arturo guevara a and j roofing · classifications: 98678 - roofer (residential) 98677 - roofer...

Quote 118117

ARTURO GUEVARAA AND J ROOFING

310-487-1806

Cover Page and Binding Instructions

Insurance Carrier: United Specialty Insurance Co. administered by UCISG (760) 345-9029Underwriter: Kevin McMullen

Retail Brokerage: Zone Insurance Services 323-518-2750Broker / Rep: Adrian Agredano

STEP 1 - Review, Sign, and Collect requirementsSigned ApplicationSigned Endorsements (if selected)Signed No Loss LetterSigned Finance AgreementPayment in the amount of: $2,476.80

STEP 2 - Upload, Email, or Fax request to (760) 345-9028Upload or email signed copy to your underwriter

Underwriter will review your submission and bind

STEP 3 - Policy issued via emailPolicy will be emailed to: [email protected]

STEP 4 - Payment Options

STEP 5 - Send UCIA Check Authorization form for amount due at time of binding.

PAY-IN-FULL $2,476.80 LOW-DOWN PFA $495.36 3RD PARTY PFA $876.80

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Coverage - Pricing - Payment Information

PRICING IS VALID FOR 30 DAYS FROM: 9/9/2013COMMERCIAL GENERAL LIABILITY

EACH OCCURRENCE LIMIT $1,000,000GENERAL AGGREGATE LIMIT $2,000,000HOT TAR & TORCHDOWN $100,000 SUBLIMITFIRE CAUSED BY HEATING DEVICE $100,000 SUBLIMITPRODUCTS/COMPLETED OPERATIONS $1,000,000PERSONAL & ADVERTISING INJURY $1,000,000FIRE LEGAL LIABILITY $50,000MEDICAL PAYMENT LIMIT $5,000

DEFENSE EXPENSES AS THE TERM IS DEFINED IN THE POLICY ARE INCLUDED WITHIN THEINDEMNITY LIMITS AS DEFINED IN THE POLICY

RATING INFORMATIONBASED ON GROSS RECEIPTS/SALES: $70,000SIR (PER CLAIM) $5,000SUNSET TERM: Yes NoPOLICY TERM: 1 YearCLASSIFICATIONS: 98678 - ROOFER (RESIDENTIAL)

98677 - ROOFER (COMMERCIAL)

PRICING INFORMATIONPREMIUM $2,000.00POLICY FEES $400.00ENDORSEMENTS $0.00SURPLUS LINES TAX $72.00STAMPING FEE $4.80PLACEMENT FEE $0.00BROKER FEE $0.00

TOTAL: $2,476.80

DOWN PAYMENT, TAX & FEES DUE WITHIN 10 DAYS OF EFFECTIVE DATE OR CANCELLATION NOTICE WILL BE SENT.

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Endorsements Selected

Please note these endorsements were selected for this policy at bind.

Endorsement Name Form #UCISG-CGL-DEC1Declarations PageUCISG-CGL-DEC2Supplemental Declarations PageUCISG-CGL-SCHSchedule of Forms and EndorsementsUSI PRIVACY STATEMENTUSI Privacy StatementUSI SIGNATURE PAGEUSI Signature PageUCISG-CGL-SOSService of SuitCA D2California D-2 Surplus Lines NoticeIL0021Nuclear Energy Liability Exclusion EndorsementCG2184Exclusion of Certified Nuclear, Biological, Chemical or Radiological Acts of TerrorismCG2170Cap on Losses from Certified Acts of TerrorismUCISG-BIP-1Bodily Injury on Property Owned by InsuredUCISG-BAI-1Blanket Additional Insured EndorsementUCISG-CGLCommercial General Liability Coverage Form

ADDITIONAL ENDORSEMENTS ARE AVAILABLE, CONTACT YOUR UNDERWRITER FOR MORE DETAILS.

of 6UCISG-CGL-APPForm Edition 05/10/13

©UCISG All rights reserved

Quote 118117


310-487-1806

Application - Page 1 of 6

INSURED'S INFORMATIONEffective Date: 9/7/2013Applicant: ARTURO GUEVARADBA: A AND J ROOFINGContact: ARTURO GUEVARAPhysical Address: 1202 W Bennett StCity, St Zip Compton, CA 90220Telephone / Fax: 310-487-1806Email Address: [email protected]'s license #:Business Type: Individual

WORK EXPERIENCE:States in which you do business: CALIFORNIAYears in business for yourself: 7Years in profession: 12Detail Description of Operation:

ROOFING

EXPOSURES:a. Gross Receipts for the next 12 months? $70,000b. What are the Gross Receipts for the last 12 months? $80,000c. What are your "Insured" subcontractor costs for the next 12 months? $0d. What is payroll for the next 12 months? $30,000e. Number of field employees? 2

WORK EXPERIENCE:Percentage of work Performed:

Residential Commercial New Track Remodel/Repair/Service90 10

Describe your largest project in the last 5 years:

Have you been involved or do you subcontract any work involving blasting operations,hazardous waste, asbestos, mold, PCB's or medical and/or industrial life? Yes No



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WORK EXPERIENCE: (continued)Do you use subcontractors? Yes NoDo you do any work for condominium or townhouse associations? Yes NoDo you do OCIP (Wrap-up) work? Yes NoAny work performed for a fee or with labor and/or material costs paid by others? Yes NoHave you allowed or will you allow your license to be used by any other contractor? Yes NoHas any lawsuit ever been filed, or any claim otherwise been made against yourcompany of any partnership or joint venture of which you have been a member of yourcompany's predecessors in business, or against any person, company or entities onwhose behalf your company has assumed liability?

Yes No

Is your company aware of any facts, circumstances, incidents, situations, damages oraccidents (including but not limited to: faulty or defective workmanship, product failure,construction dispute, property damage or construction worker injury) that a reasonablyprudent person might expect to give rise to a claim or lawsuit, whether valid or not, whichmight directly or indirectly involve the company?

Yes No



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SUPPLEMENTAL QUESTIONS: (work in progress)Yes NoDo you have a project in progress for which you are seeking coverage under this application?

SUPPLEMENTAL QUESTIONS: (litigation against applicant's)Within the past 4 years have you filed any lawsuits and/or arbitration actions against any ofyour customers for nonpayment of your services and/or materials you supplied?

Yes No

X HAS NO LOSSES



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Application Signature Pages - Page 4 of 6

The policy you are applying for is issued by a Surplus Lines Carrier. The Surplus Lines Carrier may not besubject to all of the insurance laws and regulations of your State. State insurance insolvency guaranty funds arenot available for a Surplus Lines Carrier.

The Applicant acknowledges that Applicant has read or has had the opportunity to read a sample of the Policy form thatwill be issued to the Applicant as well as commonly used endorsements. The Applicant further acknowledges that thesample may not contain all of the endorsements, restrictions that may be ultimately issued to the Applicant. The Applicantfurther acknowledges that a copy of the Policy form and commonly used endorsements has been made available toApplicant’s broker. Further the Applicant acknowledges that a copy of the UCISG Policy form and commonly usedendorsements are available for review by either the Applicant or the Applicant’s broker by contacting United ContractorsInsurance Agency at (760) 345-9029 or [email protected].

Applicant’s Initials:

THERE ARE EXCLUSIONS, RESTRICTIONS, SUBLIMITS AND CONDITIONS IN THE POLICY THAT LIMITCOVERAGE. SOME, BUT NOT ALL OF THESE ARE TITLED AS FOLLOWS:.

b DEFENSE COSTS REDUCE INDEMNITY LIMITSb BINDING ARBITRATION CLAUSEb SELF INSURED RETENTIONb TORCH AND HOT TAR SUBLIMIT OF $100,000b ·HEATING DEVICE SUBLIMIT OF $100,000b ·SOME OF THE EXCLUSIONS

○ SUB-CONTRACTOR RELATED CLAIMS UNLESS INDEMNITEE AGREEMENTS, CERTIFICATES EVIDENCING QUALOR GREATER LIMITS AND ADDITIONAL INSURED STATUS ARE OBTAINED PRIOR TO COMMENCEMENT OFWORK

○ OPEN ROOF WATER DAMAGE EXCLUSION○ TOTAL POLLUTION○ VARIOUS MATERIAL, BIOLOGIC AND RADIATION EXCLUSIONS: ASBESTOS; CHROMATER COPPER ARSENATE;

CONCRETE SULFATES; ELECTROMAGNETIC RADIATION; LEAD; MOLD; BACTERIA AND OTHER ORGANICALLY-CAUSED DAMAGES; CHINESE DRYWALL AND OTHER IMPORTED BUILDING MATERIALS; FIBERGLASS;FORMALDEHYDE; ARSENIC; FIRE RETARDANT TREATED PLYWOOD; ENTRAN PIPE; CCA WOODPRESERVATIVES; AIRBORNE MANGANESE; DIOXIN; SILICA; MIXED DUST; POLYCHLORINATED BIPHENYLS;TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHY; COMMUNICABLE DISEASE

○ EARTH MOVEMENT○ BLASTING OPERATIONS○ LIABILIITY TO EMPLOYEES (ACTION OVER)○ EXTERIOR INSULATION AND FINISH SYSTEMS (E.I.F.S)○ PAST PROJECTS/PRIOR WORK○ JOBS IN PROGRESS REQUIRE ENDORSEMENT○ CONDOMINIUM AND TOWNHOUSE EXCLUSION EXCEPT FOR REPAIR TO INDIVIDUAL UNIT FOR UNIT OWNER○ WRAP-UP/OCIP○ EXCAVATION FOR OTHER THAN SINGLE FAMILY HOUSING, AND EXCAVATION OVER 8'○ FOUNDATION REPAIR○ GREEN BUILDING○ MULTIFAMILY DWELLINGS IN EXCESS OF 15 UNITS○ TRACTS IN EXCESS OF 15 HOMES○ NON-COMPLIANCE WITH BUILDING CODES○ UNLICENSED WORK○ PROFESSIONAL LIABILITY○ SINGLE JOBS OVER 50% ESTIMATED ANNUAL REQUIRE AN ENDORSEMENT○ TERMINATION OF COVERAGE FOR FAILURE TO PAY OR COOPERATE WITH AUDIT

The Applicant further acknowledges the Policy has other restrictions in coverages.




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The Applicant authorizes the Broker to sign on behalf of the Applicant any documents modifying the terms and conditionsof the policy including but not limiting to the purchase of additional endorsements, changes in coverage including policylimits, and the execution of any documents necessary to obtain a renewal and/or extension of the policy.


The Applicant warrants that after inquiry, no one employed by or associated with Applicant is aware of any complaints,allegations, demand for payment of money or the performance of services, claims, incidents, potential claims, acts, errors,omissions, facts, circumstances, situations, events or transactions that could reasonably result in a claim or lawsuit beingpresented against Applicant or anyone employed by or associated with Applicant

The Applicant warrants that the above statements and particulars, together with any attached or appended documents ormaterials (this application), are true and complete, and do not misrepresent misstate, or omit any material facts.Furthermore, the Applicant authorizes UCISG as administrative and servicing manager, to make any investigation andinquiry in conjunction with the application as it may deem necessary. The Applicant agrees to notify UCISG of anymaterial changes in the answers to the questions on this application which may arise prior to the effective date of ourPolicy issued in pursuant to this application and the Applicant understands that any outstanding quotations may bemodified or withdrawn based upon such changes at the sole discretion of UCISG.

The Applicant further understands that, if a Policy is issued, this Application will be incorporated into and form a part ofsuch Policy and any false information provided in this application will result in nullification of the Policy. The Applicantunderstands that information contained herein is specifically relied upon by UCISG in the issuance of the Policy. Theundersigned, therefore, warrants that the information contained herein is true and correct. The Applicant understands thatmisrepresentation or omission shall constitute grounds for either an early cancellation or denial of coverage of claims, ifany. It is understood that the Applicant and or affiliated companies are under a continuing obligation to immediately notifyUCISG of any material alteration of the information given. The Applicant also acknowledges, that the Applicant has notsustained a loss nor has any claim been made against the Applicant within the last 5 years unless otherwise disclosed inthis application.


The Applicant understands that if the Applicant utilizes the premium finance arrangement provided through UCISG theprogram & filing fees, inspection fee and agency fee will be fully earned and Applicant is responsible for and will guarantythose payments.




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Notwithstanding any of the foregoing, the Applicant understands UCISG is not obligated nor under any duty toissue a Policy of insurance based upon this application. UCISG is relying on the statements in issuing the policy.The Applicant's statements are material and truthful. The applicant is signing this statement under penalty ofperjury.

NOTICE: In some states, any person who knowingly, and with the intent to defraud any insurance company or otherperson, files an application for insurance or statement of claim containing any materially false information, or, for thepurpose of misleading, conceals information concerning any fact material thereto, may commit a fraudulent insuranceact which is a crime in many states.

Please bind per quote with the effective date of 9/7/2013

Date:__________________

Signature of Applicant:_________________________________________

Title (Owner, Office, Partner):___________________________________________________

UCISG Notice of Terrorism

NOTICE OF TERRORISM INSURANCE COVERAGE

I

You are hereby notified that under the federal Terrorism Risk Insurance Act, as amended ("the Act"), the Company

must make available insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of

the Act. This policy includes such coverage for damages arising out of certified acts of terrorism and is limited by

the terms, conditions, exclusions, limits, other provisions of the coverage quote or renewal

application/questionnaire to which this offer is attached and by the policy, any endorsements to the policy and

The term "act of terrorism" means any act that is certified by the Secretary of the Treasury, in concurrence with the

Secretary of State, and the Attorney General of the United States to be an act of terrorism; to be a violent act or an

act that is dangerous to human life, property, or infrastructure; to have resulted in damage within the United States,

or outside the United States in the case of an air carrier or vessel or the premises of a United States mission; and to

have been committed by an individual or individuals as part of an effort to coerce the civilian population of the

United States or to influence the policy or affect the conduct of the United States Government by coercion.

YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES RESULTING

FROM CERTIFIED ACTS OF TERRORISM, SUCH LOSSES MAY BE PARTIALLY REIMBURSED BY

THE UNITED STATES GOVERNMENT UNDER A FORMULA ESTABLISHED BY FEDERAL LAW.

UNDER THE FORMULA, THE UNITED STATES GOVERNMENT GENERALLY REIMBURSES 85% OF

COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE

NO PREMIUM IS CHARGED FOR THIS COVERAGE NOR IS ANY CHARGE MADE FOR THE

PORTION OF LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDER THE

YOU SHOULD ALSO KNOW THAT THE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S

GOVERNMENT REIMBURSEMENT, AS WELL AS INSURERS' LIABILITY FOR LOSSES, RESULTING FROM

CERTIFIED "ACTS OF TERRORISM" WHEN THE AMOUNT OF SUCH LOSSES IN ANY ONE CALENDAR YEAR

EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED $100 BILLION,

YOUR COVERAGE MAY BE REDUCED.

COVERAGE FOR "INSURED LOSSES" AS DEFINED IN THE ACT IS SUBJECT TO THE COVERAGE

TERMS, CONDITIONS, AMOUNTS AND LIMITS IN THIS POLICY APPLICABLE TO LOSSES ARISING

FROM EVENTS OTHER THAN "ACTS OF TERRORISM".

INSTRUCTIONS FOR COMPLETING CALIFORNIA SL-2 FILING

SECTION 1: Please provide the full name of the licensed individual who performed or supervised the diligent search. Ifthe search was performed under the individual's license number, enter his/her license number in section (A) or if theindividual was authorized as an endorsee under an organizational license, enter the name of the organization and itslicense number in section (B).

SECTION 6: Please provide a complete response on section (A). Note: The Insurance Commissioner or his designeemay require the surplus line broker to conduct a further or additional search among admitted insurers for similarplacements in the future. [California Insurance Code Section 1763(b)] An incomplete response may unnecessarily resultin a request for a further search to be conducted. If the individual named on line 1 did not perform the diligent search,please provide the full name of the individual who performed the search on section (B).

SECTION 7(B): To avoid mis-identification among insurers with similar names, please provide the complete name of theadmitted insurer as listed in the CDI Official Publication of Admitted Companies.

Insurer group names, such as Cigna Group, Chubb Group, California Ins. Group, Hartford Group, etc., are acceptable ifthe person performing the search verifies that the representative of the group, who declines the risk, does in factrepresent an admitted insurer in the group that actually writes the particular type of insurance being sought. (For a list goto http://www.sla-cal.org/ You will find a look up site under Fast Link on the left of the page.)

IMPORTANT: Persons who are licensed only as an agent may only submit a risk to admitted insurers that have appointedthem as their agent. Agents are not authorized to offer a risk to admitted insurers for which they are not appointed agents.A search which is limited to only those companies that have appointed the agent may not necessarily constitute a diligentsearch of the admitted market.

CODE TYPE OF INSURANCE CODE TYPE OF INSURANCE This list does not include those coverages on the exportlist.

050 Auto Liability-Private051 Auto Liability-Commercial100 Auto Physical Damage-Private101 Auto Physical Damage-Commercial150 Crime151 Crime-Kidnap & Ransom200 Combined Auto Liability & P.D.-Private201 Combined Auto Liability & P.D.-Comm.300 Excess Liability (Incl. Umbrella)350 Fidelity Surety & Bonds-Bonds351 Fidelity Surety & Bonds-Fidelity400 Fire-Single Family Dwelling, Duplex401 Fire-Commercial402 Fire-Homeowners403 Fire-Homeowners Multiple Peril404 Fire-Farm Owners Multiple Peril414 Residential Earthquake450 Inland Marine500 General Liability501 Gen. Liability-Pollution Legal Liability502 General Liability-Product Tampering

510 Aviation550 Errors & Omissions-All Others551 Errors & Omission-Directors & Officers600 Malpractice-All Other606 Malpractice-Hospitals650 Miscellaneous651 Miscellaneous-Glass652 Miscellaneous-Boiler & Machinery653 Miscellaneous-Nuclear Risks655 Miscellaneous-Political Risks700 Accident701 Accident-Disability Income702 Accident-Group Health Ins.703 Accident-Ind. Health Ins.800 Garage Liability980 Excess Workers Compensation990 Commercial Property-All Risk994 Commercial Property-Special Multi-Peril996 Commercial Property-DIC997 Commercial Property-Earthquake998 Commercial Property-Terrorism999 Commercial Property-Special Multi-Peril

MOST COMMON MISTAKES MADEPlease make sure your binding request contain an accurate SL-2. The following are the most common SL-2 errors:

1. Full name of individual submitting the SL-2 (Section 1)2. Address of insured matches address on Acord application (Section 2)3. Sufficient and adequate diligent efforts were taken (Section 6)4. Full name of admitted company (Section 7) See above under section 7(B) for the most updated current list.5. First & last name of company representative AND telephone number (Section 7)6. Signature of licensee match name on line 1 and dated

DILIGENT SEARCH REPORT(Please Refer to the Instructions on Page 3 of This Form)

1. hereby submits that he/she is:(Full Name of the Individual)

(A) Duly licensed under California Department of Insurance license number ;,

OR (B) Duly licensed and authorized to act as an endorsee on the organizational license of, California Department of Insurance license number ;,

(Name of Organization)

an (C) that he/she or said organization licensee was engaged by the insured named herein, or the insured's broker, toobtain insurance as described in this report;

an (D) is the licensee who performed or supervised this diligent search.

2. (A) Name of Insured ARTURO GUEVARA

(B) Address of Insured 1202 W Bennett St(Street and Number)

Compton, CA 90220(City) (State) (Zip Code)

(C) Description of the Risk(e.g. Laundromat, Liquor Store, -NOT TYPE OF

(D) Location of Risk 1202 W Bennett St(Street and Number)

Compton, CA 90220(City) (State) (Zip Code)

(E) Type of Insurance coverage(Enter Appropriate Code Number from Pg. 3)

3. If Private Passenger Automobile Liability Insurance is identified on line 2(E), complete the following:(A) Does the insured qualify as a "Good Driver" under Section 1861.025 of the California Insurance Code?

(CHECK ONE) Yes No

(B) Does the coverage that you have placed include, in whole or in part, the limits of coverage provided under theCalifornia Automobile Assigned Risk Plan (CAARP)? (CHECK ONE) Yes No

(C) If Yes, has this risk been submitted to and found to be ineligible by CAARP?(CHECK ONE) Yes No

If your answer is NO, then this coverage cannot be placed with a non-admitted insurer. (See Insurance Code section 1763.5)

4. If Health Insurance is identified on line 2(E), does the insured qualify as a "Small Employer" under Section 10700(x) ofthe California Insurance Code? (CHECK ONE) Yes No

5. If this insurance was placed pursuant to Section 125 et seq. of the Califonia Insurance Code governing transactionswith risk purchasing groups authorized by the Federal Liability Risk Retention Act of 1986, complete the following:

(A) Provide the name and address of the purchasing group of which the insured is a member

6. (A) Describe the diligent efforts made to place this coverage with admitted insurers and describe how the searchwas performed (please add additional pages if necessary):

SL-2 (Revised 06/2004)

(B) If search was performed by someone other than the person named on line 1, please provide full name of thatindividual:

7. (A) Was the risk described in Section 2 submitted by you or by someone under your supervision to at least (3) insurers thatare admitted in California and who actually write the type of insurance described on lines 2(C) and 2(E)?

(CHECK ONE) Yes No

(B) If YES, please complete ALL sections of the following table; if NO, skip to Section 8:

Full Name of Admitted Company First & Last Name of Company Check if Month, Year DeclinationRepresentative AND Telephone Employee (E) of Declination Code*Number or Agent (A)

1. E ( X )

or "Online Declination" A ( )Website

2. E ( X )


3. E ( X )


Declination Codes: 1-Company's capacity reached 2-underwriting reason 3-refused to state 4-other

8. If 7(A) was answered NO, complete the following:

(A) Did you determine that fewer than 3 admitted insurers actually write the type of insurance described on lines 2(C)and 2(E)? (CHECK ONE) Yes No

(B) If NO, please explain in detail why the risk was subitted to less than three admitted insurers in California that writethis type of insurance.

(C) If Yes, please describe how you made this determination.

The undersigned licensee hereby certifies that this report is true and correct, and that this risk is not being placed with a non-admittedinsurer for the sole purpose of securing a rate or premium lower than the lowest rate or premium available from an admitted insurer.

(Signature of Licensee Named on Line 1) (Date)

SL-2 (Revised 06/2004)

ARTURO GUEVARA1202 W Bennett StCompton, CA 90220

Loss Warranty Letter

During the last five (5) years, we warrant that with respect to the insurance being applied for:

1. I/We have not sustained a loss,2. I/We have not had a claim made against us,3. I/We have no knowledge or a reason to anticipate a claim or loss.

If my business is less than five (5) years old, the above referenced warranty applies to workperformed through all my prior business entities whether as an owner or an employee.

I understand that this warranty will be incorporated into the insurance contract.

ARTURO GUEVARADBA Date

Signature of Partner, Officer, Principal or Owner Title

Warranty: The purpose of this no loss letter is to assist in the underwriting process.Information contained herein is specifically relied upon in determination of insurability. Thisletter warrants that the information contained herein is true and accurate to the best of his/herknowledge and belief. This no loss letter shall be the basis of any insurance that may beissued and will be a part of such policy. It is understood that any misrepresentation oromission shall constitute grounds for immediate cancellation of coverage or rescission ofpolicy and denial of claims, if any. It is further understood that the applicant and or affiliatedcompany is under a continuing obligation to immediately notify his/her underwriter throughhis/her broker of any material alteration of the information given.

Premium Finance Contract Account Number

LENDING DISCLOSUREPhone: (888) 280-0235 Fax: (619) 697-0326

Terms of agreement listed below and on page 2 of this document This agreement is between all the parties listed on the premium finance contract. All parties must adhere to the terms and provisions of the premium finance contract.

This agreement becomes effective once the Lender receives it and the Borrower is notified in writing. All the terms of this finance contract are listed herein.

PARTIES IN CONTRACT TERMS OF FINANCING

Producer

LOAN TYPE

TOTAL PREMIUM $

CASH DEPOSIT REQUIRED

UNPAID BALANCE

DOCUMENTARY STAMP TAX (FL ONLY)

AMOUNT OF PREMIUM FINANCED

FINANCE CHARGE

TOTAL AMOUNT OF LOAN

$

$

$

$

$

$

PREPAYMENT Insured may prepay full amount due and receive a refund of unearned interest SECURITY Payments are to be made to Premium Finance, Inc. We reserve right to cancel policy as agreed upon in the terms for financing for the policies and premiums listed below. LATE PAYMENT A late charge may be assessed on any payments not received within 5 days of the due date. The late charge will be 5% of overdue amount or maximum allowed per state law.

Borrower

FEIN/SSN:

PAYMENT SCHEDULE

SCHEDULE OF POLICIES

FULL NAME & CITY OF INSURANCE

COMPANY AND GENERAL AGENT

FIRST PAYMENTDUE DATE

MONTHLYDUE DATE

NUMBER OF PAYMENTS

AMOUNT OF EACH PAYMENT

POLICY NUMBER DATE OF

INCEPTION

TYPE OF

COVERAGE

TERM IN MONTHS

COVERED

PREMIUM

AMOUNTS

*IF ADDITIONAL POLICIES ARE FINANCED PLEASE SEE ATTACHED SCHEDULE OF POLICIES ON PAGE THREE.

NOTICE TO INSURED

1. DO NOT SIGN THIS CONTRACT UNTIL YOU READ BOTH PAGES AND FILL IN ANY BLANKS. 2. YOU ARE ENTITLED TO A COMPLETELYFILLED IN COPY OF THIS CONTRACT AT THE TIME YOU SIGN IT. 3. YOU UNDERSTAND AND HAVE RECEIVED A COMPLETE COPY OF THIS CONTRACT. KEEP IT TO PROTECT YOUR LEGAL RIGHTS. 4. UNDER LAW, YOU HAVE THE RIGHT TO PAY OFF IN ADVANCE THE FULL AMOUNT DUE AND UNDER CERTAIN CONDITIONS TO OBTAIN A PARTIAL REFUND OF THE FINANCE CHARGE. 5. SEE PAGE 2 FOR ADDITIONAL TERMS AND PROVISIONS.

PRODUCER REPRESENTATION & WARRANTIES INSURED�S AGREEMENTBy signing below each Insured agrees to make all the payments and adhere to the terms and conditions listed within this premium finance contract.

NAMED INSURED (PRINT OR TYPE)

__________________________________________________ SIGNATURE TITLE DATE

The undersigned agent or broker has read the representations and warranties on page two of this premium finance contract. The producer agrees to the terms of financing and the conditions listed on this premium finance contract. The undersigned agent or broker warranties that all information listed on this finance agreement is accurate and truthful.

_______________________________ _________ SIGNATURE OF PRODUCER DATE

______________________________________________ TITLE

All loan amounts under $1,000 will be subject to a $10

payment processing fee, which will be added to the

payment shown on the monthly invoce.

COMMERCIAL

2,476.80

495.36

1,981.44

1,981.44

177.39

2,158.83

21%

Zone Insurance Services1526 Ravenna Ave

Wilmington, CA 90744323-518-2750

ARTURO GUEVARA1202 W Bennett StCompton, CA 90220310-487-1806

239.87 10/7/2013 7 9

9/7/2013United Specialty Insurance Co., Inc.Administered by: UCISG.United Contractors Insurance Agency, Inc.

GL 122,000.00

Fee: 400.00Tax: 76.80

Broker Fee: 0.00TOTAL: 2,476.80

ARTURO GUEVARA

PROVISONS OF PREMIUM FINANCE CONTRACT

PROMISE TO MAKE PAYMENTS LENDER shall make payments for the amount financed, and as such, insured shall promise to pay the necessary down payments to the insurance company(ies) agreed upon in the Schedule of Policies. In addition, insured shall promise to pay LENDER any and all payments set forth within this agreement. POWER OF ATTORNEY Insured shall agree to appoint LENDER as its attorney-in-fact. This appointment shall be irrevocable. This appointment shall be made in the event of a default as defined herein. RIGHT TO CANCEL If insured fails to make a payment by its issued due date, or if insured is in default set forth by any provision in this contract, LENDER may cancel said policy and act on its own behalf with regard to this policy. This will include endorsing any written instrument in the insured�s name as funds assigned to LENDER as security, and as such will in effect act as power of attorney. As required by law, LENDER must provide written notice to the insured before it cancels the policy. Insured agrees that this right to cancel the policy shall be irrevocable. This irrevocable power of attorney shall include giving LENDER full power of substitution, authority to cancel policies in event of default, receipt and collection of all unearned premiums, which are the result of said cancellation, and execute and serve on behalf of the insured any written document in the furtherance of this contract. Also insured agrees that LENDER shall retain the right to cancel by which can only be terminated after all of the insured�s indebtedness has been paid in full to the satisfaction of LENDER. DEFAULT Insured shall be in default by terms under this contract when and if: 1.A payment is not received by LENDER upon proper due date. 2. Insured fails to fully comply with all terms set forth under this contract. 3. Insured, or any of its insurance companies, become involved with Bankruptcy proceedings against them, or if they become financially insolvent. 4. If premiums are increased as set forth within any of the policies of this agreement, and insured fails to pay these increases within a time period of thirty days of written notice from LENDER. 5. Or if insured should default on any other provision under this contract with LENDER. The term default shall mean any one of, but not limited to, any one of the terms listed above. In the event of a default on part of insured, LENDER shall no longer be under any further obligation to provide services to and on behalf of insured. LENDER shall retain the right to pursue any remedy it feels necessary in the event of default. ATTORNEY COSTS In the event LENDER has to retain services of an attorney(s), for the collection of unpaid balances, or any other legal matter concerning LENDER and insured, insured agrees and shall pay any and all reasonable costs as allowed under state law. FINANCIALLY SOLVENT It is the duty of the insured to make actual and proper representations that the insured is not insolvent nor is currently subject to any insolvency proceedings. RIGHT TO DEMAND PAYMENT IN FULL In the event of default, LENDER shall retain the right to accelerate demand an immediate payment in full equal to the total amount due under the agreement. This right shall also be included in the event LENDER has not received any part of the unearned premium. RETURNED CHECKS In the event a check is returned, or not honored, for any reason, including insufficient funds (NSF), insured shall be charged $15.00 or the maximum allowed per state law, whichever is applicable. DELINQUENT INSTALLMENTS As provided by law, if an installment or payment by insured has not been received by LENDER within ten (10) days after its due date, there shall be a delinquency charge equal to five (5)% of the installment due on each installment not received by its due date. INSTALLMENTS RECEIVED AFTER CANCELLATION NOTICE SENT Upon issuance of a notice of cancellation to any interested party, LENDER has no longer any duty to rescind the policy or request for the policy to be reinstated. This will be upheld even in the event LENDER receives payment from insured at a later date beyond the due date. LIABILTY Insured shall agree that LENDER is not acting as an insurance agent, broker, or carrier, and as such, shall have no liability to that effect, LENDER, nor its assignees, shall not be liable for any damage or loss suffered on part of insured by the acts or omissions of the insurance companies in implementing any provision of the policies of this contract. In addition, insured agrees that its insurance agent, broker, or carrier is insured�s producer and not that of LENDER and therefore, has no authority or power to enter into agreements or contracts on behalf of LENDER. Also, as provided by California law, 860B of the California Financial Code, or any other applicable state financial code or insurance code, LENDER�S liability to insured through the exercise of LENDER�S right to cancel the contract shall be limited to the amount of the principal balance of the loan. This shall be in effect only in the event of intentional or willful misconduct on the part of LENDER. CONFLICT OF LAWS Insured and LENDER shall agree that in the event any portion of this agreement is contrary to applicable law, said provision(s) shall be deemed invalid and ineffective without invalidating the remaining provisions under the contract. Also, in no instance shall insured be forced to pay more interest than is permissible under applicable law. In the event LENDER inadvertently agrees for charges or in fact receives more interest than is permissible, LENDER shall refund the excess amount back to insured or, shall apply it to the remaining unpaid balance of the loan. PREPAYMENT As provided by applicable state or insurance financial code, insured retains the option of prepaying the full amount due as prescribed within the agreement and may receive a refund or a portion of the finance charge itself. CORRECTIONS OR ASSIGNMENTS Unless prohibited by applicable law, LENDER retains the right to insert policy number, insurer�s name, and installment dates if they are not known or have been omitted at the time insured signs agreement, or has it signed on its behalf. Insured shall retain the right to add or assign additional mortgages and/or parties as loss payees without consent of LENDER. However, consent from LENDER is required in the event insured elects to assign any policy or portion thereof. LENDER shall retain the right to transfer any and all rights under this contract to any other party without consent from insured. In addition, insured shall assign to LENDER as security for the complete amounts payable as set forth within said contract. This shall include any and all unearned premiums, refunds, and loss payments which may be payable as listed in the Schedule of Policies. AUDIT AND REPORTING FORM CONTRACTS Any portion of this contract which may be of reporting type or is auditable, insured shall agree to pay the insurance company the difference between earned premium produced for the policy and those premiums financed in the contract. SIGNATURE This contract has been signed by insured and has received an original copy of it for their records. In the event that insured is a corporation, the signature is from a person who is a recognized officer of that corporation, and has authority to sign said contract. In the event insured is not a corporation, all of the insured appearing on the contract have signed said contract. Said contract shall become a legal binding contract upon LENDER mailing written acceptance of this contract to insured.

PAYMENT PROCESSING FEE The loan processor will be assessing a $10 per payment fee on all loan amounts under $1,000. The fee will be added to the payment, and included in the monthly invoice. By signing this agreement, the borrower authorizes the fee to be charged and agrees to pay.

WARRANTIES AND REPRESENTATIONS OF PRODUCER

SIGNATURE GENUINE The signature on all relevant documents is genuine. PAYMENT Agent or broker agrees to release any and all funds received from LENDER and insured to the insurance companies listed, in a timely manner. In the event of default or cancellation, Agent or Broker also agrees to remit any and all unearned premiums, commissions, or other funds to LENDER in a prompt and timely manner. AUTHORIZATION If said contract has been signed by the Agent or Broker to act on behalf of the insured, then the Agent or Broker shall act accordingly with the proper authority to act as such. Insured shall authorize this action. In addition, Agent or Broker has presented a genuine original copy of said contract to insured. NOT AGENT FOR LENDER Agent or Broker is not an employee of LENDER nor shall LENDER be bound to any agreements, contracts, or declarations (wrongfully) made on its behalf by agent or broker. RECEIPT Insured has received a copy of this contract and agrees to be bound to its provisions set forth herein. Insured is legally qualified to enter said contract. FINANCIALLY SOLVENT Insured claims to not be insolvent, nor to be engaged in any insolvency proceedings. FULL FORCE AND EFFECT The provisions detailed within said contract are in full force and effect and are correct. LIABILITY OF AGENT OR BROKER Agent or Broker shall be liable to LENDER for any and all losses, damages, and costs. This shall include any and all reasonable attorneys� fees and or court costs which LENDER may deem necessary in the institution of legal proceedings in the event of any breach made by Agent or Broker or misrepresentations or misleading warranties made herein. In addition Agent or Broker agrees to be liable for any and all damages or losses incurred by LENDER as the result of any action taken by Agent or Broker, ad as such, shall indemnify LENDER for said losses. DOWN PAYMENT Any and all installments, including the down payment, which are due from the insured and Agent or Broker agrees to collect, have actually been collected from insured.

PAYMENT PROCESSING FEE In the event the agent is signing on behalf of the insured, the agent warrants that they have disclosed the $10 per payment processing fee on loan amounts under $1,000.

Mountain West Premium Finance Group of Companies

PO BOX 1748 LA MESA, CA 91944 Toll Free (888) 280-0235 Fax: (619) 697-0326

www.financepremium.com

AUTHORIZATION AGREEMENT FOR CONTINUOUS ELECTRONIC FUNDS TRANSFER

__________________________________________________________________ (Insured’s Name & Fax Number)

_________________________________________________________________ (Account Number)

I hereby authorize the initiation of a continuous electronic deduction from the account set forth below by MW Premium Finance for the payment of the loan installment(s) as described in the Premium Finance Agreement between MW Premium Finance and me. I further authorize the

financial institution named below to debit such account. By my signature below I hereby authorize Mountain West Premium Finance to deduct the amount written below from my account with the

financial institution named below.

Financial Institution Information

Financial Institution Name: _____________________________

Routing Number: ______________________ Account Number: ____________________

______________________________________________Email: __________________________ (Signature and Title of Representative)

***Current amount due is what will be withdrawn ***

***ACH is posted to the loan on the due date*** Please complete form and fax to (619) 697-0326 Confidential and Proprietary MW Premium Finance

3/27/2013

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