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SWORN STATEMENT IN PROOF OF LOSS $ $25,000,000.00 Primary Layer Amount of Policy at Time of Loss AD3739595AO05 Policy Number 05/01/16 -17 INSURANCE COMPANY AJG. Orlando, FI. Policy Effective Dates Agency and Location Chubb, Certain Underwriters at Lloyd's, London, Liberty International Underwriters and Markel / Evanston. By the above indicated policy of insurance you insured Indian River County Board of County Commissioners Against loss by: Hurricane Damage Upon property described according to the terms and conditions of said policy and all forms, endorsements, transfers and assignments attached thereto. Time and Origin: A Hurricane loss occurred about ------ O'clock ------ , on the 7th Day of October 2016 . The cause and origin of the said loss were: Hurricane Matthew struck the Florida East coast. Property involved in Claim: County /Municipal Occupancy: The building described, or containing the property described, was occupied at the time of loss as follows, and for no other purpose whatever: County Title and Interest: At the time of the loss the interest of your insured in the property described therein was Ownership No other person or entity had any interest therein or encumbrance thereon, except: Not applicable Changes: Since the above policy was issued there has been no change in title, use or possession of said property except: None The Total Insurance covering the described property including this policy and all other policies ( whether valid or not), binders or agreements to insure was at the time of loss $25,000,000.00 The Replacement Cost of said property at the time of loss Not Determined Full Cost of Repair or Replacement: $17,672,153.13 Applicable Depreciation: ( None ) _Actual Cash Value Loss X Replacement Cost Loss $17,672,153.13 Less Deductibles; Deductibles/ Limits applied per policy / Unit of Insurance (- $11,983,778.04 _Actual Cash Value Claim X Replacement Cost Claim $5,688,375.09 Supplemental Claim, to be filled in accordance with the terms and conditions of the Replacement Cost coverage within N/A days from date of loss will not exceed NA This loss did not originate by any act, design or procurement of the insured, or this subscriber; nothing has been done by or with the privity or consent of the insured or this subscriber to violate the conditions of the policy; no articles are mentioned herein or in annexed schedules but such as were in the building damaged or destroy, belonging to and in possession of the insured at the time of loss; no property saved has been concealed and no attempt to deceive the company has been made. Any other information that may be required will be furnished and considered a part of this proof. State of: Florida Countyof: INDIAN RIVER Subscribed and sworn to before me this Insured: INDIAN RIVER COUNTY BOARD OF COUNTY COMMISSIONERS BY: Notary Pubic Jason E. Brown, County Administrator Day of 20 Any person who knowingly and with intent to injure, defraud or deceive any insurance company flies a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree 2