I mt Laude rdale , FL 33309

INSPECTION ACKNOWLEDGEMENT

Deai· Policyholder:
Thank you for your recent application for property insurance with Universal Property & Casualty Insu rance
Company ('UPCIC'). We appreciate the opportunity to meet your residential insurance needs .

UPCIC will conduct a brief inspection of your property to verify basic information we use in our underw1iting
process . For all policies other than the condominium unit owners' policies, the inspection is an exterior home
inspection that includes photographs and measurements of the dwelling. The inspection generally does not take
longer than I 0-15 minutes and does not require you to be home unless you live in a gated community, in which
case you will need to grant access to our inspection company , Universal Inspection Corporation. 1fyou have
applied for a condominium unit owners' policy with Coverage A of $200 ,000 or more, our inspection company
will contact you to aITange for an interior inspection at a convenient time.

Sincerely,

Universal Property & Casualty Ins urance Company

~ eceived / / By _ _ _ _-:----:-~-::~-:--~---
--(D~ (Applicant Signature)

Agent: Pleas1.: retain this signed notice in your policy file

 PolicvN umber: 1501 - 1805-5763 GENl-:HAL lJ NDERWHITll\'G
lndical(' number oflnssrs rrportrd h~· n ny 11rosp~r 1in• ln,urr<I wllhin lh,•
l. Ills! live ,V<IIN'! (S.-r 1l<•fin ition of ln,u1·(',I ll<'hm) Gs]Non•~
0
s D~tc ot' 1.,,ss D.:-.s,·nrt1<'11 /\ mriunt 1>a 1d
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rr iur Curi<••is) ( Lti5t I '} Mt>11ths )· ::; ,\[T POI N I 11\ SU l{ AN C'I t 'OM l'o li cy No (s} S F I.H0'2 3K4J4 loxp Uatc ls). WCl /2JJ\ 8
0 I h avC' n,,c h..'!d property ,nsnnmcc ,H1 lh b prope r!) in the last 12 mo nths .

Rrplacc mrnt Y:tluc $225 .137 \farkct Value $0 Property pa rti ally or entirely over water? O '(c.,0'\Jo
$() Ir yes. e xpl ai 11 :
, car Purch:tscd Purchase Price
Prinrnr~ Heal Source None

II 0 Profcssiom1II) Installed'? 0Yes WNo

I \\ ' Explain All "Yes" Answers In REMARKS Property partially 01· entirely over sand~ beach
F
I I l. Any Business (including Daycare) conducted on prem ises? 0Ycs [Kl No surfaces in areas susceptible to erosion'!
I I. ~- Is the dwelling loc ated 011 a farm . rdnch . orchard or grove. o r I i' yes. explain : 0 Yc ~ 0 No
I
:-.;
any 01 her property on which farm ing. ranch ing. ur any other 0Ye s D No
agricultural activ ity is conduct.;d? tHA WAIi ONL Y l
G
PROTECTIVE DEVICE DISCOl l"-j 'fS
3. Any sinkhole exposure or claims? Yes 5:]No D
Ir yes. all damaged repaired? 0Yes 0No ( Attach documentation) Roof Shape : !·hp
4. Is home currently condemned? 0Yes 5:]Nu
*Central Burg lar Alarm : 0 *Central Fire Al arm : 0
5. Any existing damage? 0Yes 5:JNo * Automatic Sprinklers:Octass A D ClassB
If yes to 5 .. Ex isting Damage Exclus ion (UPCIC-10) appl ies. (*Documentation and Rate Sheet Required)
REMARKS
CO:\IPLETE IF HO\tE IS UNOCCl!PIEO AT ANY TJ\1E

6. Swimming Poul or sim ilar stmcture? 0Ycs 0No I . Name: & Phone or person checking home:
If yes, is ii completely fcncecL'screened? 0Ycs 0No
Iffenccd. height 0 ft. 2. I lo w often is home checked? #Error
If yes, diving board or slide? ('-lotc: exclus ion below) 0Yes
.. ~Ole
□ No
,,.-IUS1 be c01.11plctt:.I~· ;cr~~ned or prott!Cted by" fc:nt.:C at lea.st -'l feet high 1hat prc1rcnts ncce;s
3. Neighbors within viewing di stance year round?
under. through or = t l the f"ncc Oihcrw i5-c endorsement CPCIC SPI. (05·'08 l (swimn11ng pool
0Yes 0No
liability exclusion) will:,;ply. COMPLETE IF RISK I'\ SPECIAL FLOOD HAZARD AREA
'":~Apph..:ant's ,nitials'~ (Coapplicant's initials)_ __ Ov, r-lomi Ins urer:
7. Skate board ramp on property? (Note : exclusion below) ,.s 0No Policy ~o : Zorn.;:
8. Trampoline on property? 0.Jote : exclusion be low) 0Yes 0No Pol icy in Effect: □ Ye:; □No EffDate: 10/1 6/2018
9. Do yo u own or h ave use of a " Personal Watercrall"? D Yes 0No Bldg. Cov . $0
(N ote : exclusion below) Conts Cov. $0
IO. Post Hurricane Inspection made with in 48 hours after the storm/hurricane
FLOOO COVERAG E AMOUNT MUST El,2UAL THE
left defined boundaries on :
l.lMITS FOR COV ERAGES A & C REQUt::STED
Date : 1/1/00!) 1 Time: 12 :00:00 AM

Under the policy requested in th is application, the "Insured"' incl udes the applicant_ spous e ii'a res1dem ofthc sume hou5ehold, and other n.-sidents of the
same household who are rcluti\·es or are under the age ot 2 1 and in the care of :m y person included in this delimtion
B
A
C Yes No

□
K Has ,my prospective insured had any bankruptcy in the pnst 60 months?
0
G
R
□ 0 Has any prospective insured been subject to any lien in die pas! 60 months'?

□
0 @ Mas any prospective insured been subject to any judgments in the past 60 months?
u
N
D □ @ Has any prospective insured had any volw1tary repossession in the past 60 monlhs?

□ [Kl Has any prospective insured had any involuntary repossession in the past 60 months?

□
Has any prospective insured been convicted ofa lelony in the last 10 years?
0

□ [Kl Has any prospective insun:d had his or her driver's license suspended in lhe last 5 years?

□ @ Has any prospective insured ever been involved in a 1sl P11rty Personal Line-s lawsuit against nn Auto
Insurance Company or a Homeov,mcrs Insurance Company?

□ @
-
Has any prospective insured ever been arrested for driving under the inlluenci: or alcohol or some o(her
illegal s ubstance, assault or battery or disorderly condm:t in the past 10 years?

□ @ Does any pros pective insured have or intend t0 have any dogs(s) on thi: premises? (NUTE: Amma l Liability Exclusion below)
If so , w hat ki nd(s)?
(policy exclusions apply; coverage may be avail a ble for ,m a<l<litional premium : consult compuny for details)
UPC !C l-fO A pp 02 12 Printed: 10~2/2018 3.34 :28 PM QuolclO: 15236252
 Pol ic, Numb'--r- 150 1 ISO~,
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ANIMAL UAUll.l'I y EX( ·r.u.-~ roN
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D" ' INC BOARD~. l'OO L SLIDES T ltAMPOLINES. AND SK ATE DOAHD l{AMJ' LIA U ff .!TY f :X < U J~ IO .'\J
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sl 1dt.·s. lm mp(.)1 111'.'-" m1d '-"- n1 ,· h" 11d 111111p ll:1 t,d 1l\• cxd us n,n. The p 1irp1.,s c of1h1:: i t·xclus1on 1s not ln pro vide co~crnec 11n<lcr lhc ful lo\,·ine, c.J / ,ed •J1rec.tly
f'
s or md1n.·,.:th ~, 1hc.."' 1..1 \\nc r'> h 1p. 111:1mh..·11:111re ,)ruse by unyunc- ofrmy of the follu w111g t:1. /U1p11u.=nt and/or .:.u.:cessor,cs !»W l mm ing root 1luJc--~ d,,,r-r ~ l--.,<r'H d .
i tmmrnl mc8 . . .~, ,\..ah' h ·,:u-J r :11111~ Su1,;h lo~s 1s cxduJc:tl n:ganll c~~ ~)r nny o th er ca use or c ,•e nt contnbutmg t'O m; urrcntl y or in any :-.-eq uiencc 10 1hr trr ·.

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\ t"':lli1..~1 n r' ~ m1l!.!ls)h/. D (Coappl1cw1t's 1111(1als)
I: PERSONAL WATERCRAJ<~r EXCLUSION
. \ II ,,r U,"' cr,.;.1I Propcrtv and Casualty Insurance ( ·omp,any l-lo111co\\11crs Forms eonl:1111 a "Per sona l Watercraft" cxc lus ,on A " personal \\-:J. tcrc ra fr'" m~ns
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\\,it,-,,-ra rl designed to carry one to three people, propc ll cJ l>y 3 water _1ct pump and c:ipa hle of spe~-Js greater rhan 25 mph. " Pt!rsonal waterc raft" include~
bur 15 not lim 1tc...--d to wutercn1li oltcn rcforn..'<.l lo u.s j e t sk1 '\, w ave nmm.:rs. u11<l si mil a r wa tc.-n.:ru.ll
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I ~ tl,A;-pl i,·J nt', 1111u:ils)1}1_,_j2(Coapp lican1's in i11als )
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NOTICE OF JNSURANCI:: JNFOR.t\-lATfON PRACTICES
s Personal inti.,m1 m1on a bout you. incluJing 1nfor111at1on from a crcJit re port. may he collected rrom persons other than you Suc h mfOrmat1on :.ss we ll as
01hcr personal and pn v1lcgcd intonnation collected by us or our agents may 111 certain cin.:ums1ances be disdoseJ to th ird parties. You havt: lht: rigln 10
re new yo ur pc::r.sona l inlOnnauo n 111 our files ;,\nd ca n rc-qucst corrcclmn ur :my 111ncc urac1es Lhc a pplican t!> will receive a cory of our prn·acy practi ces w ith
vour pol,cy. and a copy 1s ava 1l ub lc upon request rrom your agent or by contacting us.

~ lf..<1. pplican('s i111Lia ls) M, la-:o::ippl ic,mt's in111 als)

FRAUD STATEMJ<.:NT
"Any per.son who know ingly and \\1th mtcnl 10 injure, defraud. or dcc.-in: "ny ins urer files a statemen t o r ch111n or an application con1ain1ng any lalsc.
111complctc. or misleading information is guilty of a folony o r the thirJ c.kgree "

~ ~ (Applicanr's iniria lsA1. i) (Coapplicam's 111 1tials)

Coverage [K]Bo und Pay rm:n l Enclosed $2,876.00 (Make check paya ble to Universa l Property & Casualty Insurance Company)
B
I Q-\'ot Bound (Do not collect prem ium) Specif)' Rt:ason
N [NSURANCE BINDER (ir covcrnge is bound, lhe fo llm.ving cond itions apply) : Binder period maJ not exceed 45 days.
D
E Un iversi!l Property & Casualty Insurance Company binds lhc kind(s) of ins urance sttpulated on this apphcat1on T his ins urarn.:c i5- subJect to the n .llL°:'.>~
R h:mns. conditions and limttations oft he pol icy(ics) antl Personal Linc.$ Underwriting manual of the Com puny applicable on 1hc effective date of the binder.
By signing this application each applicant and co-appli..:anl u<.:kno wlcdges awareness of thi s tact.

This binder mus t be presented to the Company 1,v ithm ten ( 10) days of the date thert.-or This bindt:r may he canceled by the insured by surrender of this
binder or by ad vance wn ttcn notice to the Company stuling when canccllauon "i ll be cffect ivi::. This binder ends upon surrender of thi s hinder or by
advance wrlllen notice 10 the Com pany stating when cancellation will he effect ive. This bi nder cnJs upon the earlier of(a) 45 days, (h) acceptunc<.: or
declinatwn of the risk. or (c) notice from the c.;ompany. Ir thi s binder ts nol replaced by fl po hey . the Cumpany is .:mi tied to chargc a premium ti.,r the
hinder according lo the:, ru les and rates in use by the Company

Binder Effective Date Time 10/22/2018 Bi nder Expiration Date I 2/6/2018 at 12:01 a.m.
Binder Effective Date (if required by g uidelines)
APPLICANT'S STATEMENT
s Each appli cant and co-applicant (t:uch an "Applican t" for purposes ofth1s paragraph) must sign th is applicat1on . Euch i\pp licanl acknowledges and U!,'T<!es
I that he or she has read the above upplication and any attachmenlS. Cach Applicant understands that a rn1srcprcscn1ation , omiss ion. concealmcnl of foci. or
G incorrect statement may prevent recovery under the pol icy Each Applicant understands that any such misn::presentation . omiss ion. conct:almcnt of fact, or
N mcorrccl statement by any Applicant may negate coverage under the policy as to all Insureds. This information is be ing otforcd Lo Lhe company as an
A induct:menl lo i~suc the policy for which !ht: undersigned Applicant(s) are applying. Euch applicant agret:s that iflhe 11111ial payment for the policy
T prem ium, or downpayment for the pol icy premium as applicable, is returned hy the bank for any reason. coverage will be null and void from inception (e g ,
u insufficient funds, closed account, stopped payment, clc.). /)
R
E
~ gnature of Applicant - M,!- M A V IS DOWNER
Signatu re ofCoApplica nt -
-- mA/~I /ru_.1~
'\::
/ Date / 2''1;JVfi me
Date Time_ _ _
?J9/J1
Print Name of Agent - Ray A. Forres t Phone
Signature of Agent Date Time
YOU MAY BE ENTITLED TO S IGN lflCANT PREMIUM DISCO UNTS r3ASED UPON Tl IL: CONSTRUCTION OF YOUR HOME, YOUR
USE OF WINDSTORM LOSS MITIGA TJON DEVICES OR OTI-IER FACTORS PLEAS!-: <.'ONTALT YOUR AGENT OR INSURER

----
UPCICHOA pp 02 12
REPRESENTATIVE FOR ADDITIONAL INFORMATION

Print~!. 10/22/2018 3 :34:28 l'M QuotclD· 15236252


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A gent's ln~airance License N u .

l'r\l)X'rt,, •\ddn.:~:-- ( I 1· dilk ~ nt th a n Mailing Addr~ss ):

Form :
IX
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l jl 10 00 03 Special t'onn T c mu, 1
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:,-\ INRISI-' . l· I :,:n5 1 0 I 10 00 06 Condominium Un it- Owne r HO 'JO <i~ I l,,m.::,; .,,r,c-n
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I ~) Ir dwc-lling docs not have a sln::d address. indicate lot. block.

Payment Submitted
0
$2 ,876.00
Premium f- inam;e (Attach copy of ContractJ
[K)Fu ll
-.;
.1J d ition or section. to,\•nship. rang~. town name:
0 2-Pay 0 4-Pay
Urand Subtotal
$:l,84 9 .00
l /\dd'I Surcharges
S27.00
Total E st. P rem i um
'b2 '-', 7f; t.,<;

·
Occupatmn o 1· N amc <l l 11sL1r'·d(s
" ·) Date o f Birth
At R~ne.,,val Bill : 0 Insured Ii] Morlgagcc .
RFl IRLIJ
I st Named Insured Spouse: or 2nd Name d l nsurc:d I
j
;s-: Oother 2/2/ 1941
T
1-: Name I Address I Zip Code Interest Type Loan Number
R
E BANK OF AMERICA NA. ISAOA, PO BOX 961291 , Fort Worth TX 76161 1st Mortgagee 870504373
s
T

BASIC COVERAGES Coverage Limits Dell uc lib le: $2.500 00

L A. Dwelling $225, 137 Hurricane Deductible: 2% - $4.503
T n. Other Structures $22,514 Risk in Ocsi~nateJ State \Vind Arca'! 0Ycs Ix !No
M
C. Personal Property
T
I
D. Loss of Lsc
$112.569 Please: !x hncludc DF-xc!L1de Wind$lonn
s $45,028 Year Built: 1988 For Dwdlmg over 35 years. ind icate year
E. Personal Liability
F . i\·l,•ni,,,11 P,.n,mn.-.•·•·
:i;300,000 upuale r..:1.m1plctc: \-\'iring:
r-,
2002 Update 0No