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Home My WebLink AboutCLAMBAKE GL BINDERBass Underwriters, Inc. INSURANCE BINDER THE TERMS AND CONDITIONS OF THIS CONFIRMATION OF INSURANCE MAY NOT COMPLY WITH THE SPECIFICATIONS SUBMITTE[ FOR CONSIDERATION. PLEASE READ THIS CONFIRMATION CAREFULLY AND COMPARE IT WITH ANY QUOTE AND SUBMISSIO? DOCUMENTS AND REVIEW THE POLICY FORMS FOR THE ACTUAL COVERAGES PROVIDED. N ACCORDANCE WITH YOUR INSTRUCTIONS, AND IN RELIANCE UPON THE STATEMENTS MADE BY THE RETAIL BROKER IN THE NSURED'S APPLICATION/SUBMISSION, WE HAVE OBTAINED INSURANCE AT YOUR REQUEST AS FOLLOWS: DATE ISSUED: September 22, 2017 PRODUCER: KE Insurance Agency 990 US Hwy 1, Ste A Sebastian, FL 32958 INSURED MAILING Sebastian Clambake Foundation Inc ADDRESS: P.O. Box 780436 Sebastian, FL 32958 POLICY NO.: 630B006703 INSURER: Burlington Insurance Co Non -Admitted AM Best Rating COVERAGE: QBI-Special Events POLICY PERIOD: 11/1/2017 TO 11/7/2017 RENEWAL OF: 12:01 A.M. STANDARD TIME AT THE LOCATION ADDRESS OF THE NAMED INSURED. THIS INSURANCE BINDER WILL BE TERMINATED AND SUPERSEDED UPON DELIVERY OF THE FORMAL POLICY(IES) ISSUED TO REPLACE IT. BINDER AS PER QUOTE: 1992096A LIMITS: PREMIUM: $4,180.00 TRIA: REJECTED FEES: Policy Fee $35.00 SURPLUS LINES TAX: $210.75 SERVICE OFFICE FEE: $4.22 MISC STATE TAX: FHCF: (Florida) CPIE: (Florida) TOTAL: $4,429.97 State of Florida Surplus Lines Binder Stamp "This insurance is issued pursuant to the Florida Surplus Lines Law. Persons insured by surplus lines carriers do not have the protection of the Florida Insurance Guaranty Act to the extent of any right of recovery for the obligation of an insolvent insurer." ""SURPLUS LINES INSURERS' POLICY RATES AND FORMS ARE NOT APPROVED BY ANY REGULATORY AGENCY." P- ")BASS �r , f unm�uw�rr�s Date : Producer / MGA: Attention : COMMERCIAL PACKAGE POLICY BINDER 08/22/2017 0630 - Bass Underwriters, Inc. , 225 S Westmonte Dr, Suite 3320, Altamonte Springs, Fl- Jodi LJodi Delaporte - KE Insurance Agency Applicant: Sebastian Clambake Foundation Inc DBA : Principal Address: P O Box 780436, Sebastian, FL 32958, USA Assigned Policy Number: Insurance Company : Proposed Policy Period Agency License #: 630B006703 The Burlington Insurance Company 11/01/2017 To 11/07/2017 A128903 SL Broker License #: PREMIUM SUMMARY TRIA Accept General Liability Premium : $ 2,575.00 No Liquor Liability Premium : $ 1,605.00 Policy Fee: $ 35.00 Surplus Lines Tax: $ 210.75 Stamping Fee: $ 4.22 Advance Premium (for policy period) : $ 4,429.97 Total Including TRIA (If accepted) : $ 4,429.97 Retail Agent Commission: % 10 A128903 TRIA Premium TRIA Tax $ 209.00 $ 10.66 This Quote is valid for 30 days from the date of this quote or until the policy effective date, whichever occurs first. THIS QUOTE IS SUBJECT TO THE FOLLOWING: Subject To Due By ❑ Receipt of the completed Acord Application signed and dated by the insured 12/01/2017 ❑ Receipt of the completed TRIA selection/rejection form signed and dated by the insured, 12/01/2017 Form C 01 15 (completed/signed to reflect insureds decision to elect or reject terrorism coverage). 225 South Westmonte Drive Suite 3320 Altamonte Springs, FL 32714 Ph:(954) 473-4488 Fax: (964) 316-3123 Date: September 22, 2017 To: Jodi Delaporte - KE Insurance Agency Fax: (772) 388-2067 From: Pamela Winn Phone: 321-777-9720 Email: pwinn@bassuw.com Fax: 321-777-9743 Re: Insured: Sebastian Clambake Foundation Inc Effective Date: 11/1/2017 This transmission is intended to be delivered, only to the named addressee(s) and may contain information that is confidential, proprietary or privileged. If this information is received by anyone other than the named addressee(s), the recipient should immediately notify the sender by e-mail and by telephone 407-551-7868 and obtain instructions as to the disposal of the transmitted material, In no event shall this material be read, used, copied, reproduced, stored or retained by anyone other than the named addressee(s), except with the express consent of the sender or the named addressee(s). Thank you. Reference #: 1992095A COMMERCIAL GENERAL LIABILITY LIMITS OF LIABILITY General Aggregate $ 2,000,000 Products Completed Ops Aggregate Limit $ 2,000,000 Personal Advertising Injury $ 1,000,000 Each Occurrence $ 1,000,000 Damages to Premises Rented to You $ 100,000 Medical Expense $ 5,000 Deductible None Deductible Type/Deductible Basis N/A COMMERCIAL GENERAL LIABILITY CLASSIFICATIONS Locationl - Building 1 US 1 & CR 512, Riverview Park, SEBASTIAN, FL 32958 Class Description State/Terr Rate Exposure Basis Premium 42102 Festivals and Celebrations - FL/6 03 Each $ 2475 Prem/Ops NOC Activity 11/01/2017 to 11/06/2017 Day $ Products Class Description StatelTerr Rate Exposure Basis Premium 49950 Additional Insured - Lessor Of 01 FLAT $ 100 Within MP Leased Equipment (SEL) (Form: CG 20 28) (ClassCode: 49950) GL Premium Subject to Minimum Premium $ 2575.00 General Liability Premium Subject to Minimum Premium $ 2575.00 Premium for Coverages in Addition to Minimum Premium $ 0.00 Total General Liability Premium $ 2,575.00 COMMERCIAL LIQUOR LIABILITY LIMITS OF LIABILITY General Aggregate $ 1,000,000 Each Common Cause $ 1,000,000 COMMERCIAL LIQUOR LIABILITY CLASSIFICATIONS Location1 - Building 1 US 1 & CR 512, Riverview Park, SEBASTIAN, FL 32958 Class Description State/Terr Rate Exposure Basis Premium 54282 Special Events - Liquor Liability FL/6 0.000 03 Gross J$ 1,605.00 Prem/Ops Sales Is Products Liquor Premium Subject to Minimum Premium $ 1605.00 Premium for Coverages in Addition to Minimum Premium $ 0.00 Total Liquor Liability Premium $ 1,605.00 POLICY ENDORSEMENTS/EXCLUSIONS IFG-1-0002 0116 Policy Cover Page IFG-1-0101 0414 Common Policy Declarations IFG-1-0150 0303 Listing of Forms and Endorsements IFG-1-0402 1100 Service of Suit Amendment GL ENDORSEMENTSIEXCLUSIONS BG -G-004 0317 Exclusion - Lead -Bearing Substance BG -G-005 0317 Exclusion - Punitive Damages BG -G-007 0317 Exclusion - Asbestos, Silica BG -G -039a 0317 Amendment Of Premium Conditions BG -G -446 -ST 0317 Amendment - Insuring Agreement CG 00 01 0413 Commercial General Liability Coverage Form CG 02 20 0312 FL - Cancellation and Nonrenewal CG 21 47 1207 Employment Practices Exclusion CG 21 67 1204 Fungi or Bacteria Exclusion CG 21 75 01 15 Exclusion Of Certified Acts Of Terrorism And Exclusion Of Other Acts Of Terrorism Committed Outside The United States CG 24 26 0413 Amendment Of Insured Contract Definition GSG-G-016 0317 Exclusion - Aircraft Products And Grounding, Including Unmanned Aircraft Or Unmanned Aerial Vehicle IFG-G-0002-DL 0503 General Liability Declarations IFG-G-0086 0317 Total Pollution Exclusion IFG-G-0190 0317 Amendment - Exclusion g. IFG-G-0192 0317 Personal - Advertising Injury IFG-G-0194 1015 Excl-Confid Info & Comp Syst Liab IFG-G-0197 0515 Amendment - Employer's Liability Exclusion IFG-1-0170 0317 Two or More Coverage Forms or Policies Issued By Us IL 00 17 1198 Common Policy Conditions IL 00 21 0908 Nuclear Energy Liability Exclusion IL P 001 0104 OFAC - Notice to Policyholder GL CLASS SPECIFIC ENDORSEMENTS/EXCLUSIONS BG -G-074 1211 Exclusions and Redefinition Described Hazards (Special Events Liability) IFG-G-0051 0317 Exclusion - Liquor Liability LIQUOR EN DORS EM ENTSIEXC LUS IONS BG -L-502 0317 Definition - Each Common Cause Limit CG 00 33 0413 Liquor Liability Coverage Form CG 24 06 0413 Liquor Liability - Bring Your Own Alcohol Establishments CG 28 06 0196 Limitation Of Coverage To Insured Premises IFG-LL-0101 01 11 Liquor Liability Declarations OPTIONAL ENDORSEMENTS/EXCLUSIONS BG -G-042 0317 Exclusion - Assault/Battery BG -1-026 0317 Fully Earned Premium BG -L-231 0317 Exclusion Assault, Battery Or Other Physical Altercation CG 20 28 0413 Additional Insured - Lessor Of Leased Equipment Special Disclosure on Terrorism To Applicant Per Terrorism Risk Insurance Act of 2015 (TRIA), the United States Government will pay a share of losses caused by certified acts of terrorism. The federal share is 85% through 2015; 84% beginning on January 1, 2016; 83% beginning on January 1, 2017; 82% beginning on January 1, 2018; 81% beginning on January 1, 2019 and 80% beginning on January 1, 2020 of covered terrorism losses exceeding the statutorily established deductible paid by the insurer. THIS IS TO ADVISE THE APPLICANT THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURERS, LIABILITY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION, YOUR COVERAGE MAY BE REDUCED. Broker must have on file a properly executed Form C 01 15 "Policyholder Disclosure Notice of Terrorism Insurance Coverage" upon binding coverage. Coverage Is offered on a Non -Admitted Basis. The Policy is subject to the Surplus Lines Laws In your state. You should make every effort to comply with any special provisions and regulations of your State. You must add all applicable Taxes and Fees to the quoted premium. You are responsible for the collection and remittance of surplus lines taxes to be filed directly with the applicable state(s). Cancellation provisions - per policy forms. State amendatory endorsements, if applicable. Coverage shall be subject to all terms and conditions of the policy to be issued which when issued will replace any and all of our quote(s) and/or binder(s) without any further notice. Please read all terms and conditions shown above carefully as they may not conform to the specifications shown in your submission. Transmittal Disclaimer This fax or email message is strictly confidential and is intended solely for the person or organization to which it is addressed. It may contain privileged and confidential information and, if you are not the intended recipient, you must not copy or distribute it or take action in reliance on it. If you have received this message in error, please notify the sender as soon as possible.