Policy Holder Acknowledgement

Acknowledgement

The content below asserts that your insurance agent or broker has told you that there is no licensed insurer in your state that is able to sell location insurance on an admitted basis, and therefore you are buying coverage from a surplus lines insurer permitted to sell insurance in your state through Evolution Brokers, a surplus lines insurance broker that is licensed in your state. Further, in the event of insolvency of the A rated surplus lines insurer, losses will not be paid by your state’s insurance guaranty fund.

PLACECovr LLC is not affiliated with Evolution Insurance Brokers, LC (“EIB”), an excess and surplus lines insurance brokerage which is domiciled in and has its principal place of business in Sandy, Utah, or Prime Insurance Company, an unlicensed excess and surplus lines insurance company domiciled in the State of Illinois and its principal place of business is in Sandy, Utah, nor any of either’s subsidiaries, and solely acts for and on behalf of PLACECovr LLC.  This insurance product is offered by an unlicensed surplus lines insurer. The NPN for EIB is 5464658 and CA license number is 0H93938.

Please carefully read the content below.

If your covered property is in Florida

At my direction, my agent or broker has placed my coverage in the surplus lines market. As required by Florida Statute 626.916, I have agreed to this placement. I understand that coverage may be available in the admitted market and that persons insured by surplus lines carriers are not protected by the Florida Insurance Guaranty Act with respect to any right of recovery for the obligation of an insolvent unlicensed insurer. I further understand the policy forms, conditions, premiums, and deductibles used by surplus lines insurers may be different from those found in policies used in the admitted market. I have been advised to carefully read the entire policy.

Named Insured By: My name as I have entered it on the policy application.

My Signature (Named Insured): By checking the Acceptance of Terms and Conditions box at the end of this statement, I am digitally signing this document.

Date: The date of my signature is the same as the policy effective date.

Printed Name and Title of Person Signing: My name as I have entered it on the policy application and I am the property owner.

Name of Excess and Surplus Lines Carrier: Prime Insurance Co.

Type of Insurance: Location insurance.