Submission Packet

From: CALIBER 360 INC, ALLWYN JOURDAN

To: UNIVERSAL NORTH AMERICA INSURANCE COMPANY
PO BOX 912017
DENVER, CO 80291-2017

Phone: 877-826-6921

Regarding Application Tracking Number: 0000112877 - OMAR PINO

The following documentation is required before the policy can be issued and may be directly
uploaded to the policy by accessing the website.
Electronic Application:
Full Annual Premium payment.
Online payments can be submitted using either of the
following payment methods:
- Credit Card
- Electronic Check

If the payment is mailed, a copy of the application must

be provided with the check.

File: 15380825 DocId: 220753390

 CALIBER 360 INC
8249 NW 36 ST SUITE 120-A
DORAL, FL 33166

Agency:
CALIBER 360 INC
8249 NW 36 ST SUITE 120-A
DORAL,FL 33166

OMAR PINO Agent:

ALLWYN JOURDAN
134 W 45TH ST Phone Number: (305) 671-3868
HIALEAH, FL 33012-4028 Email: [email protected]

New Application Invoice

Application Number : 0000112877

Policy Expiration Date : 07/29/2024
Application ID : 000015380825
Billing ID : 000220753390

Insured Property Location : Coverage Deductible

134 W 45TH ST Building $250,000 $1,250
HIALEAH, FL 33012-4028
Contents $75,000 $1,000

Payment Options : Premium Total Due : $657.00

ACH or Credit Card : Call our Payment Processing Center at 877-826-6921.
Check : Follow the instructions noted on the bottom of this invoice.
Please don't forget to include the application number on your check.
On-Line : Visit https://uictx.manageflood.com and select "Pay New Application Online."

Please be aware that this application is subject to a full underwriting review of all documentation and rates may change based on that review.

IF PAYING BY CHECK PLEASE DETACH HERE AND SEND THIS PORTION WITH YOUR PAYMENT.

Insured Name : OMAR PINO

Effective Date : 07/29/2023
Application No : 0000112877
Application ID : 000015380825
To pay by check or money order :
Billing ID : 000220753390
Make payment for the exact premium amount due.
Full payment is required.
Write your application number on your check. Amount Enclosed : $ .00
Mail this stub and the payment to the address below.

Make check payable to : UNIVERSAL NORTH AMERICA INSURANCE COMPANY

PO BOX 912017
DENVER, CO 80291-2017

000015380825 000220753390 8
CALIBER 360 INC
8249 NW 36 ST SUITE 120-A
DORAL, FL 33166 Standard Flood Insurance Policy Application
Dwelling Form
Date Type Application Number Effective Date Expiration Date Waiting Period
06/29/2023 New 0000112877 07/29/2023 07/29/2024 Standard 30 Day Wait
Insured Name(s) Mailing Address and Phone Property Address Agency Name, Address, and Phone
OMAR PINO 134 W 45TH ST 134 W 45TH ST CALIBER 360 INC
HIALEAH, FL 33012-4028 HIALEAH, FL 33012-4028 8249 NW 36 ST SUITE 120-A
SIXELA SOCAS DORAL, FL 33166

Home Phone: (305) 497-1899 Property Address Type:

Work Phone:
Cell Phone: (305) 497-1899 Email: [email protected]
Applicant Type: Individual Email: [email protected] Phone Number: 305-671-3868
Other Policy Number: Agent Name: ALLWYN JOURDAN
Prior Policy Number:
Prior Company Name: Prior Company NAIC:
Renewal Billing: Other - REGIONS BANK DBA REGIONS PO BOX 200401 Potential Duplicate Policy: N/A

1st Mortgagee 2nd Mortgagee Additional Interest Disaster Agency

Phone Number:
Phone Number: Phone Number: Phone Number: Fax Number:
Fax Number: Fax Number: Fax Number: Loan Number:
Loan Number: Loan Number: Loan Number: Case Number:
Current Community Information Prior Community Information
Community Name: HIALEAH, CITY OF Community Number: N/A
Community Number: 120643 Map Panel: N/A
Map Panel: 0281 Map Panel Suffix: N/A
Map Panel Suffix: L Flood Zone: N/A
Current Flood Zone: AH FIRM Date: N/A
FIRM Date: 09/29/1972 Has This Property Been Remapped?: No
Program: Regular Map Revision Date: N/A
Program Status: Active and participating
County: N/A
Current Map Date: 09/11/2009
Rating Map Date: 09/11/2009

Construction/Substantial Improvement Date Property Ownership Information

Date of Original Construction: 12/01/1988 Coverage for Owner or Tenant: Owner
Building Substantially Improved: No Building a Rental Property: No
Building is on list of Historic Buildings: N/A Is the policyholder a condominium No
Post-FIRM Construction: Yes association?
Substantial Improvement Date: N/A
Prior NFIP Coverage
Did the applicant purchase the building No Did the applicant have a prior NFIP policy N/A
within the last 365 days? for the building that lapsed?
Prior Owner Policy Number: N/A Was the policy receiving a Pre-FIRM or N/A
Prior Owner Company Name: N/A Newly Mapped discount when it lapsed?
Did the policy lapse for a valid reason? N/A

File: 15380825 Page 1 of 3 DocID: 220753390

 Did the policy lapse for a valid reason? N/A
Building Information
Building Located In CBRS/OPA: None Building Located Over Water: Not Over Water
CBRS/OPA Designation Date: N/A Building in Course of Construction: No
If the building is in the buffer zone, did N/A Building Construction Type: Masonry
USFWS issue an official determination Construction Type Description: N/A
showing the building outside the system
Estimated Building Replacement Cost: N/A
unit or OPA?
Replacement Cost Value Returned By $165,065
Is the building use consistent with the N/A
FEMA:
protected area purpose?
Prior NFIP Claims: N/A Total sq. footage of the building: 1,111
Building Severe Repetitive Loss (SRL) No Total # of floors in building: 1
Property: What floor is the unit located on? N/A
Property on NFIP SRL list, document(s) N/A Number of Detached Structures: 0
provided indicating non-SRL: Building Located on Federal Land: No
Coverage Req'd for Disaster Assistance: No Is the policy force-placed by the lender? N/A

Occupancy Information
Occupancy Type: Single-Family Home Number Of Units In Building: 1
Is the insured a nonprofit entity? No
Is this the Applicant's Primary Yes Building Description: Main Dwelling
Residence:
"Other" Description: N/A
Is the insured a small business with less No
than 100 employees?
Foundation Information Mobilehome/Travel Trailer Information
Foundation: Slab on grade (non-elevated) On Permanent Foundation: N/A
Anchored By: none
Enclosure/Crawlspace Size: N/A Serial Number: N/A
Number of Elevators: 1
Venting Information
Enclosure/Crawlspace Has Valid Flood No Area of Permanent Openings (Sq. In.): 0
Openings: Has Engineered Openings: No
Number of Openings: 0
Machinery, Equipment and Appliances
Does the building contain appliances? Yes Does the building contain machinery Yes
and equipment servicing the building?
Are all appliances elevated above the No Is all machinery and equipment servicing Yes
first floor? the building, located inside or outside the
building, elevated above the first floor?
Elevation Certificate Information
Elevation Certificate Section Used: N/A Flood Proofing Certificate: N/A
Elevation Certificate Date: N/A Flood Proofing Elevation: N/A
Diagram Number: N/A Lowest (Rating) Floor Elevation: N/A
Top of Bottom Floor: N/A Elevation Certificate First Floor Height: N/A
Top of Next Higher Floor: N/A FEMA First Floor Height: 2.3
First Floor Height Method Used: FEMA Determined
Lowest Adjacent Grade (LAG): N/A
Premium Calculations
COMPONENTS OF THE TOTAL AMOUNT DUE
RATING ENGINE
COVERAGE DEDUCTIBLE BUILDING PREMIUM: $346.00
BUILDING $250,000 $1,250 CONTENTS PREMIUM: $193.00
CONTENTS $75,000 $1,000 INCREASED COST OF COMPLIANCE (ICC) PREMIUM: $10.00
MITIGATION DISCOUNT: ($0.00)
COMMUNITY RATING SYSTEM REDUCTION: ($53.00)
FULL RISK PREMIUM: $496.00
ANNUAL INCREASE CAP DISCOUNT: ($0.00)
STATUTORY DISCOUNTS: ($0.00)
DISCOUNTED PREMIUM: $496.00
RESERVE FUND ASSESSMENT: $89.00
HFIAA SURCHARGE: $25.00
FEDERAL POLICY FEE: $47.00
PROBATION SURCHARGE: $0.00
TOTAL AMOUNT DUE: $657.00

File: 15380825 Page 2 of 3 DocID: 220753390

A separate flood insurance policy is required for each building with the following exception: Under the Standard Flood Insurance Policy Dwelling Form, appurtenant structure coverage may apply to a detached garage
at the described location provided the detached garage is not used for dwelling, business, or farming purposes. Coverage is limited to 10% of the limit of liability on the dwelling and reduces the building limit of
liability.

The above statements are correct to the best of my knowledge. I understand that any fraudulent statements may be punishable by fine or imprisonment under the applicable federal law. The Federal
EmergencyManagement Agency (FEMA) provides flood insurance under the terms of the National Flood Insurance Act of 1968 and its Amendments, and Title 44 of the Code of Federal Regulations. The premium
shown above must comply with FEMA rules and rates and may be revised in accordance with applicable policy provisions.

Signatures

06/29/2023
Signature of Agent/Producer Date Signature of Insured (Optional)
This policy is not subject to cancellation for reasons other than those set forth in the National Flood Insurance Program rules and regulations. In matters involving billing disputes, cancellation is not
available other than for billing processing error or fraud.

PDF Creation: 06/29/2023 02:58 PM Pacific Standard Time

Application Produced For: UNIVERSAL NORTH AMERICA INSURANCE COMPANY

File: 15380825 Page 3 of 3 DocID: 220753390

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