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Blk 86 City of Okee/Jean Paige/Alley40203000238017 Nationwide® is on your side City Of Okeechobee 55 SE 3Rd Ave Okeechobee FL 34974 -2903 Notice: A Homeowner policy will be cancelled THIRD PARTY NOTICE/' Jean R. Paige Page 1 of 1 Date prepared Jura "29 , 2016 at Policy number HOk e&4449638 . Insuring company Nationwide Insur e Comp'6ny c °� Flori,1a',- Policy type Homeowrier ' Property location 501 NE 6th Okeechobee FL 349722691 Questions? Contact a Nationwide representative at 800- 282 -1446 Our records indicate you have a financial interest in the Homeowner insurance held by Jean R. Paige. This policy will be cancelled as of 12:01 a.m. local time on June 18, 2016. Policy details Policy number: HOF 0024449638 Insured: Jean R. Paige Property location: 501 NE 6th Av Okeechobee FL 349722691 For help when you need it If you have any questions or concerns, please contact a Nationwide representative at 800- 282 -1446. Nationwide Mutual Insurance Company and Affiliated Companies, One Nationwide Plaza, Columbus, OH 43215 -2220, nationwide.com Nationwide, the Nationwide N and Eagle and Nationwide is on your sde are service marks of Nationwide Mutual Insurance Company. '2015 Nationwide NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL AMENDED DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including an approximate cost for labor and materials in your area, and specific information that you have provided about your home. HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -6 ACCOUNT NUMBER: 7783000403 Policy Period From: 06 -18 -15 To: 06 -18 -16 12:01 A.M. Standard Time Effective Date of Change 082015 COVERAGE INFO QUALIFIER MISC NON INFO INSURED INFO PERIL PREMIUMS PERIL PREMIUMS RATING INFO DDL PPLICATION INFO The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No., Street, City, State, Zip Code) PREVIOUS POLICY NUMBER HOF 0024449638 -5 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 TO BE PAID BY NAMED INSURED COVERAGE AND LIMITS OF LIABILITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 142,500 2,850 71,250 14,250 100,000 1,000 FOR LOSSES ARISING UNDER SECTION I, WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM BASIC COVERAGE HO3 01 /00 Special Form 1,714.25 12501S 08/08 ORD OR LAW 12501AS 08/08 SURCHARGES 12501HD 08/08 HURR DEDUCTIBLE 12501SK 08/08 CAT GRND CVR COL H0277FL 08/08 Ord or Law - 50% 85.71 12559A 06/12 Per Prop Repl 257.14 12567F 06/12 Replacement Cost 5.02 12747 09/08 Biological Det HO216 08/08 Prem Alarm Prot 74.32CR IN2525 08/08 Opt Ded Offer IN2542 08/08 Hurr Mit Dsc Inf H041 01 /00 Add Ins Res Prem 12800 08/08 Hurricane Prov IN2531 07/10 FL Hurr Cat Fund IN2533 07/10 Loss Mitigation IN2532 06/12 Checklist of Coy IN2537 06/12 Outline of Coy OIRB11802 01/12 Inspection Form 16373 06/12 Grnd Cvr Collaps HO300FL 10/13 Spec Provisions IN0000 04/09 Privacy Stmt IN2526 08/08 Hurr Ded Option IN2541 08/08 ID Fraud Offer TOTAL SURCHARGES 21.88 TOTAL ANNUAL POLICY AMT DUE 2,009.68 Additional Residence Occupied By Insured NO ADDL PREMIUM Mortgage Loss Payee or Other Interest Loan Number CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL 34974 -2903 NATIONWIDE INS CO OF FLORIDA Authorized Representative DIRECT BILL LT2I 15245 012636 MEMO COPY T 7783000403 59 NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL CONTINUATION DECLARATIONS NAME INSURED AND ADDRESS PAIGE. JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including an approeamate cost for labor and materials in your ijrea, and specific information that you have provided about your home. The described residence premises covered hereunder is located at the above address. unless otherwise stated herein. (No., Street, City, State, Zip Code) 501 NE 6TH AV OKEECHOBEE, L 34972 -2691 HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -6 ACCOUNT NUMBER: 819760561 Policy Period From: 06 -18 -15 To: 06 -18 -16 12:01 A.M. Standard Time Effective Date of Change PREVIOUS POLICY NUMBER HOF 0024449638 -5 TO BE PAID BY NAMED INSURED COVERAGE AND LIMITS OF LIABILITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 142,500 2,850 71,250 14,250 100,000 1,000 FOR LOSSES ARISING UNDER SECTION , WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM BASIC COVERAGE H03 01/00 Special Form 1,714.25 85.71 5.02 74.32CR 12501S 08/08 12501HD 08/08 12501SK 08/08 12559A 06/12 12747 09/08 IN2525 08/08 H041 01/00 IN2531 07/10 IN2532 06/12 OIRB11802 01/12 HO300FL 10/13 IN2526 08/08 ORD OR LAW HURR DEDUCTIBLE CAT GRND CVR COL Per Prop Repl Biological Det Opt Ded Offer Add Ins Res Prem FL Hurr Cat Fund Checklist of Coy Inspection Form Spec Provisions Hurr Ded Option TOTAL SURCHARGES TOTAL ANNUAL RENEWAL AMT DUE 257.14 21.88 2,009.68 12501AS 08/08 12501PC 08/08 H0277FL 08/08 12567F 06/12 H0216 08/08 IN2542 08/08 12800 08/08 IN2533 07/10 IN2537 06/12 16373 06/12 IN0000 04/09 SURCHARGES PREM CHG INFO Ord or Law - 50% Replacement Cost Prem Alarm Prot Hurr Mit Dsc Inf Hurricane Prov Loss Mitigation Outline of Coy Grnd Cvr Collaps ! Privacy Stmt (CONTINUED) Additional Residence Occupied By Insured Mortgage Loss Payee or Other Interest Loan Number CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL 34974 -2903 NATIONWIDE INS CO OF FLORIDA Authorized Representative DIRECT BILL 0000 15116 023990 MEMO COPY T 819760561 59 June 5, 1984 LETTER OF UNDERSTANDING To: City of Okeechobee From: Mrs. Jean Paige Subject: AGREEMENT FOR USE OF ALLEY RIGHT -OF -WAY In consideration of the agreement of the council at its meeting of June 4, 1984, for the use of a 15 -foot alley- way, adjacent to my home, on the north side of blocks 10, 11 and 12 - block 86, I, hereby, agree as follows: 1 I will request my insurance company to attach a rider to my home owner's policy insuring the City against any liability arising out of injur- ies by any person or persons utilizing the 15- foot alley right -of -way. 2 The alleyway will not be used for any permanent structure. 3 If at any time the City requires the use of said alley for the installation of utilities or for any other purpose including drainage, etc., I agree to remove, from the 15 -foot alley right - of -way, all materials, buildings and other matter which may be located thereon, at my ex- pense, within 15 -days notice in writing. Witnesses: .4 ,, ,gi,zi,,210C6tS ATTEST: ■ City Clerk Signed: 7—f—) Paige Adtss: ( AV (eE1i 33'7 2 00 (L0-Z0) NL000I NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL CONTINUATION DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including an approximate cost for labor and materials in your area, and specific information that you have provided about your home. HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -5 ACCOUNT NUMBER: 819760561 Policy Period From: 06 -18 -14 To: 06 -18 -15 12:01 A.M. Standard Time Effective Date of Change The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No., Street, City, State, Zip Code) PREVIOUS POLICY NUMBER HOF 0024449638 -4 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 TO BE PAID BY NAMED INSURED COVERAGE AND LIMITS OF LIABILITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 142,500 2,850 71,250 14,250 100,000 1,000 FOR LOSSES ARISING UNDER SECTION , WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM BASIC COVERAGE H03 01/00 Special Form 1,667.10 12501S 08/08 ORD OR LAW 12501AS 08/08 SURCHARGES 12501HD 08/08 HURR DEDUCTIBLE 12501PC 08/08 PREM CHG INFO 12501SK 08/08 CAT GRND CVR COL H0277FL 08/08 Ord or Law - 50% 83.36 12559A 06/12 Per Prop Repl 250.07 12567F 06/12 Replacement Cost 5.02 12747 09/08 Biological Det H0216 08/08 Prem Alarm Prot 68.65CR IN2525 08/08 Opt Ded Offer IN2542 08/08 Hurr Mit Dsc Inf H041 01/00 Add Ins Res Prem 12800 08/08 Hurricane Prov IN2531 07/10 FL Hurr Cat Fund IN2533 07/10 Loss Mitigation IN2532 06/12 Checklist of Cov IN2537 06/12 Outline of Cov OIRB11802 01/12 Inspection Form 16373 06/12 Grnd Cvr Collaps HO300FL 10/13 Spec Provisions IN0000 04/09 Privacy Stmt IN2526 08/08 Hurr Ded Option (CONTINUED) TOTAL SURCHARGES 62.05 TOTAL ANNUAL RENEWAL AMT DUE 1,998.95 4 ResAdditional ide nal nce Reside �� Occupied By Insured^ Mortgage Loss Payee or Other P r.IYL0 Interest Loan Number MAY 0 5 Z014 "� CITY OF OKEECHOBEE ; : - /--, 55 SE 3RD AVE '•� OKEECHOBEE, FL 34974 -2903 w ... NATIONWIDE INS CO'OF: -FLOR, Authorized Reares'ntative DIRECT BILL 0000 14117 002159 MEMO COPY T 819760561 59 00 (L0-00) NIOSZI Nationwide' On Your Side- NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL AMENDED DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including an approximate cost for labor and materials in your area, and specific information that you have provided about your home. HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -4 ACCOUNT NUMBER: 819760561 Policy Period From: 06 -18 -13 To: 06 -18 -14 12:01 A.M. Standard Time Effective Date of Change 080613 COVERAGE INFO QUALIFIER NON PERIL INFO PREMIUMS SURCHARGE MOUNTS PERIL PREMIUMS RATING INFO MISC PPLICAN INFO The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No., Street, City, State, Zip Code) PREVIOUS POLICY NUMBER HOF 0024449638 -3 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 TO BE PAID BY NAMED INSURED COVERAGE AND LIMITS OF LIABILITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 142,500 2,850 71,250 14,250 100,000 1,000 FOR LOSSES ARISING UNDER SECTION , WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM BASIC COVERAGE H03 01/00 Special Form 1,425.02 12501S 08/08 ORD OR LAW 12501AS 08/08 SURCHARGES 12501HD 08/08 HURR DEDUCTIBLE 12501SK 08/08 CAT GRND CVR COL H0277FL 08/08 Ord or Law - 50% 71.25 12559A 06/12 Per Prop Repl 213.75 12567F 06/12 Replacement Cost 5.02 12747 09/08 Biological Det H0216 08/08 Prem /arm On 61.50CR IN2525 08/08 Opt Ded Offer IN2542 08/08 Hurr Mit Dsc In' H041 01/00 Add Ins Res Prem 12800 08/08 Hurricane Prov IN0000F 05/09 Privacy Stmt IN2531 07/10 FL Hurr Cat Fund IN2533 07/10 Loss Mitigation HO300FL 06/12 Spec Provisions IN2526 08/08 Hurr Ded Option IN2532 06/12 Checklist of Cov IN2537 06/12 Outline of Cov IN2541 08/08 ID Fraud Offer 1N2606 06/12 Change in Policy 1N2608 06/12 Change in Policy (CONTINUED) TOTAL SURCHARGES 40.04 TOTAL ANNUAL POLICY AMT DUE FRie ISM- 3 Additional Residence Occupied By Insured RETURN PREMIUM C'!-- PILITW Mortgage Loss Payee or Other Interest Loan Number CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL 34974 -2903 NATIONWIDE INS CO OF FLORIDA Authorized Representative DIRECT BILL LQN5 13224 004395 MEMO COPY T 819760561 59 00 (10-00) Nl0 Nationwide On Your Side" NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL CONTINUATION DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 'The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including an appro,dmate cost for labor and materials in your area, and specific information that you have provided about your home HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -4 ACCOUNT NUMBER: 819760561 Policy Period From: 06 -18 -13 To: 06 -18 -14 12:01 A.M. Standard Time Effective Date of Change The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No., Street, City, State, Zip Code) PREVIOUS POLICY NUMBER HOF 0024449638 -3 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 TO BE PAID BY NAMED INSURED COVERAGE AND LIMITS OF LIABILITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 142,500 2,850 71,250 14,250 100,000 1,000 FOR LOSSES ARISING UNDER SECTION I, WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM BASIC COVERAGE H03 01/00 Special Form 1,425.02 12501S 08/08 ORD OR LAW 12501AS 08/08 SURCHARGES 12501HD 08/08 HURR DEDUCTIBLE 12501PC 08/08 PREM CHG INFO 12501SK 08/08 CAT GRND CVR COL H0277FL 08/08 Ord or Law - 50% 71.25 12559A 06/12 Per Prop Repl 213.75 12567F 06/12 Replacement Cost 5.02 12747 09/08 Biological Det H0216 08/08 Prem Alarm Prot 10.25CR IN2525 08/08 Opt Ded Offer IN2542 08/08 Hurr Mit Dsc Inf H041 01/00 Add Ins Res Prem 12800 08/08 Hurricane Prov IN0000F 05/09 Privacy Stmt IN2531 07/10 FL Hurr Cat Fund IN2533 07/10 Loss Mitigation HO300FL 06/12 Spec Provisions IN2526 08/08 Hurr Ded Option IN2532 06/12 Checklist of Cov IN2537 06/12 Outline of Cov IN2541 08/08 ID Fraud Offer IN2606 06/12 Change in Policy (CONTINUED) TOTAL SURCHARGES 41.21 TOTAL ANNUAL RENEWAL AMT DUE 1,746.00 Additional Residence Occupied By Insured Mortgage Loss Payee or Other Interest Loan Number CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL 34974 -2903 NATIONWIDE INS CO OF FLORIDA Authorized Representative DIRECT BILL 0000 13118 MEMO COPY 000558 T 819760561 59 0 0 Nationwide Nationwide' On Your Side - NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL CONTINUATION DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including an approximate cost for labor and materials in your area, and specific information that you have provided about your home. The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No , Street, City, State, Zip Code) HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -3 ACCOUNT NUMBER: 819760561 Policy Period From: 06 -18 -12 To: 06 -18 -13 12:01 A.M. Standard Time Effective Date of Change PREVIOUS POLICY NUMBER HOF 0024449638 -2 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 TO BE PAID BY NAMED INSURED ITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 142,500 2,850 71,250 14,250 100,000 1,000 FOR LOSSES ARISING UNDER SECTION , WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM BASIC COVERAGE H03 01/00 Special Form 1,207.13 12501S 08/08 ORD OR LAW 12501AS 08/08 SURCHARGES 12501HD 08/08 HURR DEDUCTIBLE 12501PC 08/08 PREM CHG INFO H0277FL 08/08 Ord or Law - 50% 60.36 12559A 08/08 Per Prop Repl 181.07 12567F 08/08 Replacement Cost 5.02 16372 05/09 Sinkhole Collaps 21.38 12747 09/08 Biological Det H0216 08/08 Prem Alarm Prot 9.59CR HO300FL 09/08 Spec Provisions IN2525 08/08 Opt Ded Offer IN2532 08/08 Checklist of Cov IN2537 08/08 Outline of Cov IN2542 08/08 Hurr Mit Dsc Inf H041 01/00 Add Ins Res Prem 12800 08/08 Hurricane Prov IN0000F 05/09 Privacy Stmt IN2531 07/10 FL Hurr Cat Fund IN2533 07/10 Loss Mitigation IN2534 07/10 Inspection Form 1N2526 08/08 Hurr Ded Option IN2541 08/08 ID Fraud Offer TOTAL SURCHARGES 35.70 TOTAL ANNUAL RENEWAL AMT DUE 1,501.07 Additional Residence Occupied By Insured Mortgage Loss Payee or Other Interest Loan Number CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL 34974 -2903 NATIONWIDE INS CO OF FLORIDA Authorized Representative DIRECT BILL 0000 12117 003191 MEMO COPY T 819760561 59 Policy Number: HOF 0024449638 -3 Declarations Continued: LAW AND ORDINANCE COVERAGE IS AN IMPORTANT COVERAGE THAT YOU MAY WISH TO PURCHASE. YOU MAY ALSO NEED TO CONSIDER THE PURCHASE OF FLOOD INSURANCE FROM THE NATIONAL FLOOD INSURANCE PROGRAM. WITHOUT THIS COVERAGE, YOU MAY HAVE UNCOVERED LOSSES. PLEASE DISCUSS THESE COVERAGES WITH YOUR INSURANCE AGENT. Your policy includes Ordinance or Law Coverage at 25% of Coverage A. Issued Hy: Nationwide Insurance Company of Florida Countersigned at: Gainesville, FL Hy: MARCUM INC How To Contact Us Your Agent MARCUM INC Customer Care Center 1 -800- 282 -1446 Internet www.nationwideonyourside.com Hearing Impaired (TTY) 1- 800 -622 -2421 24 -Hours Claims Reporting 1 -800- 282 -1446 (863) 467 -0331 12501S (08 -08) HOF 00244496383 04/26/12 003192 MEMO COPY 59 Policy Number: HOF 0024449638 -3 Declarations Continued: Assessments and Surcharges EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE TRUST FUND SURCHARGE FLORIDA HURRICANE CATASTROPHE FUND 2006 EMERGENCY ASSESSMENT CITIZENS PROPERTY INSURANCE CORPORATION 2005 EMERGENCY ASSESSMENT Total Assessments and Surcharges $2.00 $19.05 $14.65 $35.70 12501 AS (08 -08) HOF 00244496383 04/26/12 003193 MEMO COPY 59 Policy Number: HOF 0024449638 -3 Declarations Continued: THIS POLICY CONTAINS A SEPARATE DEDUCTIBLE FOR HURRICANE LOSSES, WHICH MAY RESULT IN HIGH OUT -OF- POCKET EXPENSES TO YOU. Your policy contains a 2% hurricane deductible = $2,850. THE HURRICANE DEDUCTIBLE MAY BE HIGHER THAN INDICATED WHEN A LOSS OCCURS DUE TO THE APPLICATION OF THE INFLATION GUARD RIDER. 12501HD (08 -08) HOF 00244496383 04/26/12 003194 MEMO COPY 59 Declarations Continued: Renewal Premium Changes: Total Premium Change = $ 108.20 Assessment Change = $ -27.47 Rate Change - Premium = $ 135.67 Coverage Change - Premium = $ 0.00 Renewal Premium Detail: Hurricane Premium Non - Hurricane Premium $ 727.50 $ 747.46 Policy Number: HOF 0024449638 -3 Annual Renewal Premium before Surcharges, Assessments and Discounts $ 1,474.96 12501PC (08 -08) HOF 00244496383 04/26/12 003195 MEMO COPY 59 IN WITNESS WHEREOF, the company listed in the Declarations has caused this policy to be signed by its President and Secretary, and countersigned as may be required on the Declarations page by a duly authorized representative of the company. • President - Gary A. Douglas Nationwide Agribusiness Insurance Company "7114 President - Mark A. Pizzi Nationwide Affinity Insurance Company of America Nationwide General Insurance Company Nationwide Mutual Fire Insurance Company Nationwide Mutual Insurance Company Nationwide Property and Casualty Insurance Company e.,464„ President - Lisa E. Gobber Nationwide Insurance Company of Florida President - David A. Bano Nationwide Indemnity Company President - David G. Arango Nationwide Assurance Company President - W. Kim Austen ALLIED Property and Casualty Insurance Company AMCO Insurance Company Crestbrook Insurance Company Depositors Insurance Company Nationwide Insurance Company of America Secretary - Robert W. Horner, 111 ALLIED Property and Casualty Insurance Company AMCO Insurance Company Crestbrook Insurance Company Depositors Insurance Company Nationwide Affinity Insurance Company of America Nationwide Agribusiness Insurance Company Nationwide Assurance Company Nationwide General Insurance Company Nationwide Indemnity Company Nationwide Insurance Company of America Nationwide Insurance Company of Florida Nationwide Mutual Fire Insurance Company Nationwide Mutual Insurance Company Nationwide Property and Casualty Insurance Company Nationwide, the Nationwide framemark, and On Your Side are service marks of Nationwide Mutual Insurance Company. © 2011 Nationwide Mutual Insurance Company. 12501A (11 -11) HOF 00244496383 04/26/12 003196 MEMO COPY Page 1 of 1 59 12801 (08 -08) ORDINANCE OR LAW COVERAGE OPTION Important Information about Protecting Your Home Dear Valued Customer, Thank you for the opportunity to provide this Important Insurance protection. As your Insurance provider, we like to keep you informed of new coverage options with your homeowners policy so you may decide which coverage option is best for you. In the event of a Toss covered by the policy, Building Ordinance or Law provides coverage for the increased costs you incur that result from any ordinance or law that regulates the construction, use, repair or tearing down of the damaged property. This coverage includes the cost of removing debris. The ordinance or law must have been in place during the policy period. Your policy automatically provides Ordinance or Law coverage equal to 25% of the Coverage A amount (or Building Additions and Alterations Coverage for Tenant policies) at no additional premium charge. You also have an option to elect an additional 25% coverage for a total of 50% of the Coverage A Limit of Liability for Ordinance or Law. The coverage limit you currently carry or Ordinance or Law is printed on your Declarations page. Should you decide to increase or decrease your present coverage, please sign the form below and return it in the enclosed envelope. If it is not returned to us, your previous selection printed on your Declarations page will continue to apply. If you have any questions regarding this Ordinance or Law coverage, please contact your Nationwide Agent. We appreciate your immediate attention to this matter. This notice does not provide coverage nor does it replace any provisions of your policy. You should read your policy and review your Declarations page for complete information on the coverage you are provided. If there is any conflict between policy, endorsements and this notice, the provisions of the policy or endorsements shall prevail. If you choose to change your present Ordinance or Law coverage, please complete and sign this form and return it in the enclosed envelope. Selection of either percentage constitutes rejection of the other. ❑ I select the 25% Ordinance or Law coverage limit provided by this policy. ❑ I select the additional 25% coverage option for a total of 50% Ordinance or Law coverage. Policyholder Signature Date Policyholder Name 12801 (08 -08) HOF 00244496383 04/26/12 003197 MEMO COPY 59 z Nationwide On Your Side- NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL AMENDED DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including an appro>amate cost for labor and materials in your area, and specific information that you have provided about your home. HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -2 ACCOUNT NUMBER: 819760561 Policy Period From: 06 -18 -11 To: 06 -18 -12 12:01 A.M. Standard Time Effective Date of Change 062811 POLICY INFO PO INDICATORS INFO POLICY INSURED INFO FO MORTGAGEE The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No., Street, City, State, Zip Code} PREVIOUS POLICY NUMBER HOF 0024449638 -1 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 TO BE PAID BY NAMED INSURED COVERAGE AND LIMITS OF LIABILITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 142,500 2,850 71,250 14,250 100,000 1,000 FOR LOSSES ARISING UNDER SECTION , WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM BASIC COVERAGE H03 01/00 Special Form 1,094.08 12501S 08108 ORD OR LAW 12501AS 08/08 SURCHARGES 12501HD 08/08 HURR DEDUCTIBLE H0277FL 08/08 Ord or Law - 50% 54.70 12559A 08/08 Per Prop Repl 164.11 12567F 08/08 Replacement Cost 5.02 16372 05/09 Sinkhole Collaps 21.38 12747 09/08 Biological Det H0216 08/08 Prem Alarm Prot 9.59CR HO300FL 09/08 Spec Provisions IN2525 08/08 Opt Ded Offer IN2532 08/08 Checklist of Cov IN2537 08/08 Outline of Cov IN2542 08/08 Hurr Mit Dsc Inf H041 01 /00 Add Ins Res Prem 12800 08/08 Hurricane Prov IN0000F 05/09 Privacy Stmt IN2526 08/08 Hurr Ded Option IN2531 07/10 FL Hurr Cat Fund IN2533 07/10 Loss Mitigation IN2534 07 /10 Inspection Form IN2541 08/08 ID Fraud Offer TOTAL SURCHARGES 63.17 TOTAL ANNUAL POLICY AMT DUE 1,392.87 Additional Residence Occupied By Insured NO ADDL PREMIUM Mortgage Loss Payee or Other Interest Loan Number! CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL 34974 -2903 NATIONWIDE INS CO OF FLORIDA Authorized Representative DIRECT BILL 7B5G 11191 002805 EMO COPY T 819760561 59 ■ Nationwide Nationwide` On Your Side- AGENCY - FL - 59225 MARCUM INC OKEECHOBEE FL 863 - 467 -0331 D- 000875 000098 59 HOS CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL 34974-2903 NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 INSURED PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 LOAN NUMBER: HOMEOWNERS POLICY NUMBER HOF 0024449638 -2 LOSS PAYEE, MORTGAGEE OR OTHER INTEREST INFORMATION .. . The enclosed material provides loss payee, mortgagee, or other interest information pertaining to your client. JLN401L (01 -05) DIRECT BILL 7650 11191 00280+! T 819760561 Policy Number: HOF 0024449638 -2 Declarations Continued: LAW AND ORDINANCE COVERAGE IS AN IMPORTANT COVERAGE THAT YOU MAY WISH TO PURCHASE. YOU MAY ALSO NEED TO CONSIDER THE PURCHASE OF FLOOD INSURANCE FROM THE NATIONAL FLOOD INSURANCE PROGRAM. WITHOUT THIS COVERAGE, YOU MAY HAVE UNCOVERED LOSSES. PLEASE DISCUSS THESE COVERAGES WITH YOUR INSURANCE AGENT. Your policy includes Ordinance or Law Coverage at 25% of Coverage A. Issued By: Nationwide Insurance Company of Florida Countersigned at: Gainesville, FL By: MARCUM INC How To Contact Us Your Agent MARCUM INC Customer Care Center 1- 800 - 282 -1446 Internet www.nationwideonyourside.com Hearing Impaired (TTY) 1- 800 -622 -2421 24 -Hours Claims Reporting 1-800-282-1446 12501S (08 -08) HOF 00244496382 07/10/11 002806 MEMO COPY (863) 467 -0331 Policy Number: HOF 0024449638 -2 Declarations Continued: Assessments and Surcharges EMERGENCY MANAGEMENT PREPAREDNESS AND ASSISTANCE TRUST FUND SURCHARGE FLORIDA HURRICANE CATASTROPHE FUND 2006 EMERGENCY ASSESSMENT CITIZENS PROPERTY INSURANCE CORPORATION 2005 EMERGENCY ASSESSMENT FLORIDA INSURANCE GUARANTY ASSOCIATIONS 2009 ASSESSMENT Total Assessments and Surcharges 12501 AS (08 -08) HOF 00244496382 07/10/11 002807 MEMO COPY $2.00 $17.29 $18.62 $25.26 $63.17 Policy Number: HOF 0024449538 -2 Declarations Continued: THIS POLICY CONTAINS A SEPARATE DEDUCTIBLE FOR HURRICANE LOSSES, WHICH MAY RESULT IN HIGH OUT -OF- POCKET EXPENSES TO YOU. Your policy contains a 2% hurricane deductible = $2,850. THE HURRICANE DEDUCTIBLE MAY BE HIGHER THAN INDICATED WHEN A LOSS OCCURS DUE TO THE APPLICATION OF THE INFLATION GUARD RIDER. 12501HD (08 -08) 07/06/2011 13:20 FAX 8637635678 MARCUM & ASSUC1Art5 Marcum & Associates FAX Fax Transmittal Form To: CITY OF OKEECHOBEE Name: Jackie Dunham Organization Name /Dept: City Of Okeechobee / Processing Phone number: 863 - 763 -3372 ext.227 Fax number: 863-763-1686 Urgent For Review Please Comment Please Reply Message; to uui /uvr 909 S Parrott Ave. PO Box 400 Okeechobee, FL 34973 Phone: 800 - 551 -0097 Fax: 863 -763 -5678 Paigejl Rnationwide.com From: Marcum & Associates Sender's Name: Jackie Paige Sender's Title: CSR Company: Marcum Inc. Date sent: 07/06/2011 Time sent; 01:28pm # of pages including cover page:7 RE: Jean R. Paige Property Address: 501 NE 6th Ave. Okeechobee, FL 34972 Jackie, Please see the following attached required evidence of insurance directly from Allied insurance as well as account summary showing first monthly payment has been made to insured's insurance policy. Insured no longer carries mortgagee and corrected declaration will be forwarded once endorsement is processed. Please contact me with any further requirements. 1 will be in touch with you regarding the insured's Alley Use Agreement after I review your email and speak with insured regarding purchasing additional liability coverage. Thank you Jackie Paige CSR VI1VO/ VJI 11 CV r6' 000(000010 MAIhLUM & AJJULlAItJ Wg002/007 Natl.onw1de NSC13 7/6/2011 11:54:27 AM PAGE 2/002 On Your Side trijt MN 1, G� � s '..: 1 111 01Ilii .M '�; lii'11� �1 m "4 uY"' ffi�{� J 1II�Uu.1I , I�t ii! III 2, W 11 !iJ' ii,i l tl �; .,.rr A' �l �' '" I , ,' i' � ' :.'. 41iii,;ii.i', .I,ei,�::',!,!;;;, ! 'I i�il' )JI I `Ilf, lli)I1 'I'..`; DATE A4M /DD 1 1 I, 11 719111 FORCE, AND ,�i�J THIS IS EVIDENCE THAT INSURANCE AS IDENTIFIED BELOW HAS BEEN INSURED, IS IN CONVEYS ALL THE RIGHTS AND PRIVILEGES AFFORDED UNDER THE POLICY. PRODUCER PHONE (AIC. No., Ext.): COMPANY Nationwide 1 100 Locust St Des Moines. IA 50391 Mali Payments to Nationwide Insurance. PO Box 10479, Des Moines, IA 50306 -0479 MARCUM INC OKEECHOBEE FL CODE: 1 SUB-CODE: AGENCY CUSTOMER ID all: INSURED JEAN R PAIGE 801 NE 8TH AVE City OKEECHOBEE State FL Zip 34972 2681 LOAN NUMBER 708293 POUCY NUMBER HOF 0024449638 EFFECTIVE DATE 06182011 EXPIRATION DATE 06182012 CONTINUED UNTIL O TERMINATED IF CHECKED THIS REPLACES PRIOR EVID NCE DATED: � ry •iI j m y .,L,:ii .IiY1u =ii.ri .ii:$dtila :ii" ::i:1, ' =iNIE{ `. 16.11E :�II:JCHi. BI .;I:: .:L: :�1G:,IE:46ha,ali,.G.E SrllE: 1:Gl: :., .:k ��A,6l�ld(�>1���t. ��'� ». 1 •,4 u,u,Ywi i ��i Yi,u �f : ,�:'.. r i. �»" ..« n�� «, ,, , .,,..., LOCATION /DESCRIPTION 501 NE 6TH AV City OKEECHOBEE State FL Zip 34972 2891 n � ,� . " . u CM T : !' y« — .V �• �., 7t '7 ,,Ii a ,t�:» °, »' • :t ... 'U 1•. ' I q- - I- IIQIt ® }dxukPair11t11IAVIliii{A U . „I, � q d' .. li`rn,1 �. ",. . . � 'r Sd`n' u r !�!:ln:: Lr «!li IiY:,,.ai:di: i: iai4 :an't�i:; 07/06/2011 13:20 FAX 8637635678 MARCUM & ASSOCIATES a 003/007 • • ' r! • E INSURANC • ' 'ANY OF FLOR ' 59 25 EXPANDED FILE DAILY NAMED PAIGE, JEAN R. INSURED 8 ADDRESS OKEECHOBEE, FL 34972.2691 POLICY NUMBER HOF 0024449638 -2 PRM/SEC PRM B LLING 0/M STATUS L NEWICONT. _ R FROM 061811 TOIO061812 cArvGEt CONTINUE DECLARATIONS 0 AGENCY MARCUM INC OKEECHOBEE FL 349730400 2 FL 59225 RUN OATS 042611 BILLING DATE 042611 RO 59 ADJUST INDICATOR 1.000 PREVIOUS POLICY NUMBER HOF 00244496381 TERMINAL 7BPZ ENTRY DATE 042611 ACCOUNT/FINANCE NO 819760561 CLIENT O. 09000 MONEY W /APP SUSPENSE NO. EFF, DATE OF AMEND. !CHANGES IN: LOCATION OF PROPERTY 501 NE 6TH AV OKEECHOBEE, FL 34872.2691 BILLING INFORMATION SUNTRUST MRTG INC PO BOX 57028 IRVINE, CA 926197028 COVERAOE$ AND LIMITS OF LIABILITY SECTION I SECTION 11 A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY 0. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAYMENTS TO OTHERS 142,500_ 2,880 71,250 14 250 100,000 1,000 PREMIUM BASIC POLICY PREMIUM ENDORSEMENT NUMBER PREMIUM ENDOASEMENT NUMBER PREMIUM ENDORSEMENT NUMBER PREMIUM TOTAL POLICY PREMIUM 1,094.08 HO277F 16372 54.70 21.38 12559A H0216 164.11 9.59CR 12567F 5.02 1,392.87 FORM oho END. H03 01/00 H0300F (008108) IN252 08/08 IN253 08/08) IN2537 08/0 1N254 /08 H041 01/00 12800 (08/08) IN 05/09 1N252 06 /08 1N253107/10 IN253 07/10 1N253 07/10 IN25411(08108) H027 (08/ ) 12559A(08/08) 12567E 08/08 16372 (06109) 12747 (09108) (CONT) POLICY DEDUCTIBLE CLAUSE $1000AP 2 %H CFIAN GEO AT THIS TIME: IN2525 IN2532 IN2537 IN2542 IN0000 1N2526 IN2531 IN2533 IN2534 IN2541 REPL COST AMT RBPL COST % VARIABLE END. 12747 ADDL. COVERAGE /DEDUL.TIbL !P.USC 10,000 H0216 ADOL COVERAGE /DEDUCTIBLE /MISC 2 MOAT, LOSS PAYEE R INTEREST SUNTRUST MRTG INC 1ST PO BOX 57028 MORT IRVINE, CA 92619 -7028 LOAN NUMB G DINO LINE a MG. 'STATE Rg 1 STAT, ERR. O T D 7 E 6 t]EDUC'T. , . OF CONST 9CL� WIDTH ::: CITY CODE 1:10.41,T F NO TIE. DOWN SURCM RETIRE FKIME CR6DIT M U FL 093 ME113111 1111 CL1 04 11111111E1171111111111 0 NMI 10.000 708 -- N WATERCRAFT LIABILITY JOR CLA3$ PERIL GODS SNOWMOBILE i.. OR COMMI9810N LAS Uri PERIL CLASS CODE COMMISSION CLOG LINEe 8 & 1 LNVE - • - PERIL INS. TATE 9TAT. TERR COMMISSION CLA$$ IT PRrMIUM CLASS LIMITS PREMIUM INE OR PERit IN --TAT STAT. TEEM. CQMMlssioN IMMI�� CLASS LIMITS NE 1111111111 PREMIUM CLASS LI MITS PREMIUM MOBILE HOME 10, MANUFACTURER SERULL NUMBER MODEL NAME OR NUMBER DOITIONAL RESIDENCE OCCUPIED rtNSURed T'S COPY 819760561 T 59 TTN. POL. NO. DIRECT' BILL 7APZ 042611 AGE t 07/06/2011 13:20 FAX 8637635678 Billing Account History Information MARCUM & ASSOCIATES tj 006/007 Page 1 of 2 Account Summary Account Account #: Unpaid Balance: Last Payment: Current Invoice: Next Invoice Date; Favor: Flex Chek: At-A-Glance 819760561 51,276.60 5116.07 pald on 07-05-2011 5118.07 due on 07-18-2011 07-29-2011 Mortgagee No Holding for Next Invoice: 50.00 Account Balance Hist° 11 Date History Typo 07-05-2011 Change Minimum Due 07-05-2011 Balance In Holding 07-05-2011 Payment 04-27-2011 Renewal 04-27-2011 Renewal 04-27-2011 Renewal 04-27-2011 Renewal 04-27-2011 Renewal 11-15-2010 Misc Refund 11-10-2010 Stop Deleted 11-06-2010 Write off 11-05-2010 Polley Change 11-05-2010 Policy Change 11-05-2010 Policy Change 11-05-2010 Policy Change 11-05.2010 Policy Change 11-05-2010 Policy Change 11-05-2010 Policy Change 11-05-2010 Stop Added 05-10-2010 Payment 04-27-2010 Renewal 04-27-2010 Renewal 04-27-2010 Renewal 04-27-2010 Renewal 04-27-2010 Renewal 04-27-2010 Renewal 04-27-2010 Renewal 05-28-2009 Payment 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business Associated Policiosz HOF 0024449638 2 Amount 50,00 (5116.07) (5116.07) $25.26 518.62 517,29 52.00 $1,329.70 535.37 50.00 (31.71) ($33.66) 50.00 50.00 50.00 50.00 50.00 50.00 50.00 (31.142.35) 514.73 514.73 533.86 514.73 510.52 52.00 51,051.98 (51.261 87) 518.66 516.24 $15.08 323.20 515.08 $11,60 $2.00 51,160.11 Account A/R Balance $1,276.80 51,276.80 51,276.80 51,392.87 51,367.61 51,348.99 51,331.70 51,329.70 50.00 (536.37) ($35.37) (533.66) 50.00 50.00 $0.00 50.00 50.00 50.00 50.00 50.00 51,142.35 $1,127.62 51,112.89 51,079,23 51,064.50 51,053.98 51,051.96 50.00 51,261.67 51,243.31 51,227.07 51,211.99 51,188.79 51,173.71 51,162.11 $1,160.11 Holding Balance History TI Insured information; Paige, Jean R. 501 Ne 6th Ave Okeechobee, FL 34972-2691 HOF 0024449636 Date JL Transaction Type 07-05-2011 Invoice 07-05-2011 Applied Funds 05-31-2011 Invoice 04-27-2011 Renewal 04-27-2011 Renewal 04-27.2011 Renewal 04-27-2011 Renewal 04-27-2011 Renewal 11-05.2010 Policy Change 11-05-2010 Policy Change 11-05-2010 Policy Change 11-05-2010 Policy Change 11-05-2010 Policy Change 11-05-2010 Policy Change 11-05-2010 Polley Change 06-01-2010 Applied Funds 08-01-2010 Invoice 04-27-2010 Renewal 04-27-2010 Renewal 04-27-2010 Renewer 04-27-2010 Renewal 04-27-2010 Renewal 04.27-2010 Renewal 04-27-2010 Renewal 05-29-2009 Applied Funds 05-29-2009 Invoice 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business 04-30-2009 New Business [ Amount 5116.07 (5116.07) 51,392.87 $25,26 518,82 517,29 52.00 51,329.70 ($33.66) $0.00 50.00 50.00 50.00 50,00 50.00 ($1,142,35) 51,142.35 $14.73 514.73 533.86 $14.73 510.52 52.00 51,051.98 (51,261.87) 51,261.87 518.56 516,24 515.08 523.20 515.08 511.60 52.00 51,160.11 https://aac3.alliedinsurance.comicenter/inquiry/Billing/Index.cfrn?event--=default&Account... 7/6/2011 Vf /VO /4V11 I3.4V rnn 003f03VOf Zi M,YMUUM Q! MJ3UI,1151CJ 1JVVf /VV( Billing Account History Information Page 2 of 2 Data JL -- History Type Current Balance 06 -01 -2010 Funds on Hold 05-29 -2009 Funds on Hold Balance $0.00 (31,142.35) ($1,251.67) https: / /aac3. alliedinsurance.com /center /Inquiry/Billing/Index. cfm ?event= default &Account... 7/6/2011 13950000033192 77 09 HO 168208 ELITE POLICY DECLARATIONS Non - Assessable Page 1 of 3 These Declarations are a part of the policy named above and identified by policy number below. They supersede any Declarations issued earlier. Your Elite Policy will provide the insurance described in this policy in return for the premium and compliance with all applicable policy provisions. See policy for details regarding the other coverages and additional coverage options. Policy Number: 77 09 HO 168208 Issued: APR 28, 2006 Policy Period From: Policyholder: (Named Insured) JEAN R PAIGE 501 N E 6TH AVENUE OKEECHOBEE FL 34972 -2691 JUN 18, 2006 to JUN 18, 2007 but only if the required premium for this period has been paid, and only for annual renewal periods if premiums are paid as required. Each period begins and ends at 12:01 A.M. standard time at the Residence Premises. The Following Change(s) Have Been Made To Your Policy: The limit of liability for Section I Coverage A Dwelling is revised. THIS POLICY CONTAINS A SEPARATE DEDUCTIBLE FOR HURRICANE LOSSES WHICH MAY RESULT IN HIGH OUT -OF- POCKET EXPENSES TO YOU. Residence Premises Information: 501 NE 6TH AV OKEECHOBEE FL 349722691 ONE FAMILY MASONRY DWELLING YEAR OF CONSTRUCTION 1975 SECTION I Property Coverages COVE RAG E —A— DWELLING COVERAGE—B--OTHER STRUCTURES COVERAGE—C--PERSONAL PROPERTY COVERAGE —D —LOSS OF USE Limits Of Liability $ 117,500 $ 2,350 $ 58,750 $ 11,750 PROTECTION CLASS 6 RATED PROTECTION CLASS 6 PROTECTED SUBURBAN WITHIN 1000 FT FROM HYDRANT WITHIN 5 MILES FROM FIRE DEPT FIRE DISTRICT 0001 PROTECTION TERRITORY 051 Deductible: $1,000 ALL PERILS In case of a Toss under Section I, we cover only that part of each loss over the deductible stated. EXCEPTIONS 2% OF COVERAGE A LIMIT HURRICANE DEDUCTIBLE. SEE ENDORSEMENT FOR DETAILS. (2% HURRICANE DEDUCTIBLE = $ 2,350 AS OF THE CURRENT DECLARATIONS ISSUED DATE) H5300 ELITE POLICY DECLARATIONS Page 2 of 3 SECTION II Liability Coverages Limits Of Liability CO FORA EACH OCCURRENCE: LIABILITY $ 100 , 000 PROPERTY DAMAGE AND BODILY INJURY COVERAGE -F- MEDICAL PAYMENTS $ 1, 000 TO OTHERS EACH PERSON THE HURRICANE DEDUCTIBLE MAY BE HIGHER THAN INDICATED WHEN A LOSS OCCURS DUE TO THE APPLICATION OF THE INFLATION GUARD RIDER. OTHER COVERAGES /OPTIONS APPLICABLE See Policy or Endorsements for details regarding the Other Coverages and Options that apply to your policy. Other Coverages Limits of Liability APPLIES INFLATION PROTECTION BOECKH INDEX 0679.3 10 , 000 BIOLOGICAL DETERIORATION /DAMAGE CLEAN UP 500 FIRE DEPARTMENT SERVICE CHARGE $ 1 , 000 CREDIT CARD - FORGERY Options Applicable OPTION -I- EXTENDED REPLACEMENT COST APPL I ES PERSONAL PROPERTY APPLIES OPTION -J- REPAIR COST PLUS DWELLING APPLIES OPTION -L- PROTECTIVE DEVICE CREDIT LOCAL FIRE OR SMOKE ALARM SYSTEMS FIRE EXTINGUISHERS DEADBOLT LOCKS ON ALL EXTERIOR ENTRYWAYS APPLIES ORDINANCE OR LAW 50% ON BUILDING, ADDITIONS, AND ALTERATIONS SPECIAL PROVISIONS FL EMPA SURCHARGE $2.00 FLORIDA CITIZENS ASSESSMENT $71.82 PREMIUM SUMMARY Premium Based On Premium Amount POLICY PREMIUM $ 1,018.82 Annual Renewal Premium $ 1,018.82 Annual Renewal Premium Includes Discounts For: HOME /CAR HOME PROTECTIVE DEVICE Annual Renewal Premium Includes Additional Charges For: FL EMPA SURCHARGE FLORIDA CITIZENS ASSESSMENT 13950000033208 77 09 HO 168208 Policy Number: 77 09 HO 168208 Issued: APR 28, 2006 ELITE POLICY DECLARATIONS Non - Assessable Page 3 of 3 Policyholder: (Named Insured) JEAN PAIGE Policy Period From: JUN 18, 2006 TO JUN 18, 2007 FORMS and ENDORSEMENTS MADE PART OF POLICY HE 09 -A Elite Homeowners Policy H- 6050 -B Hurricane Coverage and Deductible Provision H 6062 Endorsement H-6125 Mandatory Endorsement Mandatory Endorsement ADDITIONAL INTERESTS FIRST MORTGAGEE SUNTRUST MRTG INC ISAOA ATIMA PO BOX 57028 IRVINE CA 92619 -7028 LOAN #708233 ADDITIONAL INSURED CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE FL 34974 -2903 Issued By: NATIONWIDE INSURANCE COMPANY OF FLORIDA Countersigned At: GAINESVILLE, FL Prior Declaration Issued: APR 25, 2005 Home Office — Columbus, Ohio By: MARCUM INC IMPORTANT PHONE NUMBERS Nationwide 24 -Hour Claims Number: 1 -800- 421 -3535 For QUESTIONS About Your Policy, CaII Your NATIONWIDE AGENT: MARCUM INC 863 - 467 -0331 For Hearing Impaired: TTY 1- 800 - 622 -2421 Nationwide Regional Office: 1- 800 - 421 -4243 77 09 HO 168208 ELITE POLICY DECLARATIONS Non - Assessable Page 1 of 4 These Declarations are a part of the policy named above and identified by policy number below. They supersede any Declarations issued earlier. Your Elite Policy will provide the insurance described in this policy in return for the premium and compliance with all applicable policy provisions. See policy for details regarding the other coverages and additional coverage options. Policy Number: 77 09 HO 168208 Issued: MAY 02, 2007 Policyholder: (Named Insured) JEAN R PAIGE 501 N E 6TH AVENUE OKEECHOBEE FL 34972 -2691 Policy Period From: JUN 18, 2007 to JUN 18, 2008 but only if the required premium for this period has been paid, and only for annual renewal periods if premiums are paid as required. Each period begins and ends at 12:01 A.M. standard time at the Residence Premises. The Following Change(s) Have Been Made To Your Policy: The limit of liability for Section I Coverage A Dwelling is revised. THIS POLICY CONTAINS A SEPARATE DEDUCTIBLE FOR HURRICANE LOSSES WHICH MAY RESULT IN HIGH OUT -OF- POCKET EXPENSES TO YOU. Residence Premises Information: 501 NE 6TH AV OKEECHOBEE FL 349722691 ONE FAMILY MASONRY DWELLING YEAR OF CONSTRUCTION 1975 SECTION I Property Coverages COVERAGE —A— DWELLING COVERAGE —B —OTHER STRUCTURES COVERAGE —C— PERSONAL PROPERTY COVERAGE —D —LOSS OF USE Limits Of Liability $ 125,400 $ 2,508 $ 62,700 $ 12,540 PROTECTION CLASS 6 RATED PROTECTION CLASS 6 PROTECTED SUBURBAN WITHIN 1000 FT FROM HYDRANT WITHIN 5 MILES FROM FIRE DEPT FIRE DISTRICT 0001 PROTECTION TERRITORY 051 Deductible: $1,000 ALL PERILS In case of a Toss under Section I, we cover only that part of each loss over the deductible stated. EXCEPTIONS 2% OF COVERAGE A LIMIT HURRICANE DEDUCTIBLE. SEE ENDORSEMENT FOR DETAILS. (2% HURRICANE DEDUCTIBLE = $ 2,508 AS OF THE CURRENT DECLARATIONS ISSUED DATE) H5300 ELITE POLICY DECLARATIONS SECTION II Liability Coverages Limits Of Liability COVERAGE -E- PERSONAL LIABILITY $ 100 , 000 FOR EACH OCCURRENCE: Page 2 of 4 17225000164198 77 09 HO 168208 Policy Number: 77 09 HO 168208 Issued: MAY 02, 2007 ELITE POLICY DECLARATIONS Non - Assessable Page 3 of 4 Policyholder: (Named Insured) JEAN PAIGE Policy Period From: JUN 18, 2007 TO JUN 18, 2008 PREMIUM SUMMARY Premium Based On Premium Amount POLICY PREMIUM Annual Renewal Premium Annual Renewal Premium Includes Discounts For: HOME /CAR • HOME PROTECTIVE DEVICE Annual Renewal Premium Includes Additional Charges For: FL EMPA SURCHARGE FL HURRICANE CAT FUND $ 965.54 $ 965.54 FORMS and ENDORSEMENTS MADE PART OF POLICY HE 09 -A Elite Homeowners Policy H- 6050 -B Hurricane Coverage and Deductible Provision H 6062 Endorsement H -6162 Mandatory Endorsement H -6125 Mandatory Endorsement Amendatory Endorsement ADDITIONAL INTERESTS FIRST MORTGAGEE SUNTRUST MRTG INC ISAOA ATIMA PO BOX 57028 IRVINE CA 92619 -7028 LOAN #708233 ADDITIONAL INSURED CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE FL 34974 -2903 Issued By: NATIONWIDE INSURANCE COMPANY OF FLORIDA Countersigned At: GAINESVILLE, FL Prior Declaration Issued: APR 28, 2006 Home Office — Columbus, Ohio By: MARCUM INC ELITE POLICY DECLARATIONS IMPORTANT PHONE NUMBERS Nationwide 24 -Hour Claims Number: 1- 800 - 421 -3535 For QUESTIONS About Your Policy, Call Your NATIONWIDE AGENT: 8 3RCU 0331 For Hearing Impaired: TTY 1- 800 - 622 -2421 Nationwide Regional Office: 1 -800- 421 -4243 Page 4 of 4 CJI Z Nationwide On Your Side - NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL CONTINUATION DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. ■ `The limit of liability for the structure (Coverage At is based on the estimate of the cost to r 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 ebu Id your home, including cost for labor and materials in your area and specific information that you have provided about your home. The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No., street, City, State, Zip Code) 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -0 ACCOUNT NUMBER: 819760561 an approwmate Policy Period From: 06 -18 -09 To: 06 -18 -10 12:01 A.M. Standard Time Effective Date of Change PREVIOUS POLICY NUMBER HOF 0024449638 -0 SUNTRUST MRTG INC ISAOA PO BOX 57028 IRVINE, CA 92619 -7028 SECTION I COVERAGE AND LIMITS OF LIABILITY A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE 134,400 2,688 67,200 13,440 FOR LOSSES ARISING UNDER SECTION , WE WILL PAY ONLY THAT PART OF TH LOSS IN EXI EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. SECTION II E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 100,000 1,000 COVERAGE BASIC COVERAGE DESCRIPTION PREMIUM H03 01/00 Special Form 12501AS H0277FL 12567F 12747 HO300FL IN2525 IN2532 IN2534 IN2540 H041 I N2546 Additional Residence Occupied By Insured 08/08 08/08 08/08 09/08 09/08 08/08 08/08 08/08 08/08 01/00 09/08 SURCHARGES Ord or Law - 50% Replacement Cost Biological Det Spec Provisions Opt Ded Offer Checklist of Cov Inspection Form Citizens Asmnt Add Ins Res Prem FL EMPA Info 957.42 47.87 4.27 COVERAGES 12501S 12501HD 12559A 16372 H0216 IN0000F IN2531 IN2533 1N2537 IN2542 12800 IN2538 08/08 08/08 08/08 09/08 08/08 07/08 08/08 08/08 08/08 08/08 08/08 08/08 DESCRIPTION PREMIUM ORD OR LAW HURR DEDUCTIBLE Per Prop Repl Sinkhole Collaps Prem Alarm Prot Privacy Stmt FL Hurr Cat Fund Loss Mitigation Outline of Cov Hurr Mit Dsc Inf Hurricane Prov Sinkhole Notice TOTAL SURCHARGES TOTAL ANNUAL POLICY AMT DUE 143.61 13.44 6.50CR 101.76 1,261.87 Loan Number Mortgage Loss Payee or Other Interest 708233 CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL DIRECT BILL 0036 09119 34974 -2903 MEMO COPY SUNTRUST MRTG INC IRVINE, CA NATIONWIDE INS CO OF FLORIDA Authorized Representative 000322 T 819760561 59 00 0000 NOS 00 00 (C0 -20) N10921 Nationwide" ... On Your Side- NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL CONTINUATION DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limi7 of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including cost for abor and materials in your area and specific information that you have provided about your home. The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No., Street, City, State, Zip Code) 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 SECTION I A. DWELLING 142,500 B. OTHER STRUCTURES 2,850 FOR LOSSES ARISING UNDER SECTION EXCEPT FOR LOSS BY HURRICANE, FOR IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION BASI.: COVERAGE H03 12501AS 12501 PC 12559A 16372 H0216 1N2525 IN2533 IN2537 H041 IN0000F IN2531 01 /00 08/08 08/08 08/08 05/09 08/08 08/08 08/08 08/08 01/00 05/09 03/10 Additional Residence Occupied By lnsured Loan Number Special Form SURCHARGES PREM CHG INFO Per Prop Repl Sinkhole Collaps Prem Alarm Prot Opt Ded Offer Loss Mitigation Outline of Cov Add Ins Res Prem Privacy Stmt FL Hurr Cat Fund HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -1 ACCOUNT NUMBER: 819760561 an approximate Policy Period From: 06 -18 -10 To: 06 -18 -11 12:01 A.M. Standard Time Effective Date of Change PREVIOUS POLICY NUMBER HOF 0024449638 -0 SUNTRUST MRTG INC ISAOA PO BOX 57028 IRVINE, CA COVERAGE AND LIMITS OF LIABILITY C. PERSONAL PROPERTY 71,250 1 D. LOSS OF USE 14,250 SECTION II E. PERSONAL LIABILITY 92619 -7028 F. MEDICAL PAY EACH PERSON 1.000 100,000 , WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, WHICH WE WILL PAY ONLY THAT PART OF THE LOSS PREMIUM COVERAGES DESCRIPTION 862.68 129.40 19.95 7.45CR 12501S 12501HD H0277FL 12567F 12747 HO300FL IN2532 IN2534 IN2542 12800 IN2526 IN2541 08/08 08/08 08/08 08/08 09/08 09/08 08/08 08/08 08/08 08/08 08/08 08/08 ORD OR LAW HURR DEDUCTIBLE Ord or Law - 50% Replacement Cost Biological Det Spec Provisions Checklist of Cov Inspection Form Hurr Mit Dsc Inf Hurricane Prov Hurr Ded Option ID Fraud Offer TOTAL SURCHARGES TOTAL ANNUAL RENEWAL AMT DUE PREMIUM 43.13 4.27 90.37 1,142.35 CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL DIRECT BILL 0000 10116 Mortgage Loss Payee or Other Interest 34974 -2903 MEMO COPY 708233 SUNTRUST MRTG INC IRVINE, CA NATIONWIDE INS CO OF FLORIDA Authorized Representative 000407 T 819760561 59 00 0000 N0S'08 IN 2384 (01 -04) ******* IMPORTANT INSURANCE INFORMATION * * * * * ** Dear Valued Customer, Thank you for being our customer and allowing us the opportunity to provide your important insurance protection. What Is Happening? We have discovered an error in the system used to calculate your policy premium. This error has been corrected and, consistent with our On Your Side promise, your account will be credited and /or you will receive a refund check for any excess premium paid. What Do You Need To Do? You may have received a bill reflecting the previous premium amount. Please be certain to pay at least the minimum amount due on your billing statement to maintain coverage. In the future, your policy records will reflect the correct premium. We are committed to providing the quality and service you deserve. We apologize for any inconvenience this may have caused you. We value your business and continually work to improve our ability to avoid issues like this from occurring. Should you have any questions about this notice or your policy in general, please contact your agent. IN 2384 (01 -04) Page 1 of 1 HOF 00244496381 11/04/10 MEMO COPY 59 12688 Nationwide On Your Side" NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA (800) 282 -1446 50391 -1100 AGENCY MARCUM INC OKEECHOBEE FL AMENDED DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including cost for labor and materials in your area, and specific information that you have provided about your home. The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No., Street, City, State, Zip Code) HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -1 ACCOUNT NUMBER: 819760561 Policy Period From: 06 -18 -10 To: 06 -18 -11 12:01 A.M. Standard Time an approximate Effective Date of Change PREVIOUS POLICY NUMBER HOF 0024449638 -0 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 SUNTRUST MRTG INC ISAOA PO BOX 57028 IRVINE, CA 92619 -7028 COVERAGE AND LIMITS OF LIABILITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY 142,500 2,850 71,250 D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 14,250 100,000 1,000 FOR LOSSES ARISING UNDER SECTION EXCEPT FOR LOSS BY HURRICANE, FOR IN EXCESS OF 2% OF COVERAGE A. COVERAGE BASIC COVERAGE H03 01/00 12501AS H0277FL 12567F 12747 HO300FL 1N2532 1N2534 IN2542 12800 1N2526 1N2541 DESCRIPTION Special Form WHICH EXCESS OF WE WILL PAY ONLY THAT PART OF THE LOSS HI H PREMIUM COVERAGES DESCRIPTION $1,000, PREMIUM 862.68 08/08 08/08 08/08 09/08 09/08 08/08 08/08 08/08 08/08 08/08 08/08 SURCHARGES Ord or Law - 50% Replacement Cost Biological Det Spec Provisions Checklist of Cov Inspection Form Hurr Mit Dsc Inf Hurricane Prov Hurr Ded Option ID Fraud Offer 43.13 4.27 12501S 08108 12501HD 08/08 12559A 08/08 16372 05/09 H0216 08/08 IN2525 08/08 IN2533 08/08 IN2537 08/08 H041 01/00 IN0000F 05/09 IN2531 03/10 ORD OR LAW HURR DEDUCTIBLE Per Prop Repl Sinkhole Collaps Prem Alarm Prot Opt Ded Offer Loss Mitigation Outline of Cov Add Ins Res Prem Privacy Stmt FL Hurr Cat Fund TOTAL SURCHARGES TOTAL ANNUAL POLICY AMT DUE 129.40 19.95 7.45CR 56.71 1,108.69 Additional Residence Occupied By Insured RETURN PREMIUM 33.66C Loan Number Mortgage Loss Payee or Other Interest 708233 CITY OF OKEECHOBEE 55 SE 3RD AVE OKEECHOBEE, FL 349742903 SUNTRUST MRTG INC IRVINE, CA DIRECT BILL. 9999 10308 MEMO COPY NATIONWIDE INS CO OF FLORIDA Authorized Representative T 819760561 59 12689 Nationwide` On Your Side NATIONWIDE INS CO OF FLORIDA 1100 LOCUST ST DES MOINES IA 50391 -1100 (800) 282 -1446 AGENCY MARCUM INC OKEECHOBEE FL CONTINUATION DECLARATIONS NAME INSURED AND ADDRESS PAIGE, JEAN R. 501 NE 6TH AVE OKEECHOBEE, FL 34972 -2691 The limit of liability for the structure (Coverage A) is based on the estimate of the cost to rebuild your home, including an approwmate cost for labor and materials in your area, and specific information that you have provided about your home HOMEOWNERS POLICY POLICY NUMBER: HOF 0024449638 -2 ACCOUNT NUMBER: 819760561 Policy Period From: 06 -18 -11 To: 06 -18 -12 12:01 A.M. Standard Time Effective Date of Change The described residence premises covered hereunder is located at the above address, unless otherwise stated herein. (No , Street, City, State, Zip Code) PREVIOUS POLICY NUMBER HOF 0024449638 -1 501 NE 6TH AV OKEECHOBEE, FL 34972 -2691 SUNTRUST MRTG INC ISAOA PO BOX 57028 IRVINE, CA 92619 -7028 COVERAGE AND LIMITS OF LIABILITY SECTION I SECTION II A. DWELLING B. OTHER STRUCTURES C. PERSONAL PROPERTY D. LOSS OF USE E. PERSONAL LIABILITY F. MEDICAL PAY EACH PERSON 142,500 2,850 71,250 14,250 100,000 1,000 , FOR LOSSES ARISING UNDER SECTION , WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF $1,000, EXCEPT FOR LOSS BY HURRICANE, FOR WHICH WE WILL PAY ONLY THAT PART OF THE LOSS IN EXCESS OF 2% OF COVERAGE A. COVERAGE DESCRIPTION PREMIUM COVERAGES DESCRIPTION PREMIUM BASIC COVERAGE H03 01/00 Special Form 1,094.08 12501S 08/08 ORD OR LAW 12501AS 08/08 SURCHARGES 12501HD 08/08 HURR DEDUCTIBLE 12501PC 08/08 PREM CHG INFO H0277FL 08/08 Ord or Law - 50% 54.70 12559A 08/08 Per Prop Repl 164.11 12567F 08/08 Replacement Cost 5.02 16372 05/09 . Sinkhole Collaps 21.38 12747 09/08 Biological Det H0216 08/08 Prem Alarm Prot 9.59CR HO300FL 09/08 Spec Provisions IN2525 08/08 Opt Ded Offer IN2532 08/08 Checklist of Cov IN2537 08/08 Outline of Cov IN2542 08/08 Hurr Mit Dsc Inf H041 01/00 Add Ins Res Prem 12800 08/08 Hurricane Prov IN0000F 05/09 Privacy Stmt IN2526 08/08 Hurr Ded Option IN2531 07/10 FL Hurr Cat Fund IN2533 07/10 Loss Mitigation IN2534 07/10 Inspection Form IN2541 08/08 ID Fraud Offer TOTAL SURCHARGES 63.17 TOTAL ANNUAL RENEWAL AMT DUE 1,392.87 Additional Residence Occupied By Insured Mortgage Loss Payee or Other Interest Loan Number 708233 SUNTRUST MRTG INC CITY OF OKEECHOBEE IRVINE, CA 55 SE 3RD AVE OKEECHOBEE, FL 349742903 NATIONWIDE INS CO OF FLORIDA Authorized Representative DIRECT BILL 7BPZ 11116 000411 MEMO COPY T 819760561 59