) LOC

CLASSIFICATION CLASS

CODE

PREMIUM

BASIS

HAZ EXPOSURE TERR

(T) OTHER

(U) UNIT - PER UNIT

(M) ADMISSIONS - PER 1,000/ADM

(A) AREA - PER 1,000/SQ FT

(P) PAYROLL - PER $1,000/PAY

(S) GROSS SALES - PER $1,000/SALES

RATING AND PREMIUM BASIS

PREM/OPS PRODUCTS

PREMIUM

PREM/OPS PRODUCTS

RATE

SCHEDULE OF HAZARDS

1. UM / UIM COVERAGE IS IS NOT AVAILABLE. 2. MEDICAL PAYMENTS COVERAGE IS IS NOT AVAILABLE. APPLICABLE ONLY IN WISCONSIN: IF NON-OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY:

OTHER:

LOCATION

PROJECT

LIMIT APPLIES PER: POLICY

GENERAL AGGREGATE

PRODUCTS & COMPLETED OPERATIONS AGGREGATE

PERSONAL & ADVERTISING INJURY

EACH OCCURRENCE

DAMAGE TO RENTED PREMISES (each occurrence)

MEDICAL EXPENSE (Any one person)

EMPLOYEE BENEFITS

COVERAGES LIMITS

TOTAL

OTHER

PRODUCTS

PREMISES/OPERATIONS

PREMIUMS

OCCURRENCE

PER

CLAIM

PER

BODILY INJURY $

PROPERTY DAMAGE $

DEDUCTIBLES

CLAIMS MADE OCCURRENCE

OWNER'S & CONTRACTOR'S PROTECTIVE

COMMERCIAL GENERAL LIABILITY

OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims-made policy. Read all provisions of the policy carefully.

Attach to ACORD 125

MARYHU012

08/01/2024

Professional Insurance Center, Inc.

01-C-PK-P20084086-0-Renewal 8/15/2024

ATEGRITY SPECIALTY INSURANCE COMPANY 16427

MARY HUGHES TRANSPORT INC

500

2,000,000

1,000,000

100,000

EXCLUDED

528.07

264

792.07

1 NON-EMERGENCY MEDICAL

TRANSPORTATION

68001 Area 500 528.07 264

Docusign Envelope ID: DEE4D108-50EC-4168-867E-94C41527E357 ACORD 126 (2016/03) Page 2 of 4

AGENCY CUSTOMER ID:

CONTRACTORS

TIME STAFF:

# PART-

TIME STAFF:

# FULL-

SUBCONTRACTED:

% OF WORK

CONTRACTORS:

DESCRIBE THE TYPE OF WORK SUBCONTRACTED $ PAID TO SUB- 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? 3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING? 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS? EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / N PRODUCTS / COMPLETED OPERATIONS

LIFE INTENDED USE PRINCIPAL COMPONENTS

EXPECTED

MARKET

PRODUCTS ANNUAL GROSS SALES # OF UNITS TIME IN

EXPLAIN ALL "YES" RESPONSES (

Contact this candidate