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BUILDERS RISK COVERAGE DECLARATIONS <br /> The Declarations , Supplemental Declarations , Common ASSURANCE COMPANY OF AMERICA <br /> Policy Conditions , Commercial Inland Marine Conditions , A Stock Company <br /> Coverage Form (s) And Endorsement(s) , if any , issued to Administrative Office : 1400 American Lane <br /> and forming a part thereof, complete the Commercial Schaumburg , IL 60196 <br /> Insurance Policy numbered as follows : <br /> THIS IS A COINSURANCE CONTRACT <br /> ® New Policy BR69566075 <br /> F-1 Renewal of Please read your policy . <br /> ❑ Rewrite of <br /> In return for the payment of the premium , and subject to all terms of this policy , we agree with you to provide the <br /> insurance as stated in this policy . <br /> 1 . Named Insured and Mailing Address : 2 . Producer Information : <br /> A. Thomas Construction Inc . A Name : <br /> P . O . Box 3285 KILLINGSWORTH AGENCY , INC . <br /> Fort Pierce , FL 34948 PO BOX 1750 <br /> B Telephone # 352-796- 1451 <br /> C Fax # 352-799-5986 <br /> D Zurich Producer # 02253656 <br /> 3 , Policy Period — From : 06/30/2010 To : 06!30/2011 E Field Office Name ORLANDO <br /> 12 : 01 a . m . Standard Time at your mailing address above . F Field Office Code ZO <br /> r4, F:orTn of Business : ❑ Individual ❑ Partnership ® Corporation ❑ Joint Venture ❑ Other <br /> its of Insurance ( either One-Shot or Reporting Form as indicated below) <br /> 0 SUPPLEMENTAL DECLARATIONS <br /> ( If this box is checked , Supplemental Declarations is attached to and forms a part of this policy) <br /> ❑ Reporting Form (continuous policy) ❑ One-shot ( <br /> Z non-reporting form/single structure policy) <br /> ❑ Annual Rate ❑ Monthly Rate ( HBIS — 4) ❑ 1 -4 Family Dwelling Q Commercial Structure <br /> Property Location <br /> A) Any one building or structure $ 4855 43rd Avenue <br /> B) All covered property at all locations $ <br /> Vero Beach , FL 32967 <br /> C) Rate Per Report <br /> D) Premium Per Report New Construction $ 571000 <br /> E) Total Taxes and Surcharges Per Report A) Any one building or structure 57 , 000 <br /> (per attached endorsement B) All covered property at all locations $ <br /> F) Total Fully Earned Policy Premium Per Report (same as A unless otherwise noted) <br /> Remodeling <br /> D) Renovations and improvements $See new cons <br /> E) Existing buildings or structures $ 0 <br /> F) Rate $ 0 . 207 <br /> G) Premium $ 400 . 00 <br /> H ) Total Taxes and Surcharges $ 12 . 00 <br /> ( per attached endorsement) <br /> 1 ) Total Fully Earned Policy Premium $ 412 . 00 <br /> minimum premium applicable) <br /> 6 . Deductible : ❑ $ 500 ® $ 1 , 000 ❑ $2 , 500 ❑ $5 , 000 ❑ Other <br /> 7 . Forms Applicable To This Coverage Part : <br /> SEE SCHEDULE OF FORMS AND ENDORSEMENTS <br /> Countersigned : By . <br /> Date Authorized Representative <br /> FM - 170001 (04-09) <br />