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SWORN STATEMENT IN PROOF OF LOSS <br />$ $25,000,000.00 Primary Laver MKLV11XP005717, 100008350405, EW0013417, D3739595A006 <br />Amount of Policy at Time of Loss Policy Numbers <br />05/01/17-18 <br />INSURANCE COMPANY ANG. Orlando, FI. <br />Policy Effective Dates Agency and Location <br />Chubb, Certain Underwriters at Lloyd's, London, Liberty International Underwriters, ACE North American and Markel / <br />Evanston. <br />By the above indicated policy of insurance you insured <br />Indian River County Board of County Commissioners <br />Against loss by: <br />Hurricane Damage Upon property described according to the terms and conditions of said policy <br />and all forms, endorsements, transfers and assignments attached thereto. <br />Time and Origin: A Hurricane loss occurred about O'clock on the 10th <br />Day of September 2017 . The cause and origin of the said loss were: Hurricane IRMA struck the Florida East <br />coast. <br />Property involved in Claim: County /Municipal <br />Occupancy: The building described, or containing the property described, was occupied at the time of loss as follows, and for <br />no other purpose whatever: County <br />Title and Interest: At the time of the loss the interest of your insured in the property described therein was Ownership <br />No other person or entity had any interest therein or encumbrance thereon, except: Not applicable <br />Changes: Since the above policy was issued there has been no change in title, use or possession of said property except: <br />None <br />The Total Insurance covering the described property including this policy and all other policies ( whether valid or not), binders <br />or agreements to insure was at the time of loss $25,000,000.00 <br />The Replacement Cost of said property at the time of loss Not Determined <br />Full Cost of Repair or Replacement: Per Statement of Loss: $7,972,417.85 <br />Applicable Depreciation: ( None <br />_Actual Cash Value Loss X Replacement Cost Loss $7,972,417.85 <br />Less Deductibles/Limits; Application of the Deductibles by Scheduled Location, Un -named Locations <br />And the Property in the Open applied in the supporting spread sheets (-4,537,235.33) <br />_Actual Cash Value Claim X Replacement Cost Claim $3,435,182.52 <br />Less amount of paid claim for Unnamed Miscellaneous Locations (-2,500,000.00) <br />Net Remaining Paid Claim $935,182.52 <br />Supplemental Claim, to be filled in accordance with the terms and conditions of the <br />Replacement Cost coverage within N/A days from date of loss will not exceed NA <br />This loss did not originate by any act, design or procurement of the insured, or this subscriber; nothing has been done by or with the privity or consent <br />of the insured or this subscriber to violate the conditions of the policy; no articles are mentioned herein or in annexed schedules but such as were in <br />the building damaged or destroy, belonging to and in possession of the insured at the time of loss; no property saved has been concealed and no <br />attempt to deceive the company has been made. Any other information that may be required will be furnished and considered a part of this proof. <br />State of: Florida <br />Insured: INDIAN RIVER COU •ARD OF CO <br />MMISSIONERS <br />County of: INDIAN RIVER BY: <br />Subsc <br />ed and sworn to bef <br />e me this <br />Any person who knowingly and wi <br />incomplete or misleading informat <br />Notary Pubic <br />.� <br />Brown un�nistrator <br />ent to injure, defraud or deceiv <br />DORIS E ROY <br />:q MYCOMMONS 00306364 <br />e co19.1103144814102/002$of cl <br />is guilty of a felony of the third de --e ;;,,,+` Boded lMYNary g <br />aniaullonowarisiamilik <br />• <br />20/7 <br />containing any false, <br />