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10/16/2024 Agreement GVS COURTq° o: A Kevin Madok, CPA - �o ........ � Clerk of the Circuit Court& Comptroller Monroe County, Florida �z cooN DATE: November 15, 2024 TO: Sheryl Graham, Director Social Services ATTN: Lourdes Francis, Administrator Social Services Kim Wilkes Wean, Sr. Administrator Social Services FROM: Liz Yongue, Deputy Clerk SUBJECT: October 16, 2024 BOCC Meeting The following item has been executed and added to the record: U2 Agreement for Disposal of Remains between Allen Funeral Directors, LLC., d/b/a Allen-Beyer Funeral Home and Monroe County BOCC/Monroe County Social Services to extend the term of the agreement by one year to a contract period of 10/16/2024-10/15/2026. Should you have any questions please feel free to contact me at(305) 292-3550. cc: County Attorney Finance File KEY WEST MARATHON PLANTATION KEY 500 Whitehead Street 3117 Overseas Highway 88770 Overseas Highway Key West, Florida 33040 Marathon, Florida 33050 Plantation Key, Florida 33070 AGREEMENT betiveen MONROE COUNTY,FL tind ALLEN FUNERAL DIRECTORS LLC d/b/a ALLEN-BEYER FUNERAL HOME fior Disposal of Remains 16th October THIS AGREEMENT is made and entered into this_:�2L day of 202,',- by and between the Monroe County, Florida, a political subdivision of the State of Florida, with principal offices located at 1100 Simonton Street, Key West, FL 33040 (the "County") and Allen Funeral Directors LI-C, d/b/a Allen-Beyer Funeral Home, a Florida Limited Liability Company with principal offices located at 101640 Overseas Highway, Key Largo, FL 33037 (the 'Conti-actor")to provide disposal of remains and associated services, WHEREAS, funcral homes throughout the County provide storage refrigerated facilities, and occasionally provide for disposal of remains at County's,cost; and. WHEREAS, Allen-Beyer Funeral Home is willing and able to provide for disposal of remains services for the County; and WI IEREAS, tile County desires to contract with Allen-Beyer Funeral Home for disposal of remains services under certain terms and conditions,as hereinafter stated. Now therefore,in exchange for good and sufficient consideration,the parties hereby agree to the following terms and conditions: 1) The WorkJScrvices `file Contractor must perform all work for the County required by this Agreement,and as set forth below: a) Contractor shall provide at Contractor's place of business refrigerated storage of deceased individuals transferred to their possession and disposal services as described herein. b) The services shall be limited to unclaimed bodies or those for which the County has made a determination of indigency. Bodies which are claimed by no one, but for which there are assets to cover the cost of cremation or burial are not covered by this Agreement. If the County has determined that there was no indigency, but the funeral home processes through a Court of competent jurisdiction a request for disposal of assets Without administration and,as a result, is paid the:full amount of known assets,which is less than$1,500.00,tile County shall reimburse the funeral home the difference between $1,50:0.00 and the amount received through the relevant Court proceeding, Court costs may be reimbursed at the discretion of the: County Administrator, or designee. No funeral service shall be authorized by County for any deceased individual processed under this Agreement. C) Conti-actor shall provide to County an original accurate Death Certificate prior to payment for services. Disposal may be by cremation or delivery of casket to the Key West, Cemetery, or other cemetery designated by the County, for vault inierinent. Cremation services include: the statutorily required approval by the Monroe County Medical Examiner for cremation, and disposal of remains, including placement in a temporary container, unless otherwise directed by the Page 1 of'15 County. County shall direct Contractor as to the means of disposal, whether cremation or burial. County represents that for each body it directs Contractor to process and dispose under this Agreement,County has anatomical board authority, if applicable,under Section 406.52,F.S.to dispose. d) Contractor must supervise the work force to ensure that all workers conduct themselves and perform their work in a safe and professional manner. Contractor must comply with all OSHA safety rules and regulations in the operation of equipment and in the performance of the work. e) Contractor must comply with any and all Federal, State, and local laws and regulations now in effect,or hereinafter enacted during the term of this Agreement, which are applicable to the Contractor,its employees,agents or subcontractors,if any, with respect to the work and services described herein. Contractor shall maintain throughout the term of this Agreement, appropriate licenses and insurance as required for the operation of a funeral home. In addition,Contractor shall obtain burial transit permits and any other legally required permits for disposal or cremation of,or transfer of, a deceased individual. Proof of any such license(s)shall be provided to the County upon request. f) Contractor agrees to complete such forms as County deems necessary in furtherance of its ordinances and policies, and any relevant state- and/or federal- mandates.The forms may include,but are not limited to: Certification Regarding Debarments, Suspension, Ineligibility and Voluntary Exclusion-Lower Tier Federally Funded Transactions,etc. 2) Costs County shall pay Contractor for each "unclaimed" or indigent body processed either through cremation or for interment, in the amount of$1,500.00. In the event the County has received only partial remains or the remains of an infant(or under the age of three(3) years old), County shall pay $900.00. This cost shall encompass burials of identified bodies, and all other services necessary for the disposal for remains by cremation or interment,including but not limited to removal and transfer of remains to funeral home,to crematory,to cemetery,or to Monroe County Social Services Department.Specifically for unidentified bodies or remains,or bodies that need to be buried for medical,forensic,legal, or other reasons, additional costs of up to $800.00 may need to be added for a Ziegler casket.The County will be responsible for transfer of cremated remains to family members or others as appropriate and shall ensure the most economical and secure delivery service possible in each set of circumstances. a) County is exempt from payment of Florida State Sales and Use taxes. Contractor shall not be exempted by virtue of the County's exemption from paying sales tax to its suppliers for materials used to fulfill its obligations under this contract,nor is Contractor authorized to use the County's Tax Exemption Number in securing such materials. Contractor shall be responsible for any and all taxes,or payments of withholding,related to services rendered under this Agreement. b) Contractor shall submit, in arrears, invoices to County with supporting documentation acceptable to the Monroe County Office of Clerk and Comptroller (County Clerk). Acceptability to the County Clerk is based upon generally accepted accounting principles and such laws,rules and regulations as may govern the disbursal of funds by the County Clerk. c) The contract amount agreed to herein may be adjusted annually, on the renewal date of each contract year,by a percentage equal to the percentage increase in the CPI for urban consumers for the preceding calendar year. Page 2 of 15 3) Agreement Subject to Funding The County's performance and obligation to pay under this contract is contingent upon an annual appropriation by the Board of County Commissioners. In the event that the County funds on which this Agreement is dependent are withdrawn,this Agreement is terminated, and the County has no further obligation under the terms of this Agreement to the Contractor beyond that already incurred by the termination date. 4) Contract Term The initial contract period is for one(1)year commencing on the date written on the first page of this Agreement.The term of this Agreement may be extended by mutual agreement for four(4)one(I)-year extension terms.Consensus of the parties to exercise an extension may be done administratively prior the current term's expiration date,and must be done in writing. 5) Contract Extension Beyond the Term In the event services are scheduled to end because of the expiration of this contract, the Contractor must continue the service upon the request of the County Administrator. The extension period will not extend for more than ninety(90)days beyond the expiration date of the existing contract. The Contractor will be compensated for the service at the rate(s) in effect when the County invokes this extension clause. 67 Independent Contractor This Agreement does not create an employee/employer relationship between the Parties. It is the intent of the Parties that the Contractor is an independent contractor under this Agreement and not the County's employee for any purposes,including but not limited to, the application of the Fair Labor Standards Act minimum wage and overtime payments, Federal Insurance Contribution Act,the Social Security Act,the Federal Unemployment Tax Act,the provisions of the Internal Revenue Code,the State Worker's Compensation Act, and the State Unemployment Insurance law. The Contractor will retain sole and absolute discretion in the judgment of the manner and means of carrying out Contractor's activities and responsibilities hereunder provided, further that administrative procedures applicable to services rendered under this Agreement will be those of Contractor, which policies of Contractor will not conflict with County,State,or United States policies,rules or regulations relating to the use of Contractor's funds provided for herein. The Contractor agrees that it is a separate and independent enterprise from the County, that it had full opportunity to find other business,that it has made its own investment in its business,and that it will utilize a high level of skill necessary to perform the work. This Agreement must not be construed as creating any joint employment relationship between the Contractor and the County and the County will not be liable for any obligation incurred by Contractor, including but not limited to unpaid minimum wages and/or overtime premiums. 7) Assignment and Subcontracting Contractor must not transfer or assign the performance required by this Agreement without the prior written consent of the Board of County Commissioners.This Agreement,or any portion thereof,must not be subcontracted without the prior written consent of the County nor may the Contractor assign any monies due or to become due to him or her,without the previous written consent. 8) Termination In the event that the Contractor is found to be negligent in any aspect of service,the County shall have the right to terminate this Agreement after seven(7)days' written notification Page 3 of 15 to the Contractor. a) Termination for Cause and Remedies: In the event of breach of any contract terms, the County retains the right to terminate this Agreement. The County may also terminate this Agreement for cause with Contractor should Contractor fail to perform the covenants herein contained at the time and in the manner herein provided. In the event of such termination,prior to termination,the County shall provide Contractor with seven (7) calendar days' written notice and provide the Contractor with an opportunity to cure the breach that has occurred. If the breach is not cured,the Agreement will be terminated for cause. If the County terminates this Agreement with the Contractor,County shall pay Contractor the sum due the Contractor under this Agreement prior to termination, unless the cost of completion to the County exceeds the funds remaining in the contract;however, the County reserves the right to assert and seek an offset for damages caused by the breach. The maximum amount due to Contractor shall not in any event exceed the spending cap in this Agreement. In addition, the County reserves all rights available to recuperate monies paid under this Agreement, including the right to sue for breach of contract and including the right to pursue a claim for violation of the County's False Claims Ordinance,located at Section 2-721 et al.of the Monroe County Code. b) Termination for Convenience: The County may terminate this Agreement for convenience,at any time,upon ninety(90)days' written notice to Contractor. if the County terminates this Agreement with the Contractor, County shall pay Contractor the sum due as of the appointed termination date, unless the cost of completion of the remaining work under the Agreement exceeds the funds remaining in the contract. The maximum amount due to Contractor shall not exceed the spending cap in this Agreement. 9) Indemnification&Hold Harmless a) The parties agree that one percent (1%) of the total compensation paid to Contractor for the work or services under this Agreement constitutes specific consideration to Contractor for the indemnification to be provided under the Agreement. Notwithstanding any minimum insurance requirements prescribed elsewhere in this Agreement,the Contractor shall defend,indemnify,and hold the County,and the County's elected and appointed officers and employees,harmless from and against any claims, actions or causes of action, any litigation, administrative proceedings,appellate proceedings,or other proceedings relating to any type of injury (including death), loss, damage, fine, penalty or business interruption,and any costs or expenses that may be asserted against,initiated with respect to, or sustained by, any indemnified party by reason of,or in connection with:(A)any activity of the Contractor or any of its employees,agents,contractors or other invitees during the term of this Agreement; (B) the negligence or recklessness, intentional wrongful misconduct, errors or other wrongful act or omission of Contractor or any of its employees,agents,sub-contractors or other invitees;or(C)the Contractor's default in respect of any of the obligations that it undertakes under the terms of this Agreement, except to the extent the claims, actions, causes of action, litigation,proceedings,costs or expenses arise from the intentional or sole negligent acts or omissions of the County or any of its employees, agents, contractors or invitees (other than the Contractor). The monetary limitation of liability under this Agreement shall be equal to the dollar value of the contract and not less than $1 million per occurrence pursuant to Section 725.06,Florida Statutes. The limits of liability shall be as set forth in the Page 4 of 15 insurance requirements included in the "Insurance Requirements," provisions herein. b) In the event that the completion of the services(to include the work of others) is delayed or suspended as a result of the Contractor's failure to purchase or maintain the required insurance,the Contractor shall indemnify the County from any and all increased expenses resulting from such delay. c) Nothing contained herein is intended,nor may it be construed,to waive County's rights and immunities under the common law or Section 768.28,Florida Statutes, as amended from time to time; nor will anything included herein be construed as consent to be sued by any third parties in any matter arising out of this Agreement. To the extent considered necessary by the County,any sums due Contractor under this Agreement may be retained by the County until all of the County's claims subject to this indemnification obligation have been settled or otherwise resolved, and any amount withheld is not subject to payment of interest by the County. Insofar as the claims, actions, causes of action, litigation, proceedings, costs or expenses relate to events or circumstances that occur during the term of this Agreement,this section will survive the expiration of the term of this Agreement or any earlier termination of this Agreement. 10) Discriminatory Vendor List Contractor hereby acknowledges its continuous duty to disclose to the County if the Contractor or any of its affiliates,as defined by Section 287.134(l)(a),Florida Statutes,are placed on the Discriminatory Vendor List. Pursuant to Section 287.134(2)(a),Florida Statutes:"An entity or affiliate who has been placed on the discriminatory vendor list may not submit a bid, proposal, or reply on a contract to provide any goods or services to a public entity;may not submit a bid,proposal,or reply on a contract with a public entity for the construction or repair of a public building or public work; may not submit bids, proposals, or replies on leases of real property to a public entity; may not be awarded or perform work as a contractor,supplier,subcontractor, or consultant under a contract with any public entity;and may not transact business with any public entity." 11) County Suspended Vendor List The eligibility of persons to bid for an award of County contract(s),or enter into a contract, may be suspended pursuant to sec.2-347(1)of the Monroe County Code of Ordinances.In the event an eligible person is suspended by the County after the contract is awarded,or a suspended person is employed to perform work (e.g. subcontractor in a bid or contract) pursuant to a County contract,same shall constitute a material breach of the contract.The County, in its sole discretion, may terminate the contract with no further liability to the contractor beyond payment of the portion of the contract price that may be due for work satisfactorily completed up to the date of termination,and hereby reserves all other rights and remedies available at law or in equity. 12) Prohibition on Conflict of Interest,Gratuities,Kickbacks,and Collusion The statements contained in this paragraph are true and correct, and made with the full knowledge that Monroe County relies upon the truth of the statements contained herein in awarding the contract for this service. a) Conflict of Interest.Contractor covenants that it presently has no interest and will not acquire any interest that would conflict in any manner or degree with the performance of services required.Each party hereto covenants that there is no conflict of interest or any other prohibited relationship between the County and itself. Page 5 of 15 1)) Gratuities.Contractor hereby certifies that it has not offered,given, or agreed to give any Monroe County employee a gratuity, favor, or anything of monetary value in connection with any decision,approval, disapproval, recommendation, preparation of any part of the service or award of this contract. c) Kickbacks. Contractor certifies that it has not given payment, gratuity, or offer of cruployrnent to be made by or on behalf of a Sub-contractor Linder a contract to Contractor or higher tier sub-contractor or any person associated therewith, as an inducement of the award of a subcontract or order. d) Non-Collusion Statement. By signing this Agreement, Contractor certifies Linder penalty of perjury that the price proposed by Contractor was arrived at independently without collusion, Consultation, or communication for the purpose of restricting competition,and no attempt has been made to induce another person or entity to submit a proposal,or not submit, for the purpose of restricting competition in the award of this contract. e) Contract Clause. The prohibitions on conflict of interest, gratuities, kickbacks, and Collusion prescribed in this paragraph must be conspicuously set forth in every contract and subcontract and solicitation initiated by Contractor in its performance of this Agreement, 13) Ethics Clause pursuant to Monroe County Ordinance No.010-1990 By signing this Agreement, the Contractor warrants that he/she/it has not employed, retained or otherwise had act on his/ber/its behalf any former County officer or employee in violation of Section 2-149, Monroe County Code of Ordinances, or any County officer or employee in violation of Section 2-150, Monroe County Code of Ordinances, For breach or violation of this provision the County rnay, in its discretion, terminate this Agreement Without liability and may also, in its discretion, deduct from the Agreement or purchase price, or otherwise recover,the full amount of any fee, conimission, percentage, gift,or consideration paid to the Conner County officer or employee pursuant to Subsection 2-152(b), Monroe County Code of Ordinances. 14) Prompt Disclosure of Litigation,Investigations,Arbitration, or Admin.Proceedings 'ri,ir0L1gh0L1t the term of this Agreement, the Contractor has a continuing duty to promptly disclose to the County, in writing, upon occurrence, all civil or criminal litigation, investigations, arbitration, or administrative proceedings relating to, or affecting Contractor's ability to perform under this Agreement. If the existence of such causes the County concern that the Contractor's ability or willingness to perform the Agreement is Jeopardized, the Contractor may be required to provide the County with reasonable assurances to demonstrate its ability to perform as required hereunder, and that its employees/agents have not or will not engage in conduct similar in nature to the conduct alleged in such proceeding. 15) Notice All written correspondence to the County shall be dated and signed by an authorized representative of the Contractor. Any written notices or correspondence required or contemplated under this Agreement shall be sent by U.S. Mail, certified, return receipt requested,postage pre-paid,or by courier with proof of delivery.Notice is deemed received by Contractor when hand delivered by national Courier with proof of delivery or by U.S, Mail upon verified receipt or upon the date of refusal or non-acceptance of delivery. Notice shall be sent to the following persons: FOR COUNTY: FOR CONTRACTOR: County Administrator Page 6 of 15 Monroe County 1100 Simonton Street, Doom 2-205Jr, 1 rv' Key West, 04( And (with to) Lnrat r Monroe County Attorney's Office l l I l 12th Street,Suite 408 Key West, F 1,33040 16) Choice of Law and Venue The pat-ties hereby agree that the only laws that apply to this Agreement are those of the State of Florida and United States of America. The parties waive the privilege of venue and agree that all litigation between them in the:Mate courts will take place exclusively in the Sixteenth Judicial Circuit in and for Monroe County, Florida, and that all litigation between theta in file federal courts will take place;exclusively in the United States District Court in and for the Southern District of Florida,or United States Bankruptcy Court for the Southern District of Florida, whenever applicable. 17) WAIVER OF JURY TRIAL& MANDATORY PRE-SUIT MEDIATION BY ENTERING INTO THIS CONTRACT,EACH OF CONTRACTOR AND THE COUNTY HEREBY EXPRESSLY WAIVE ANY RIGHT'S EACH MAY HAVE TO A TRIAL BY JURY RELATED TO THIS CONTRACT. IF A PARTY FAILS TO WITHDRA"VW A REQUEST FOR A JURY TRIAL IN A LAWSUIT ARISING OUT OF THIS CONTRACTOR SOLICITATION AFTER WRITTEN NOTICE BY THE OTHER PARTY OF VIOLATION OF THIS SECTION, THE PARTY MAILING THE REQUEST FOR JURY TRIAL WILL BE LIABLE FOR THE REASONABLE .ATTORNEY'S FEES AND COSTS OF THE OTHER PARTY CONTESTING THE REQUEST FOR JURY TRIAL,AND SUCH AMOUNTS MUST BE AWARDED BY THE COURT IN ADJUDICATING THE MOTION. THE COUNTY AND CONTRACTOR AGREE THAT, IN THE EVENT OF CONFLICTING INTERPRETATIONS OF THE TERMS OR A TERM OF THIS AGREEMENT BY OR BETWEEN ANY OF THEM THE ISSUE SHALL BE SUBMITTED TO MEDIATION PRIOR TO THE INSTITUTION OF ANY OTHER ADMINISTRATIVE OR LEGAL PROCEEDING, MEDIATION PROCEEDINGS INITIATED AND CONDUCTED PURSUANT TO THIS AGREEMENT SHALL BE IN ACCORDANCE WITH THE FLORIDA RULES OF CIVIL PROCEDURE AND USUAL AND CUSTOMARY PROCEDURES REQUIRED BY THE CIRCUIT COURT OF MONROE COUNTY. IS) Attorney's Fees and Costs. County and. Contractor agree that in the event any cause of action or administrative proceeding is initiated or defended by any party relative to the enforcement or interpretation of this .Agreement, the prevailing party shall be entitled to reasonable attorney's fees,court costs,investigative,and out-of-pocket expenses,as an award against the non-prevailing party, at all levels of the court system, including ill appellate proceedings. 19) Cooperation in. Claims for Federal or State Aid & In General Contractor and County agree that each shall be, and is, empowered to apply for, seek,and obtain federal and state funds to further the purpose of'this Agreement; provided that all applications,requests„grant proposals,and Funding solicitations shall be approved by each Page 7 of'15 party prior to submission. In the event any administrative or legal proceeding is instituted against either party relating to the formation, execution, performance, or breach of this Agreement,County and Contractor agree to participate,to the extent required by the other party, in all proceedings,hearings,processes,meetings,and other activities related to the substance of this Agreement or provision ofthe services under this Agreement.County and Contractor specifically agree that no party to this Agreement shall be required to enter into any arbitration proceedings related to this Agreement. No covenant or agreement contained herein shall be deemed to be a covenant or agreement of any member,officer, agent, or employee of Monroe County in his or her individual capacity, and no member, officer,agent,or employee of Monroe County shall be liable personally on this Agreement or be subject to any personal liability or accountability by reason of the execution of this Agreement. 20) Public Records County is a public agency subject to Chapter 119,Florida Statutes,as amended from time to time. To the extent Contractor is a Contractor acting on behalf of the County pursuant to Section 119.0701, Florida Statutes, as amended from time to time, Contractor must comply with all public records laws in accordance with Chapter 119,Florida Statutes. In accordance with state law,Contractor agrees to: a) Keep and maintain all records that ordinarily and necessarily would be required by the County in order to perform the services. b) Upon request from the County's custodian of public records,provide the County with a copy of the requested records or allow the records to be inspected or copies within a reasonable time at a cost that does not exceed the costs provided in Chapter 119,Florida Statutes,or as otherwise provided by law. c) Ensure that public records that are exempt,or confidential and exempt,from public records disclosure are not disclosed except as authorized by law for the duration of the Agreement term and following completion of the Agreement if the Contractor does not transfer the records to the County. d) Upon completion of the services within this Agreement,at no cost,either transfer to the County all public records in possession of the Contractor or keep and maintain public records required by the County to perform the services. If the Contractor transfers all public records to the County upon completion of the services,the Contractor must destroy any duplicate public records that are exempt, or confidential and exempt, from public records disclosure requirements. If the Contractor keeps and maintains public records upon completion of the services, the Contractor must meet all applicable requirements for retaining public records. All records stored electronically must be provided to the County, upon request from the County's custodian of public records,in a format that is compatible with the information technology systems of the County. IF THE CONTRACTOR HAS QUESTIONS REGARDING THE APPLICATION OF CHAPTER 119, FLORIDA STATUTES, TO THE CONTRACTOR'S DUTY TO PROVIDE PUBLIC RECORDS RELATING TO THIS AGREEMENT, CONTACT THE COUNTY'S CUSTODIAN OF PUBLIC RECORDS, BRIAN BRADLEY, AT PHONE NO. 305-292-3470, BRADLEY-BRIAN@MONROECOUNTY- FL.GOV, MONROE COUNTY ATTORNEY'S OFFICE, 1111 12TH STREET, SUITE 408, KEY WEST, FL 33040. Page 8 of 15 If Contractor does not comply with this section, the County will enforce the Agreement provisions in accordance herewith and may unilaterally cancel this Agreement in accordance with state law. 21) Audit Rights The Contractor must maintain accurate books,records,documents and other evidence that sufficiently and properly reflect all direct and indirect costs of any nature expended in the performance of this Agreement, in accordance with generally accepted accounting principles. County reserves the right to audit the records of the Contractor for the commodities and/or services provided under the contract at any time during the performance and term of the contract and for a period of five (5) State of Florida fiscal years after completion and acceptance of the Work by the County. Such records must be retained by Contractor for a minimum of five(5)State of Florda fiscal years following the close of the Agreement, or the period required for this particular type of service by the General Records Schedules maintained by the Department of State, whichever is longer. The Contractor agrees to cooperate with the County, and if relevant, the State Inspector General pursuant to Section 20.055(5),as amended,in any investigation and facilitate the duplication and transfer of such records upon the County's request. Contractor agrees to submit to an audit as required by the County, Florida Fish and Wildlife Conversation Commission,the Chief Financial Officer of the State of Florida,the Auditor General of the State of Florida, the Florida Office of Program Policy Analysis and Government Accountability,or other authorized representative(s)of the State of Florida.The Contractor must allow the County or such other auditing agency to have access to and inspect the complete records of the Contractor in relation to this Agreement at any and all times during normal business hours for the purposes of conducting audits or examinations or making excerpts or transcriptions. Such requirements will survive the termination of this Agreement. 22) No Third Party Beneficiaries Neither Contractor nor County intends to directly or substantially benefit a third party by this Agreement. Therefore, the Parties acknowledge that there are no third-party beneficiaries to this Agreement and that no third party is or will be entitled to assert a right or claim against either of them based upon this Agreement. 23) Uncontrollable Circumstances("Force Majeure") As used herein,"Force Majeure"means the occurrence of any event that prevents or delays the performance by either party of its obligations hereunder which are beyond the reasonable control of the non-performing party. Examples of"Force Majeure"include,but are not limited to, acts of God, natural disasters, or emergency governmental action. To invoke this paragraph, immediate written notice, consistent with the "Notice"provisions of this Agreement,must be sent by the non-performing party describing the circumstances constituting force majeure and proof that the non-performance or delay of performance is a direct and reasonable result of such event(s). Any claim for extension of time by Contractor pursuant to this paragraph will be made not more than Seventy-two(72)hours after the commencement of the delay.Otherwise,it shall be waived. The Contractor shall immediately report the termination of the cause for the delay within seventy-two(72)hours after such termination. The County reserves its right to challenge the invocation by the Contractor within five(5)calendar days of receipt of said notice,in such case uninterrupted performance in required. However,in the event the invocation is accepted by the County, the Contractor must take all reasonable measures to mitigate any and all resulting damages, Page 9 of 15 costs, delays, or disruptions to the Contractor's performance requirements under this Agreement. All obligations must resume when the circumstances of such event(s) have subsided, or other arrangements are made pursuant to a written amendment to this Agreement. 24) Conditions for Emergency/Hurricane or Disaster It is hereby made a part of this agreement that before,during and after a public emergency, disaster,hurricane,flood,pandemic or other substantial loss that the Monroe County will require a"first priority"basis for goods and services. It is vital and imperative that the majority of citizens are protected from any emergency situation which threatens public safety and health, as determined by the County Administrator. Contractor agrees to perform services for the County or other governmental entities, as opposed to a private citizen or corporation, on a first priority basis. The County expects to pay a fair and reasonable price for all products/services in the event of a disaster,pandemic,emergency or hurricane. Contractor must furnish a twenty-four(24) hour telephone number in the event of such an emergency. 25) Public Entity Crimes Statement Pursuant to Section 287.133(2)(a), Florida Statutes, as amended from time to time, Contractor hereby certifies that neither it nor its affiliate(s) have been placed on the convicted vendor list following a conviction for a public entity crime.If placed on that list, Contractor agrees:to immediately notify the County and is prohibited from providing any goods or services to a public entity; it may not submit a bid on a contract with a public entity for the construction or repair of a public building or public work;it may not submit bids on leases of real property to a public entity; it may not be awarded or perform work as a contractor, supplier, subcontractor, or consultant under a contract with any public entity; and, it may not transact business with any public entity in excess of the threshold amount provided in Section 287.017, Florida Statutes, for Category TWO ($35,000), as may be amended, for a period of thirty-six(36)months from the date of being placed on the convicted vendor list. 26) Foreign Gifts and Contracts The Contractor must comply with any applicable disclosure requirements in Section 286.101,Florida Statutes.Pursuant to Section 286.101(7)(b),Florida Statutes:"In addition to any fine assessed under[§286.101(7)(a),Florida Statutes],a final order determining a third or subsequent violation by an entity other than a state agency or political subdivision must automatically disqualify the entity from eligibility for any grant or contract funded by a state agency or any political subdivision until such ineligibility is lifted by the Administration Commission [Governor and Cabinet per §14.202, Florida Statutes] for good cause." 27) Scrutinized Companies and Countries of Concern per Sections 287.135, 215A73, & 287.138,Florida Statutes Contractor hereby certifies that it: a) has not been placed on the Scrutinized Companies that Boycott Israel List,nor is engaged in a boycott of Israel;b)has not been placed on the Scrutinized Companies with Activities in Sudan List nor the Scrutinized Companies with Activities in the Iran Terrorism Sectors List (formerly the Iran Petroleum Energy Sector List); and c) has not been engaged in business operations in Cuba or Syria. If County determines that Contractor has falsely certified facts under this paragraph,or if Contractor is found to have been placed on a list created pursuant to Section 215.473,Florida Statutes, as amended, or is engaged in a boycott of Israel after the execution of this Agreement, Page 10 of 15 County will have all rights and remedies to terminate this Agreement consistent with Section 287.135, Florida Statutes, as amended. The County reserves all rights to waive certain requirements of this paragraph on a case-by-case exception basis pursuant to Section 287,135, Florida Statutes, as amended. Beginning January 1, 2024„ the County must not enter into a contract that grants access to an individual's personal identifying information to any Foreign Country of Concern such as: People's Republic of China, the Russian Federation, the Islamic Republic of Iran, the Democratic People's Republic of Korea, the Republic of Cuba, the Venezuelan regirne of Nicol6s Maduro, or the Syrian Arab Republic, unless the Contractor provides the County with an affidavit signed by an authorized representative: of the Contractor, wider penalty of perjury, attesting that the Contractor does not meet any of the criteria in subparagraphs(2)(a)-(c)of Section 287.138, Florida Statutes, as may be amended. Beginning January 1, 2025, the County must not extend or renew any contract that grants access to an individUal'S personal identifying information unless the Contractor provides the County with ail affidavit signed by an authorized representative of'the Contractor, Linder penalty of perjury, attesting that the Conti-actor does not rueet any of the criteria in subparagraphs(2)(a)�-(c)of Section 287.138, Florida Statutes, as may be amended. Violations of this Section will result in termination of this Agreement and may result in administrative sanctions and penalties by the Office of the Attorney General of the State of Florida, ALLEN FUNERAL DIRECTORS LLC d/b/a ALLEN-BEYER FUNERAL HOC ME is not owned by the government ofa Foreign Country of Concern, is not organized under the laws of nor has its Principal Place of Business in a Foreign Country of Concern, and the government of a Foreign Country of Concern does not have a Controlling Interest in the entity. Under penalties of perjury, I declare that I have read the foregoing statement and that the facts stated in it are true. Printed Narne: 71)ii r44, Title: 0't,-h / Signature: Date: 1�,e V 0 4 2 28) Noncoerei onduct for Labor or Services As a nongovernmental entity Submitting a proposal, executing, renewing, or extending a contract with a government entity, Contractor is required to provide an affidavit under penalty of perjury attesting that Contractor does not use coercion For labor or services in accordance with Section 787.06, Florida Statutes. As an authorized representative of Contractor, I certify Linder penalties of perjury that Contractor does riot use coercion for labor or services as prohibited by Section 787.06. Additionally, Contractor has reviewed Section 787.06, Florida Statutes,and agrees to abide by same. 29) Nondiscrimination Covenant The Contractor and County agree that there will be no discrimination against any person, and it is expressly understood that upon a determination by a court of competent jurisdiction that discrimination has occurred, this Agreement automatically terminates without any further action on the part of any party, effective the date of the Court order. Contractor agrees to comply with all Federal and Florida statutes,and all local ordinances, Page I I of 15 as applicable,relating to nondiscrimination. These include but are not limited to: 1)Title VII of the Civil Rights Act of 1964 (PL 88-352) which prohibits discrimination in employment on the basis of race,color,religion, sex or national origin;2)Title IX of the Education Amendment of 1972, as amended (20 USC ss. 1681-1683, and 1685-1686), which prohibits discrimination on the basis of sex;3)Section 504 of the Rehabilitation Act of 1973, as amended (20 USC s. 794), which prohibits discrimination on the basis of disability; 4) The Age Discrimination Act of 1975, as amended (42 USC ss. 6101-6107) which prohibits discrimination on the basis of age; 5) The Drug Abuse Office and Treatment Act of 1972(PL 92-255),as amended,relating to nondiscrimination on the basis of drug abuse; 6) The Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1970 (PL 91-616), as amended, relating to nondiscrimination on the basis of alcohol abuse or alcoholism; 7) The Public Health Service Act of 1912, ss. 523 and 527 (42 USC ss. 690dd-3 and 290ee-3), as amended, relating to confidentiality of alcohol and drug abuse patient records; 8)Title VIII of the Civil Rights Act of 1968 (42 USC s. 3601 et seq.), as amended, relating to nondiscrimination in the sale, rental or financing of housing; 9) The Americans with Disabilities Act of 1990(42 USC s. 12101 Note),as may be amended from time to time, relating to nondiscrimination on the basis of disability; 10) Monroe County Code Chapter 14, Article II, which prohibits discrimination on the basis of race, color, sex, religion, national origin,ancestry,sexual orientation, gender identity or expression,familial status or age; 11)The Pregnant Workers Fairness Act(PWFA)pursuant to 42 U.S.C.2000gg et seq.;and 12)Any other nondiscrimination provisions in any Federal or state statutes which may apply to the parties to,or the subject matter of,this Agreement. 30) E-Verify Requirements Effective January 1, 2021, public and private employers, contractors and subcontractors must require registration with,and use of the E-verify system in order to verify the work authorization status of all newly hired employees.Contractor acknowledges and agrees to utilize the U.S. Department of Homeland Security's E-Verify System to verify the employment eligibility of: a) All persons employed by Contractor to perform employment duties within Florida during the term of the contract;and b) All persons (including subvendors/subconsultants/subcontractors) assigned by Contractor to perform work pursuant to the contract with the County. The Contractor acknowledges and agrees that use of the U.S.Department of Homeland Security's E-Verify System during the term of the contract is a condition of the contract with the County. By entering into this Agreement, the Contractor becomes obligated to comply with the provisions of Section 448.095, Florida Statutes, "Employment Eligibility," as amended from time to time.This includes,but is not limited to,utilization of the E-Verify System to verify the work authorization status of all newly hired employees, and requiring all subcontractors to provide an affidavit to Contractor attesting that the subcontractor does not employ,contract with,or subcontract with,an unauthorized alien.Contractor agrees to maintain a copy of such affidavit for the duration of this Agreement. Failure to comply with this paragraph will result in the termination of this Agreement as provided in Section 448.095, Florida Statutes, as amended, and Contractor may not be awarded a public contract for at least one (1) year after the date on which the Agreement was terminated. Contractor will also be liable for any additional costs to County incurred as a result of the termination of this Agreement in accordance with this Section. Upon executing this Agreement,Contractor will provide proof of enrollment in E-verify to the County. Page 12 of 15 31) Antitrust Violations;Denial or Revocation under Section 287.137,Florida Statutes Pursuant to Section 287.137,Florida Statutes,as may be amended,a person or an affiliate who has been placed on the antitrust violator vendor list (electronically published and updated quarterly by the State of Florida)following a conviction or being held civilly liable for an antitrust violation may not submit a bid, proposal,or reply for any new contract to provide any goods or services to a public entity; may not submit a bid,proposal,or reply for a new contract with a public entity for the construction or repair of a public building or public work; may not submit a bid,proposal, or reply on new leases of real property to a public entity;may not be awarded or perform work as a contractor,supplier,subcontractor, or consultant under a new contract with a public entity;and may not transact new business with a public entity. By entering this Agreement, Contractor certifies neither it nor its affiliate(s)are on the antitrust violator vendor list at the time of entering this Agreement. False certification under this paragraph or being subsequently added to that list will result in termination of this Agreement, at the option of the County consistent with Section 287.137,Florida Statutes,as amended. 32) Environmental and Social Government and Corporate Activism Pursuant to Section 287.05701, Florida Statutes, as may be amended,the County cannot give preference to a contractor based on social,political or ideological interests as defined in the statute. Contractor is also prohibited from giving preference to any of its subcontractors based on the above referenced factors.Violations of this Section will result in termination of this Agreement and may result in administrative sanctions and penalties by the Office of the Attorney General of the State of Florida. 33) Merger;Amendment This Agreement constitutes the entire Agreement between the Contractor and the County, and negotiations and oral understandings between the parties are merged herein. This Agreement can be supplemented and/or amended only by a written document executed by both the Contractor and authorized designees of the County. 34) Interpretation The titles and headings contained in this Agreement are for reference purposes only and will not in any way affect the meaning or interpretation of this Agreement. All personal pronouns used in this Agreement include the other gender, and the singular includes the plural,and vice versa,unless the context otherwise requires. Terms such as"herein"refer to this Agreement as a whole and not to any particular sentence, paragraph, or section where they appear,unless the context otherwise requires. Whenever reference is made to a section or article of this Agreement,such reference is to the section or article as a whole, including all subsections thereof,unless the reference is made to a particular subsection or subparagraph of such section or article. Any reference to "days" means calendar days, unless otherwise expressly stated. 35) Joint Preparation It is acknowledged that each party to this Agreement had the opportunity to be represented by counsel in the preparation of this Agreement and accordingly the rule that a contract will be interpreted strictly against the party preparing same does not apply herein due to the joint contributions of both parties. 36) Severability;Waiver of Provisions Any provision in this Agreement that is prohibited or unenforceable in any jurisdiction will, as to that jurisdiction, be ineffective to the extent of such prohibition or Page 13 of 15 Linen forceabi I ity without invalidating the remaining provisions hereof or affecting the validity or enforceability of such provisions in any other jurisdiction,The non-enforcement ol'any provision by either party will not constitute a waiver of that provision nor will it affect the enforceability of that provision or of the remainder ol'this Agreement. 37) Signatory Authority Upon request, the Contractor Must provide the County With copies of requisite (10CLUTIC11tation evidencing that the signatory for Contractor has the authority to enter into this Agreement, 38) Counterparts and Multiple Originals. This Agreement may be executed in multiple originals, and may be executed in counterparts, each ol'which is hereby deemed to be an original, but all of which, taken together,constitutes one and the same:agreement. IN WITNESS WHEREOF,County and Contractor have executed this Agreement as of the date first written above, CONTRACTOR: ALLEN FUNERAL DIRECTORS LLC d/b/a ALLEN-BEYER FUN ERA By: 4 i store Kint Name& Title STATE Of, Ft' I IDA coU The foregoing instrument was sworn to/affirV and acknowledge before me by ofK) by means ofp,physical presence or 0 online notarization,this "20 Anthony W.Allen,Manager of ALLEN FUNEIZAL DIRECTORS LLC A/a ALLEN-BE—Iyft FUNERAL HOME, a Florida Limited Liability Company. ,He/She is-perso nally- .no wqlq_metor has produced (typ�ofiden.tification)aVentification. "'EJ Ll(L J, C-C CAROLYN R. HENRY $i�nat'ure ol"N ry P lic STATE Of FLORIDA NOTARY PUBUC 2102 my CO COMMISS10#j No,M 49S"' NOSSION EXPIRES MARCH 23, (Print Stamp kommissioned Nance ol'Not y Public) [County Signatures to follow] Page 14 of 15 , AGREEMENT between MONROE COUNTY,FL& ALLEN FUNERAL DIRECTORS LLC d/b/a ALLEN-BEYER FUNERAL HOME for Disposal of Remains BOARD OF COUNTY COMMISSIONERS OF MONROE COUNTY,FLORIDA: BY.'fr- 40 Mayor Holly Merrill Raschein ... ,:-.2,„ ..,,,,S,•',...i3,,,,k 03-",'-`:*42.),, ,,-,„ At,:ri,inT,„(..',TY(Seallki\r"\ ',111 #eii ,:414:6 :Vit,e Iii*adok,Clerk •ri,.-1,1 mok Attest-4:1,: : 4 1)14.t1,1A-;?i4t.- ',7,-,,E./64),Ho witor ifDeputy Clerk P,,,, p.• ._. Approved as to legal form&sufficiency: Eve I . Lewis Digitally signed by Eve M.Lewis Date 2024.10.1608:2651-041001 Assistant County Attorney ,.....) -71 .,-,....;) ..= r---- -::, e7:72. ni ..,:,.„.., ......., tr',= r---) ...,.....,.... ., ,.,-- ... -* ,..„,_ .....ri ,..,. . ,....) c--) ..„............... ........,...v..: ....• ,.. , PO -- Page 15 of 15 ... . . Docusign Envelope ID:980A341A-FDCC-452D-BFAB-0IEF6964417A 0 FLORIDA COMMERCIAL INSURANCE APPLICATION DATE(MMIDD[YYYY) AC"RO APPLICANT INFORMATION SECTION 09/25/2024 AGENCY CARRIER NAIC CODE MIGI 3, LLC dba The Morgan Insurance Group <Prospect> 102481 Overseas Highway COMPANY POLICY OR PROGRAM NAME PROGRAM CODE Key Largo, FL 33037 APPROVED BY RISK MANAGEMENT POLICY NUMBER BY i CONTACT DATE UNDERWRITER UNDERWRITER OFFICE PHONE A,.,No,E,:(305)451-4788 WAIVER N/A YES FAX RENEW (A/C,No (305)451-1539 QUOTE L-1 ISSUE POLICY Ll E-MAIL STATUS OF ADDRESS: vsmith@_tbigfla.com TRANSACTION BOUND(Give Date and/or Attach Copy): CODE: ISUBCODE: CHANGE DATE TIME AM AGENCY CUSTOMER ID: 00000324 CANCEL PM LINES OF BUSINESS INDICATE LINES OF BUSINESS PREMIUM PREMIUM PREMIUM BOILER&MACHINERY $ CRIME $ TRUCKERS $ BUSINESS AUTO $ CYBER AND PRIVACY $ UMBRELLA $ BUSINESS OWNERS $ FIDUCIARY LIABILITY $ YACHT $ COMMERCIAL GENERAL LIABILITY $ GARAGE AND DEALERS $ $ COMMERCIAL INLAND MARINE $ LIQUOR LIABILITY $ $ COMMERCIAL PROPERTY $ MOTOR CARRIER $ $ ATTACHMENTS ACCOUNTS RECEIVABLE/VALUABLE PAPERS ELECTRONIC DATA PROCESSING SECTION PROFESSIONAL LIABILITY SUPPLEMENT ADDITIONAL INTEREST SCHEDULE GLASS AND SIGN SECTION RESTAURANT/TAVERN SUPPLEMENT ADDITIONAL PREMISES INFORMATION SCHEDULE HOTEL/MOTEL SUPPLEMENT STATEMENT/SCHEDULE OF VALUES APARTMENT BUILDING SUPPLEMENT INSTALLATION/BUILDERS RISK SECTION STATE SUPPLEMENT(If applicable) CONDO ASSN BYLAWS(for D&O Coverage only) INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT VACANT BUILDING SUPPLEMENT CONTRACTORS SUPPLEMENT INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT VEHICLE SCHEDULE COVERAGES SCHEDULE LOSS SUMMARY DEALERS SECTION OPEN CARGO SECTION DRIVER INFORMATION SCHEDULE PREMIUM PAYMENT SUPPLEMENT POLICY INFORMATION PRO PROPOSED BILLING PLAN PAYMENT PLAN � METHOD OF PAYMENT � AUDIT $ DEPOSIT � $ MINIMUM POLICY PREMIUM POSED PREMIUM .P EFFECTIVE DATE EXPIRATION DATE Y� $ 10/27/2024 � 10/27/2025 kX DIRECT F AGENCY APPLICANT INFORMATION NAME(First Named Insured)AND MAILING ADDRESS(including ZIP,4) GL CODE sic NAICS FEIN OR SOC SEC# Allen-Beyer Funeral Home PO Box 373000 BUSINESS PHONE#: Key Largo, FIL 33037 WEBSITE ADDRESS � CORPORATION HJOINT VENTURE NOT FOR PROFIT OR SUBCHAPTER'S"CORPORATION INDIVIDUAL LLC NO.OF MEMBERS PARTNERSHIP TRUST x AND MANAGERS H NAME(Other Named Insured)AND MAILING ADDRESS(including ZIP+4) GL CODE sic NAICS FEIN OR SOC SEC# BUSINESS PHONE#: WEBSITE ADDRESS CORPORATION HJOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER'S"CORPORATION INDIVIDUAL LLC NO.OF MEMBERS PARTNERSHIP TRUST AND MANAGERS H NAME(Other Named Insured)AND MAILING ADDRESS(including ZIP+4) GL CODE sic NAICS FEIN OR SOC SEC# BUSINESS PHONE#: WEBSITE ADDRESS CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION L-1 INDIVIDUAL LLC NO.OF MEMBERS PARTNERSHIP TRUST H AND MANAGERS H H DEFINITIONS: GL CODE: General Liability Code SIC: Standard Industrial Classification NAICS: North American Industry Classification System SOC SEC#: Social Security Number FEIN: Federal Employer Identification Number LLC: Limited Liability Corporation ACORD 125 FL(2016/03) Page 1 of 4 2011-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by VXS on October 03,2024 at 11:27AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A CONTACT INFORMATION AGENCY CUSTOMER ID: 00000324 CONTACT TYPE. Girl Conn CONTACT TYPE: CONTACT NAME-Tony Allen CONTACT NAME: PRIMARY ❑ HOME BUS CELL PHONE#ARY ❑ HOME BUS CELL PRIMARY ❑ HOME❑ BUS ❑CELL SECONDARY ❑HOME❑BUS ❑CELL PRIMARY E-MAIL ADDRESS:weCSre allenbe er=cord PRIMARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS: PREMISES INFORMATION Attach ACORD 823 for Additional Premises,if applicable) LOC# STREET CITY LIMITS INTEREST #FULL TIME EMPL ANNUAL REVENUES:$ 1 101640 Oversees Hwy INSIDE OWNER OCCUPIED AREA: SQ FT BLD# CITY:Key Largo STATE:FL OUTSIDE TENANT *PART TIME EMPL OPEN TO PUBLIC AREA: SO FT COUNTY:Monroe Zip:33037 TOTAL BUILDING AREA: SQ FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y I N LOC# STREET CITY LIMITS INTEREST #FULL TIME EMPL ANNUAL REVENUES:$ INSIDE OWNER OCCUPIED AREA: SO FT BLD# CITY: STATE: OUTSIDE TENANT #PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT COUNTY: ZIP: TOTAL BUILDING AREA: SO FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y I N LOC# STREET CITY LIMITS INTEREST #FULL TIME EMPL ANNUAL REVENUES:$ INSIDE OWNER OCCUPIED AREA: SQ FT BLD# CITY: STATE: OUTSIDE TENANT #PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT COUNTY: ZIP: TOTAL BUILDING AREA: SO FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y I N LOC# STREET CITY LIMITS INTEREST #FULL TIME EMPL ANNUAL REVENUES:$ INSIDE OWNER OCCUPIED AREA: SO FT BLD# CITY: STATE: OUTSIDE TENANT #PART TIME EMPL OPEN TO PUBLIC AREA: SO FT COUNTY: ZIP: TOTAL BUILDING AREA: SQ FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y I N DEFINITIONS: LOC#: Location Number #FULL TIME EMPL: Number Full Time Employees SQ FT: Square Feet BLD#: Building Number #PART TIME EMPL: Number Part Time Employees NATURE OF BUSINESS DATE BUSINESS APARTMENTS CONTRACTOR MANUFACTURING RESTAURANT SERVICE STARTED(MMIDDIYYYY) CONDOMINIUMS INSTITUTIONAL OFFICE RETAIL WHOLESALE DESCRIPTION OF PRIMARY OPERATIONS Funeral Home INSTALLATION,SERVICE OR REPAIR WORK OFF PREMISES INSTALLATION,SERVICE OR REPAIR WORK RETAIL STORES OR SERVICE OPERATIONS%OF TOTAL SALES: DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS ADDITIONAL INTEREST Provide only the necessary data Attach ACORD 45 for more Additional Interests,if applicable INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LIENHOLDER LOCATION: BUILDING: INSURED BREACH OF LOSS PAYEE VEHICLE: BOAT: WARRANTY CO-OWNER MORTGAGEE AIRPORT: AIRCRAFT: EMPLOYEE OWNER ITEM ITEM: AS LESSOR CLASS: LEASEBACK REGISTRANT ITEM DESCRIPTION OWNER LENDER'S TRUSTEE REFERENCE I LOAN#: INTEREST END DATE: LOSS PAYABLE LIEN AMOUNT: PHONE(A/C,No,Ext): FAX(AIC,No): REASON FOR INTEREST: E-MAIL ADDRESS: ACORD 125 FL(2016/03) Page 2 of 4 Printed by VXS on October 03,2024 at 11:27AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A GENERAL INFORMATION AGENCY CUSTOMER ID:00000324 EXPLAIN ALL"YES"RESPONSES Y I N 1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY? PARENT COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 1 b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? SAFETY MANUAL 71 SAFETY POSITION MONTHLY MEETINGS OSHA 3. ANY EXPOSURE TO FLAMMABLES,EXPLOSIVES,CHEMICALS? 4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER 5. ANY POLICY OR COVERAGE DECLINED,CANCELLED OR NON-RENEWED DURING THE PRIOR THREE(3)YEARS FOR ANY PREMISES OR OPERATIONS?(Missouri Applicants-Do not answer this question) NON-PAYMENT H AGENT NO LONGER REPRESENTS CARRIER ❑ NO N- UNDERWRITING CONDITION CORRECTED(Describe): 6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS:DISCRIMINATION OR NEGLIGENT HIRING? 7. DURING THE LAST FIVE YEARS(TEN IN RI),HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY,ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI,this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? N OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 9. HAS APPLICANT HAD A FORECLOSURE,REPOSSESSION,BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE(5)YEARS? N OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE(5)YEARS? OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 11. HAS BUSINESS BEEN PLACED IN A TRUST?NAME OF TRUST: N 12. ANY FOREIGN OPERATIONS,FOREIGN PRODUCTS DISTRIBUTED IN USA,OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES? (If"YES',attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) 13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? 14. DOES APPLICANT OWN/LEASE/OPERATE ANY DRONES? (If"YES',describe use) 15. DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If"YES',describe use) REMARKS/PROCESSING INSTRUCTIONS ACORD 101,Additional Remarks Schedule,may be attached if mores ace is required) ACORD 125 FL(2016/03) Page 3 of 4 Printed by VXS on October 03,2024 at 11:27AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A PRIOR CARRIER INFORMATION AGENCY CUSTOMER ID:00000324 YEAR CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE LOSS HISTORY IXICheckifnone (Attach Loss Summary for Additional Loss Information) ENTER ALL CLAIMS OR LOSSES(REGARDLESS OF FAULT AND WHETHER OR NOT INSURED)OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST YEARS TOTAL LOSSES: $ SUBRO- CLAIM DATE OF LINE DATE OF CLAIM AMOUNT PAID AMOUNT RESERVED GY YIN OPEN OCCURRENCE TYPE I DESCRIPTION OF OCCURRENCE OR CLAIM YIN Y I N REMARKS(ACORD 101,Additional Remarks Schedule,may be attached if mores ace is required,if applicable) SIGNATURE PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSON OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL All OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIE WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR TH PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT T REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST It WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE. THESE RIGHTS MA BE LIMITED IN SOME STATES. PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS O HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE; DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATIO CONTAINING ANY FALSE,INCOMPLETE,OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HE KNO ,LEDGE. PR D CER'S SIGNATU PRODUCER'S NAME(Please Print) STATE PRODUCER LICENSE NO (Required in Florida) \!XS Vanessa Smith D00 7 4 APPLICANT SIG 1 /9��024 NATIONAL PRODUCER NUMBER a" ACORD 3)485-. Page 4 of 4 Printed by VXS on October 03,2024 at 11:27AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A AGENCY CUSTOMER ID: 00000324 DATE(MM/DD/YYYY) AC" COMMERCIAL GENERAL LIABILITY SECTION 109/25/2024 AGENCY CARRIER NAIC CODE G13, LLC de The Morgan Insurance Group <Pros eot> POLICY NUMBER EFFECTIVE DATE APPLICANT I FIRST NAMED INSURED 10/27/2024 Allen-Beyer Funeral Horne IMPORTANT-If CLAIMS MADE is checked in the COVERAGE/LIMITS section below,this is an application for a claims-made policy. Read all provisions of the policy carefully. COVERAGES LIMITS COMMERCIAL GENERALLIABILITY GENERAL AGGREGATE $ 2,000,000 PREMIUMS CLAIMS MADE 171 OCCURRENCE LIMIT APPLIES PER: POLICY LOCATION PREMISES/OPERATIONS OWNER'S&CONTRACTOR'S PROTECTIVE PROJECT OTHER: PRODUCTS&COMPLETED OPERATIONS AGGREGATE $ InIcuded PRODUCTS DEDUCTIBLES PERSONAL&ADVERTISING INJURY $ 1,000,000 PROPERTY DAMAGE $500 EACH OCCURRENCE $ 1,000,000 OTHER BODILY INJURY $500 CLAIM DAMAGE TO RENTED PREMISES(each occurrence) $ 100000 $ OCc URRENCE MEDICAL EXPENSE(Any one person) $ 5,000 TOTAL EMPLOYEE BENEFITS $ OTHER COVERAGES,RESTRICTIONS AND/OR ENDORSEMENTS(For hired/non-awned auto coverages attach the applicable state Business Auto Section,ACORD 137) APPLICABLE ONLY IN WISCONSIN: IF NON-OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY: 1. UM/UIM COVERAGE F IS IS NOT AVAILABLE. 2. MEDICAL PAYMENTS COVERAGE1-1 IS F IS NOT AVAILABLE. SCHEDULE OF HAZARDS L# HAZ CLASSIFICATION CLAS5 PREMIUM EXPOSURE TERR RATE PREMIUM # # CODE BASIS PREMIOPS PRODUCTS PREMIOPS PRODUCTS 1 Funeral Horne or 71365 S 100,000 Chapels RATING AND PREMIUM BASIS (P)PAYROLL-PER$1,000/PAY (C)TOTAL COST-PER$1,000/COST (U)UNIT-PER UNIT (S)GROSS SALES-PER$1,000/SALES (A)AREA-PER 1,000/SQ FT (M)ADMISSIONS-PER 1,000/ADM (T)OTHER CLAIMS MADE(Explain all"Yes"responses) EXPLAIN ALL"YES"RESPONSES Y I N 1. PROPOSED RETROACTIVE DATE: 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 3. HAS ANY PRODUCT,WORK,ACCIDENT,OR LOCATION BEEN EXCLUDED,UNINSURED OR SELF-INSURED FROM ANY PREVIOUS COVERAGE? 4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? EMPLOYEE BENEFITS LIABILITY 1. DEDUCTIBLE PER CLAIM: $ 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: 2. NUMBER OF EMPLOYEES: 4. RETROACTIVE DATE: ACORD 126(2016/03) Attach to ACORD 125 ©1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by VXS on October 03,2024 at 11:28AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A CONTRACTORS AGENCY CUSTOMER ID: 00000324 EXPLAIN ALL"YES"RESPONSES(For all past or present operations) Y I N 1. DOES APPLICANT DRAW PLANS,DESIGNS,OR SPECIFICATIONS FOR OTHERS? 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? 3. DO ANY OPERATIONS INCLUDE EXCAVATION,TUNNELING,UNDERGROUND WORK OR EARTH MOVING? 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? DESCRIBE THE TYPE OF WORK SUBCONTRACTED $PAID TO SUB- %OF WORK #FULL- #PART- CONTRACTORS: SUBCONTRACTED: TIME STAFF: TIME STAFF: PRODUCTS/COMPLETED OPERATIONS PRODUCTS ANNUAL GROSS SALES #OF UNITS TIME IN EXPECTED MARKET LIFE INTENDED USE PRINCIPAL COMPONENTS EXPLAIN ALL"YES"RESPONSES)For all pastor present products or operations) PLEASE ATTACH LITERATURE,BROCHURES,LABELS,WARNINGS,ETC. Y I N 1. DOES APPLICANT INSTALL,SERVICE OR DEMONSTRATE PRODUCTS? 2. FOREIGN PRODUCTS SOLD,DISTRIBUTED,USED AS COMPONENTS? (If"YES',attach ACORD 815) N 3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED? 4. GUARANTEES,WARRANTIES,HOLD HARMLESS AGREEMENTS? 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? 6. PRODUCTS RECALLED,DISCONTINUED,CHANGED? 7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL? 8. PRODUCTS UNDER LABEL OF OTHERS? 9. VENDORS COVERAGE REQUIRED? 10.DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS? ACORD 126(2016/03) Page 2 of 4 Printed by VXS on October 03,2024 at 11:28AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A AGENCY CUSTOMER ID:00000324 ADDITIONAL INTEREST/CERTIFICATE RECIPIENT ACORD 45 attached for additional names INTEREST NAME AND ADDRESS RANK:1 EVIDENCE: CERTIFICATE INTEREST IN ITEM NUMBER X ADDITIONAL INSURED ELKS LODGE LOCATION: BUILDING: EMPLOYEE AS LESSOR ITEM ITEM: 92600 OVERSEAS f I CLASS: LENDER'S LOSS PAYABLE Tavernier, FL 33070 ITEM DESCRIPTION LIENHOLDER LOSS PAYEE MORTGAGEE REFERENCE/LOAN#: GENERAL INFORMATION EXPLAIN ALL"YES"RESPONSES(For all past or present operations) Y I N 1. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? 2. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? 3. DOMAVE PAST,PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D)STORING,TREATING.DISCHARGING,APPLYING,DISPOSING,OR N TRANSPORTING OF HAZARDOUS MATERIAL?(e.g.landfills,wastes,fuel tanks,etc) 4. ANY OPERATIONS SOLD,ACQUIRED,OR DISCONTINUED IN LAST FIVE(5)YEARS? 5. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS? EQUIPMENT TYPE OF EQUIPMENT INSTRUCTION GIVEN(YIN) SMALL TOOLS LARGE EQUIPMENT SMALL TOOLS LARGE EQUIPMENT 6. ANY WATERCRAFT,DOCKS,FLOATS OWNED,HIRED OR LEASED? 7. ANY PARKING FACILITIES OWNED/RENTED? 8. IS A FEE CHARGED FOR PARKING? 9. RECREATION FACILITIES PROVIDED? 10. ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? (If"YES",answer the following): #APTS TOTAL APT AREA [DE"BE OTHER LODGING OPERATIONS Sq.Ft. 11. IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply) APPROVED FENCE 7 LIMITED ACCESS 7 DIVING BOARD SLIDE ABOVE GROUND 7 IN GROUND F LIFE GUARD 12. ARE SOCIAL EVENTS SPONSORED? 13. ARE ATHLETIC TEAMS SPONSORED? LEITEN F SPORT CONTACT TYPE OF SPORT CONTACT SPORT(YIN) AGEGROUP 13-18 SPORT(Y/N) AGE GROUP 13-1812&UNDER OVER 18 12&UDER OVER 18 T OF SPONSORSHIP: EXTENT OF SPONSORSHIP: 14. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? 15. ANY DEMOLITION EXPOSURE CONTEMPLATED? ACORD 126(2016/03) Page 3 of 4 Printed by VXS on October 03,2024 at 11:28AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A GENERAL INFORMATION(continued) AGENCY CUSTOMER ID:00000324 EXPLAIN ALL"YES"RESPONSES(Far all past or present operations) Y I N 16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? 17. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? WORKERS WORKERS LEASE TO COMPENSATION LEASE FROM COMPENSATION COVERAGE CARRIED(YIN) COVERAGE CARRIED(Y/N) 18. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? 19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? 20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE(3)YEARS? 21. IS THERE A FORMAL,WRITTEN SAFETY AND SECURITY POLICY IN EFFECT? 22. DOES THE BUSINESSES'PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? REMARKS(ACORD 101,Additional Remarks Schedule,may be attached if mores ace is required) SIGNATURE Applicable in AL,AR, DC, LA, MD, NM, RI and WV:Any person who knowingly(or willfully)*presents a false or fraudulent claim for payment of a loss or benefit or knowingly(or willfully)*presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.*Applies in MD Only. Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false,incomplete,or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall b reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,incomplete,or misleading information is guilty of a felony(of the third degree)*.*Applies in FL Only. Applicable in KS: Any person who,knowingly and with intent to defraud,presents,causes to be presented or prepares with knowledge or belief that it will b presented to or by an insurer, purported insurer,broker or any agent thereof,any written statement as part of,or in support of,an application for the issuanc of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy fo commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals,forth purpose of misleading,information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,which is a crime and subjects such person to criminal and civil penalties(not to exceed five thousand dollars an the stated value of the claim for each such violation)*.*Applies in NY Only. Applicable in ME,TN,VA and WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties(may)*include imprisonment,fines and denial of insurance benefits.*Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: Any person who knowingly and with the intention of defrauding presents false information in an insurance application,or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit,or presents more than one claim for the same damage or loss, shall incur a felony and,upon conviction,shall be sanctioned for each violation by a fine of not less than five thousand dollars($5,000)and not more than to thousand dollars($10,000),or a fixed term of imprisonment for three(3)years,or both penalties. Should aggravating circumstances[be]present,the penalt thus established may be increased to a maximum of five (5)years, if extenuating circumstances are present, it may be reduced to a minimum of two (2) ears. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HE KN WLEDGE. P O UCER'S GNAT E * PRODUCER'S NAME(Please Print) STATE PRODUCER LICENSE NO (Required in Florida) .ned VXS Vanessa Smith 008784 APPLIC NT' GNATU R�„ 1 F�ZOZ4 NATIONAL PRODUCER NUMBER ACOR OM IIL/tt/rUr LSY4V185 Page 4 of 4 Printed by VXS on October 03,2024 at 11:28AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A AGENCY CUSTOMER ID: 00000324 DATE(MMIDD/YYYY) A V ADDITIONAL INTEREST SCHEDULE -- 09/25/2024 AGENCY CARRIER NAIC CODE G13, LLC d a The Morgan Insurance Group < rospect> POLICY NUMBER EFFECTIVE DATE NAMED INSURED(S) 10/27/2024 Allen-Beyer Funeral Horne ADDITIONAL INTEREST Not all fields apply to all scenarios-provide only the necessary data INTEREST NAME AND ADDRESS RANK:2 EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LOSS PAYEE LOCATION: BUILDING:U U I BREACH OF MORTGAGEE AND DISBURSEMENT CENTER VEHICLE: BOAT: WARRANTY CO-OWNER OWNER 14925 KINGSPORT RD AIRPORT: AIRCRAFT: EMPLOYEE REGISTRANT Fort Worth TX 76155 SCHED A: ITEM: AS LESSOR LEASEBACK TRUSTEE ITEM CLASS: OWNER LENDER'S LOSS PAYABLE ITEM DESCRIPTION LIENHOLDER REFERENCE I LOAN#: INTEREST END DATE: LIEN AMOUNT: PHONE(A/C,No,Ext): REASON FOR INTEREST: E-MAIL ADDRESS: INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LOSS PAYEE LOCATION: BUILDING: INSURED BREACH OF MORTGAGEE VEHICLE: BOAT: WARRANTY CO-OWNER OWNER AIRPORT: AIRCRAFT: EMPLOYEE REGISTRANT SCHEDW: ITEM: AS LESSOR LEASEBACK TRUSTEE ITEM CLASS: OWNER LENDER'S LOSS PAYABLE ITEM DESCRIPTION LIENHOLDER REFERENCE I LOAN N: INTEREST END DATE: LIEN AMOUNT: PHONE(A/C,No,Ext): REASON FOR INTEREST: E-MAIL ADDRESS: INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LOSS PAYEE LOCATION: BUILDING: INSURED BREACH OF MORTGAGEE VEHICLE: BOAT: WARRANTY CO-OWNER OWNER AIRPORT: AIRCRAFT: EMPLOYEE REGISTRANT SCHED A: ITEM: AS LESSOR LEASEBACK TRUSTEE ITEM CLASS: OWNER LENDER'S LOSS PAYABLE ITEM DESCRIPTION LIENHOLDER REFERENCE I LOAN#: INTEREST END DATE: LIEN AMOUNT: PHONE(A/C,No,Ext): REASON FOR INTEREST: E-MAIL ADDRESS: INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LOSS PAYEE LOCATION: BUILDING: INSURED BREACH OF MORTGAGEE VEHICLE: BOAT: WARRANTY CO-OWNER OWNER AIRPORT: AIRCRAFT: EMPLOYEE REGISTRANT SCHED#: ITEM: AS LESSOR LEASEBACK TRUSTEE ITEM CLASS: OWNER LENDER'S LOSS PAYABLE ITEM DESCRIPTION LIENHOLDER REFERENCE I LOAN#: INTEREST END DATE: LIEN AMOUNT: PHONE(A/C,No,Ext): REASON FOR INTEREST: E-MAIL ADDRESS: INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LOSS PAYEE LOCATION: BUILDING: INSURED BREACH OF MORTGAGEE VEHICLE: BOAT: WARRANTY CO-OWNER OWNER AIRPORT: AIRCRAFT: EMPLOYEE REGISTRANT SCHED 4: ITEM: AS LESSOR LEASEBACK TRUSTEE ITEM CLASS: OWNER LENDER'S LOSS PAYABLE ITEM DESCRIPTION LIENHOLDER REFERENCE I LOAN N: INTEREST END DATE: LIEN AMOUNT: PHONE(A/C,No,Ext): REASON FOR INTEREST: E-MAIL ADDRESS: ACORD 45(2016/03) ©1993-2016 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by VXS on October 03,2024 at 11:28AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A AGENCY CUSTOMER ID: 00000324 DATE(MMIDD/YYYY) AC"RV PROPERTY SECTION .- 09/25/2024 AGENCY NAME CARRIER NAIC CODE M G13, LLC dba The Morgan Insurance Group < ros eot> POLICY NUMBER EFFECTIVE DATE NAMED INSURED(S) 10/27/2024 Allen-Beyer Funeral Horne BLANKET SUMMARY BLKT# AMOUNT TYPE BLKT# AMOUNT TYPE PREMISES#: 01 STREET ADDRESS: 101640 Oversees Hwy Key Largo FL 33037 PREMISES INFORMATION BUILDING#: 01 BLDG DESCRIPTION:FUneral Home SUBJECT OF INSURANCE AMOUNT COINS%ATAION CAUSES OF LOSS (GUARD%NFLAON DED DED TYPE B#KT FORMS AND CONDITIONS TO APPLY Contents 56000 50 FCC Spec 500 Business Income/EE 75000 1/3 ADDITIONAL INFORMATION BUSINESS INCOME I EXTRA EXPENSE-Attach ACORD 81D VALUE REPORTING INFORMATION-Attach ACORD 811 ADDITIONAL COVERAGES,OPTIONS,RESTRICTIONS,ENDORSEMENTS AND RATING INFORMATION SPOILAGE DESCRIPTION OF PROPERTY COVERED LIMIT REFRIG MAINT OPTIONS COVERAGE (Y I N) $ AGREEMENT BREAKDOWN OR CONTAMINATION (YIN)❑ DEDUCTIBLE ❑ POWER OUTAGE SELLING PRICE SINKHOLE COVERAGE(Required in Florida) ACCEPT COVERAGE REJECT COVERAGE LIMIT: $ MINE SUBSIDENCE COVERAGE(Required in IL,IN,KY and WV) ACCEPT COVERAGE REJECT COVERAGE LIMIT: $ PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK #OF OPEN SIDES ON STRUCTURE: CONSTRUCTION TYPE DISTANCE TO FIRE DISTRICT CODE NUMBER PROT CL #STORIES #BASM'TS YR BUILT TOTAL AREA HYDRANT FIRE STAT FT MI BUILDING IMPROVEMENTS BLDG CODE TAX CODE ROOF TYPE OTHER OCCUPANCIES GRADE WIRING,YR: PLUMBING,YR: ROOFING,YR: HEATING,YR: WIND CLASSaSEMI-RESISTIVE HEATING SOURCE INCL WOODBURNING DATE STOVE OR FIREPLACE INSERT INSTALLEDOTHER: YR: RESISTIV MANUFACTURER: PRIMARY HEAT SECONDARY HEAT BOILER SOLID FUEL BOILER Ll SOLID FUEL IF BOILER,IS INSURANCE PLACED ELSEWHERE? Y/N IF BOILER,IS INSURANCE PLACED ELSEWHERE? Y/N RIGHT EXPOSURE&DISTANCE LEFT EXPOSURE&DISTANCE FRONT EXPOSURE&DISTANCE REAR EXPOSURE&DISTANCE BURGLAR ALARM TYPE CERTIFICATE# EXPIRATION DATE CENTRAL LOCAL STATION GONG WITH KEYS BURGLAR ALARM INSTALLED AND SERVICED BY EXTENT GRADE #GUARDS I WATCHMEN I CLOCK HOURLY PREMISES FIRE PROTECTION(Sprinklers,Standpipes,CO2I Chemical Systems) /SPRNK FIRE ALARM MANUFACTURER CENTRAL STATION LOCAL GCNG ADDITIONAL INTEREST ACORD 45 attached for additional names INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE INTEREST IN ITEM NUMBER LENDER'S LOSS PAYABLE ELKS LODGE LOCATION: 01 BUILDING: ®1 LOSS PAYEE 92600 OVERSEAS H T SS: ITEM: MORTGAGEE Tavernier FL 33070 ITEM DESCRIPTION X Al REFERENCE/LOAN#: ACORD 140(2016/03) Attach to ACORD 125 ©1985-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD Printed by VXS on October 03,2024 at 11:28AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A AGENCY CUSTOMER ID: 00000324 ADDITIONAL PREMISES#. STREET ADDRESS: PREMISES INFORMATION BUILDING#: BLDG DESCRIPTION: SUBJECT OF INSURANCE AMOUNT COINS%VALU- CAUSES OF LOSS INFLATION DED DED BLKT FORMS AND CONDITIONS TO APPLY ATION GUARD/. TYPE # ADDITIONAL INFORMATION BUSINESS INCOME I EXTRA EXPENSE-Attach ACORD 810 VALUE REPORTING INFORMATION-Attach ACORD 811 ADDITIONAL COVERAGES,OPTIONS,RESTRICTIONS,ENDORSEMENTS AND RATING INFORMATION SPOILAGE DESCRIPTION OF PROPERTY COVERED LIMIT REFRIG MAINT OPTIONS COVERAGE AGREEMENT (YIN) $ (Y I N) BREAKDOWN OR CONTAMINATION ❑ DEDUCTIBLE ❑ POWER OUTAGE ❑ SELLIN PRICE G SINKHOLE COVERAGE(Required in Florida) ACCEPT COVERAGE REJECT COVERAGE LIMIT: $ MINE SUBSIDENCE COVERAGE(Required in IL,IN,KY and WV) ACCEPT COVERAGE REJECT COVERAGE LIMIT: $ PROPERTY HAS BEEN DESIGNATED AN HISTORICAL LANDMARK #OF OPEN SIDES ON STRUCTURE: CONSTRUCTION TYPE DISTANCE TO FIRE DISTRICT CODE NUMBER PROT CL #STORIES #BASM'TS YR BUILT TOTAL AREA HYDRANT FIRE STAT FT MI BUILDING IMPROVEMENTS BLDG CODE TAX CODE ROOF TYPE OTHER OCCUPANCIES GRADE WIRING,YR: PLUMBING,YR: ROOFING,YR: HEATING,YR: WIND CLASS SEMI-RESISTIVE HEATING SOURCE INCL WOODBURNING DATE STOVE OR FIREPLACE INSERT INSTALLED: OTHER: YR: RESISTIVE MANUFACTURER: PRIMARY HEAT SECONDARY HEAT BOILER ❑SOLID FUEL ❑ BOILER ❑SOLID FUEL ❑ IF BOILER,IS INSURANCE PLACED ELSEWHERE? Y/N IF BOILER,IS INSURANCE PLACED ELSEWHERE? Y/N RIGHT EXPOSURE&DISTANCE LEFT EXPOSURE&DISTANCE FRONT EXPOSURE&DISTANCE REAR EXPOSURE&DISTANCE BURGLAR ALARM TYPE CERTIFICATE# EXPIRATION DATE H CENTRAL LOCAL STATION GONG WITH KEYS BURGLAR ALARM INSTALLED AND SERVICED BY EXTENT GRADE #GUARDS I WATCHMEN d CLOCK HOURLY PREMISES FIRE PROTECTION(Sprinklers,Standpipes,CO2/Chemical Systems) %SPRNK FIRE ALARM MANUFACTURER CENTRAL STATION LOCAL GONG ADDITIONAL INTEREST ACORD 45 attached for additional names INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE INTEREST IN ITEM NUMBER LENDER'S LOSS PAYABLE US SMALL BUSINESS ADMINISTRATION PROCESSING LOCATION01 BUILDING:01 X LOSS PAYEE AND DISBURSEMENT CENTER T Ss: ITEM: MORTGAGEE 14925 K NGSPO T RD ITEM DESCRIPTION Ford Worth TX 76155 REFERENCE/LOAN#: REMARKS ACORD 101,Additional Remarks Schedule,may be attached if mores ace is required) ACORD 140(2016/03) Page 2 of 3 Printed by VXS on October 03,2024 at 11:28AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A SIGNATURE AGENCY CUSTOMER ID: 00000324 Applicable in AL,AR,DC,LA,MD, NM,RI and WV Any person who knowingly (or willfully)` presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)' presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. `Applies in MD Only. Applicable in CO It is unlawful to knowingly provide false,incomplete,or misleading facts or information to an insurance company for the purpose of defrauding or attempting t defraud the company. Penalties may include imprisonment,fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding o attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorad Division of Insurance within the Department of Regulatory Agencies. Applicable in FL and OK Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete,or misleading information is guilty of a felony(of the third degree)'. 'Applies in FL Only. Applicable in KS Any person who, knowingly and with intent to defraud,presents, causes to be presented or prepares with knowledge or belief that it will be presented to or b an insurer,purported insurer, broker or any agent thereof,any written statement as part of,or in support of,an application for the issuance of,or the rating o an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or persona insurance which such person knows to contain materially false information concerning any fact material thereto, or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY,NY,OH and PA Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,which is a crime and subjects such person to criminal and civil penalties'(not to exceed five thousand dollars and the stated value of the claim for each such violation)'.'Applies in NY Only. Applicable in ME,TN,VA and WA It is a crime to knowingly provide false,incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties (may)'include imprisonment,fines and denial of insurance benefits. "Applies in ME Only. Applicable in NJ Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as t any material fact may be violating state law. Applicable in PR Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents, helps, or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit, or presents more than one claim for the same damage or loss,shall incur felony and, upon conviction, shall be sanctioned for each violation by a fine of not less than five thousand dollars ($5,000) and not more than ten thousan dollars ($10,000), or a fixed term of imprisonment for three (3)years, or both penalties. Should aggravating circumstances [be] present, the penalty thu established may be increased to a maximum of five(5)years,if extenuating circumstances are present,it may be reduced to a minimum of two(2)years. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HE KNOWLEDGE. PR DUCER'S S NAT RE PRODUCER'S NAME(Please Print) STATE PRODUCER LICENSE NO (Required in Florida) VXS Vanessa Smith D000704 APPLICA §90AT91kF: l91/E T3/2024 NATIONAL PRODUCER NUMBER ACOREdAVAORA7485 Page 3 of 3 Printed by VXS on October 03,2024 at 11:28AM Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A Surplus Lines Disclosure Form Instructions This form is designed to provide guidance based on the statutory requirements for such form and it has not been approved by the Florida Department of Financial Services.This is a suggested form; however the law requires that the following language be included in the form and that the insured sign the form: "As required by Florida Statute 626.916, 1 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." The statute does not require the retail/producing agent to sign the form. However,the retail/producing agent should keep the original signed form in the insured's file in the event of a future E&O claim. The statute clearly states that if the form is signed by the insured that the insured is presumed to have been informed and to know that other coverage may be available and that the retail/producing agent has no liability for placing the policy in the surplus lines market. Some surplus lines brokers may ask for copies of these forms, but they are not required by statute to obtain or maintain these forms. Retail/producing agents may choose to comply with their requests for copies of the forms, but agents and brokers should note that the Florida Surplus Lines Service Office will not be looking for copies of these forms during compliance reviews of the files of surplus lines brokers. Only when a surplus lines broker acts in both a retail/producing agent capacity and a surplus lines broker capacity on a given risk/policy should the broker maintain a copy of this form. Please click on the link below to access the Diligent/Effort Matrix: , ,Il.s,;;,, ,f ,;�;",, ,,,,,. Ir „ ,D ,ai,,ilrm, ,,s„�,,, a,lr,lrr�„, ,� ,«�;t,rb( Docusign Envelope ID:980A341A-FDCC-452D-BFAB-01EF6964417A Surplus Lines Disclosure and Acknowledgement Morgan Insurance Group At my direction, has placed my coverage in the surplus lines market. As required by Florida Statute 626.916, 1 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. Allen-Beyer Funeral Home Named Insured By: Signed by: I� Q" 10/3/2024 Signature of Named Insured Date Printed Name and Title of Person Signing Century Insurance Group Name of Excess and Surplus Lines Carrier Type of Insurance 10/27/2024 Effective Date of Coverage 0110112022 1 Florida Surplus Lines Service Office