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HomeMy Public PortalAbout2014 Hangar Lessee Contact Information Hangar Lessee Contact and Aircraft Information Form 4, 4 2Pi15 O Mailing address is not correct or has changed to the following: ck 393� q►D.I-7 Name: Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: 2� 4 �✓�{ �' Phone 2: Email: Aircraft N Number(s)for aircraft stored in your hangar(s): s x explain what actions you are taking to use the If no aircraft is stored in the hangar, please hangar for aircraft storage. 2 216 East Park Street City of McCall McCall, Idaho 83638 AIRPORT www.mccaI1.id.us Phone 208-634-1488 Main 208-634-7142 Fax 208-634-3038 November 10, 2015 24 2015 McCall Municipal Airport 216 East Park Street McCall, ID 83638 RE: Annual Lease Billing and Information Requests Dear Hangar Owner, Enclosed is your annual lease billing for the period October 1,2015 through September 30, 2016. With your lease payment,please return: • A completed Lessee Contact and Aircraft Information Form (Page 2) Please send all documents to: City of McCall McCall Municipal Airport 216 E. Park St. McCall, ID 83638 If you have any questions or concerns regarding this letter,please contact me by phone at 208-634- 1003 or via email at ncoyle a,mccall.id.us. Respectfully, Nathan Coyle Airport Manager 1 AL INVOICE CITY OF MCCALL 216 E. Park Street McCall ID 83638 City of McCall FINANCE Date Number Page Phone: (208) 634-2103 11/03/2015 3780 1 Bill To: JP Furlco LLC Richardson Customer No. 97.7 _. 2223 Cardinal Drive Contact: 9 Springfield IL 62704 Terms: Net 30 Days Quantity Description Unit Price Net Amount Y 1 Annual Lease-Oct. 2015 thru Sept. 2016- Hangar 213 5,159.22 5,159.22 C� Amount 5,159.22 Freight Balance Due 5,159.22 0 Dcr 0 7 2015 E Hangar Lessee Contact and Aircraft Information For , . - --------- 0 Mailing address is not correct or has changed to the following: Name: P co L L C. Mailing address: V Ito City, State Zip: a Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: Phone 2: Z.- 7 72 62 0 0 0 p r Email: Aircraft/N Number(s) for aircraft stored in your hangar(s): �5 `�L 'P If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. i 3 s - 2 1 i CITY OF MCCALL INVOICE 216 E. Park Street McCall ID 83638 City of McCall FINANCE Date Number Page Phone: (208) 634-2103 11/03/2015 3760 1 Bill To: David Allmen Customer No. 15.2 1127 Rollings Hills Way Valley Center CA 92082 Contact: Terms: Net 30 Days Quantity Description Unit Price Net Amount 1 Annual Lease-Oct. 2015 thru Sept. 2016 - Hangar 106E 520.45 520.45 CEC � � 2p15 Amount 520.45 a Freight Balance Due 520.45 Hangar Lessee Contact and Aircraft Information Form } � O Mailing address is not correct or has changed to the following: S Sao > Name: Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone l:(, /Ie 7 �-- Phone 2: Email: /��dc, 2 Awee (i? /12�r drYJ Aircraft N Number(s) for aircraft stored in your hangar(s): If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. 2 DEC 0 4 2015 Hangar Lessee Contact and Aircraft Information Form i .�,. , .- - O Mailing address is not correct or has changed to the following: a 1 °� 3 F Name: A i Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: S 3© Ltb' " 68IG Phone2: S10 Zz--$�11P Email: -3 Mu LLE1T 18 o C� F MLL cpt,. Aircraft N Number(s) for aircraft stored in your hangar(s): N ZZ(e 6 x t1I i kC If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. TWA 2 CITY OF MCCALL INVOICE 216 E. Park Street 3 McCall ID 83638 City of McCall FINANCE Date Number Page Phone: (208) 634-2103 11/03/2015 3795 1 l-,l 1 T k Bill To: BVnita Sloat Customer No. 24.4 3351 East Antler Way Contact: Cottonwood Heights UT 84121 Terms: Net 30 Days Quantity Description Unit Price Net Amount 1 Annual Lease-Oct. 2015 thru Sept. 2016- Hangar 535 410.17 410.17 k ni✓'^t Z� �_.. i...a. 3 v 13 .ro. DEC t Amount 410.17 Freight Balance Due 410.17 Hangar Lessee Contact and Aircraft Information ram., O Mailing address is not correct or has changed to the folloN-, ng: Name:2�h Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: 0 g70� 0 Phone 2: S U ( 2 9 7 3 O0 8 Email: k Aircraft N Number(s) for aircraft stored in your hangar(s): 41 0 (� 1 If no aircraft is stored in the hangar,please explain what actions you are takin a hangar for aircraft storage. Y g to use the 2 DEC U 3 2015 Hangar Lessee Contact and Aircraft Information Form Y. ._____o__a� Y 9 O Mailing address is not correct or has changed to the following: Name: I.-wa-k Lc/h arm 3 3 Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: 'q 70 - 9 ys Phone 2: l --2vg 876 7 Email: s Aircraft N Number(s) for aircraft stored in your hangar(s): If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. 2 DEC U 3 2015 Hangar Lessee Contact and Aircraft Information Form i O Mailing address not correct or has changed to the following: / Name: �- (� Mailing address: �✓ / / � 7�4 City, State, Zip:,�6"�;'/ Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside paies. Phone 1: �� Phonc 2: Email: Aircraft NLNumber(s) for aircraft stored in your hangar(s): If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. 2 DEC 17 2015 3 Hangar Lessee Contact and Aircraft Information Form cam# �55 O Mailing address is not correct or has changed to the following: S7o Name: SNEaM�a+•� (,-RASP LLL �'L? Mailing address: $38 SW few- QQve $,jrrF- 210 City, State, Zip: 'Porzruak%jp DR 972oq ,x Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone l: Aag&o LAgEPS - 503 4Sto. 284S Phone 2: (V1a4�1�. I t-t_EtiZ S03. 9S1 t Slot Email: AtAQW4& Mf:jA t�Lc-. t oy%. OVA 49-1t a rAF,aaLc..e-ar A. Aircraft N Number(s) for aircraft stored in your hangar(s): 0 113 M14 N 396k RA n Z 83 t'6 If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. 2 tF Hangar Lessee Contact and Aircraft Information Form ®E� 7 20 15 O Mailing address is not correct or has changed to the following: n Name: V Mailing address: FT61 (,,J AS X 6 a Lt- FN P /Jr. City, State, Zip: �� �e -:C D 3 I6 Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: c e / 2 og — 8 PO — o I Phone 2: Email: �' l�S/A n I c 0 Aircraft N Number(s) for aircraft stored in your hangar(s): 1�5P�G �� ow-f If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. z L. MONTHLY FUEL FLOWAGE REPORT DISTRIBUTOR:EPIC A VIA TION,LLC REPORT FOR: November-15 { (month) The following fuel was delivered to the McCall Air Terminal in the name of the customers listed: NON-EXEMPT EXEMPT CUSTOMER GALLONS CUSTOMER GALLONS F McCall Aviation Inc 8,034 NONE McCall Aviation Inc 0 5 k s 3 :F Y f ,J 1 Total Non-exempt Fuel: 8,034 Total Exempt Fuel Delivered: ,3 Times Fuel Flowage Fee: X $0.08 Total Fuel Flowage Due: $ 642.72 TOTAL FUEL DELIVERED: 8,034 Owner's/Corporate Officer's Certification: I hereby certify this report is a correct and true accounting of the aviation fuel delivered to the McCall Air Terminal Printed Name Trina King Signed: - Title Jr Tax Adminstrator Dated: 12/8/2015 • Report and payment due to City of McCall,216 East Park St.,McCall,ID 83638, by the 1 Oth of the following month. \ } 0 2� in § . \ � § to § 2 z \ p % p 22 k } k 7i _ _ _ J } 0 \ 0 a � co } �J 0 \ ) m # - \ 7 Cl) C co co co mJ \ > � $ u- w 7 § ° L R °z 0 § 1 § — k ) k / z / � kE k\ Q § k : ) } § \_ I _ . � ] § )f § § � d « . ] CD . 0k / 0 ( k � o 4; CITY OF MCCALL INVOICE 216 E. Park Street McCall ID 83638 City of McCall FINANCE Date Number Page Phone: (208) 634-2103 11/03/2015 3759 1 Bill To: Donald Betzold Customer No. 93.7 PO Box 296 Contact: Horseshoe Bend ID 83629 Terms: Net 30 Days Quantity Description Unit Price Net Amount 1 Annual Lease-Oct. 2015 thru Sept. 2016- Hangar 106A 500.52 500.52 P 1D WtI " Amount 500.52 Freight Balance Due 500.52 Hangar Lessee Contact and Aircraft Information Form f O Mailing address is not correct or has changed to the following: Name: Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: Phone 2: 7 V Email: Aircraft N Number(s) for aircraft stored in your hangar(s): 1j3gSge If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. 2 CITY OF MCCALL INVOICE 216 E. Park Street McCall ID 83638 City of McCall FINANCE Date Number Page Phone: (208) 634-2103 11/03/2015 3779 1 Bill To: Southcoast Lumber Customer No. 16.7 Jig GIAMm Contact: P.O. Box 670 Brookings OR 97415 Terms: Net 30 Days Quantity Description Unit Price Net Amount F 1 Annual Lease-Oct. 2015 thru Sept. 2016-Hangar 212 2,471.00 2,471.00 s . L}15 -zg1I ,vn Amount 2,471.00 Freight Balance Due 2,471.00 Hangar Lessee Contact and Aircraft Information Form O Mailing address is not correct or has changed to the following: ��,q'(��� l�Q 0AJ Name: Tl d.l i x'1 T', � Mailing address: G RQQ/ 1 City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will notbe released or distributed to outside parties. Phone 1: Yy Phone 2: y � 1 6 1 Email: e e 9' C© S a c y vn I . c d v►� f Aircraft N Number(s) for aircraft stored in your hangar(s): If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. NIA 2 t CITY OF MCCALL INVOICE 216 E. Park Street } McCall ID 83638 City of McCall FINANCE Date Number Page Phone: (208) 634-2103 11/03/2015 3803 1 Bill To: William & Elaine Boggess Customer No. 25.1 5220 Mount Aukum Road Placerville CA 95667 Contact: Terms: Net 30 Days Quantity Description Unit Price Net Amount } x 1 Annual Lease-Oct. 2015 thru Sept. 2016- Hangar 551 410.17 410.17 f 'r Ct-ff s5125- a I g i Amount 410.17 Freight Balance Due 410.17 Hangar Lessee Contact and Aircraft Information Form O Mailing address is not correct or has changed to the following: Name: Mailing address: F City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by z email. This information will not be released or distributed to outside parties. Phone 1: Phone 2: Email: �2 r S 9 g► �� Aircraft N Number(s) for aircraft stored in your hangar(s): If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. 'k 2 5 g Hangar Lessee Contact and Aircraft Information For Mailing address is not correct or has changed to the following: G 3 io1954l.q2 Name: Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: . LEA S� 2,��� - 7 7 f 14 Phone 2: Email: Aircraft N Number(s) for aircraft stored in your hangar(s): Y 7 �1 �-- x If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. 2 F CITY OF MCCALL INVOICE 216 E. Park Street - - McCall ID 83638 City of McCall FINANCE Date Number ngePhone: (208) 634-2103 11/03/2015 3793 _ Y d k Bill To: Johnny & Joanne Miller Customer No. 91.2 P.O. Box.2955 Contact: McCall ID 83638 Terms Net 30 Days f i s Quantity Description Unit Price Net Amount I i 1 Annual Lease - Oct. 2015 thru Sept. 2016 - Hangar 533 584.66 584.66 `rp $ 2 ; t Amount 584.66 Freight n Balance Due 584.66� L� s 3 3 { Hangar Lessee Contact and Aircraft Information Form O Mailing address is not correct or has changed to the following: Name: Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: 9) 7/ ©O q 7 Phone 2: _ Email: ALL I ;.,r( r, s 515 Aircraft N Number(s) for aircraft stored in your hangar(s): If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. 2 `t CITY OF MCCALL INVOICE 216 E. Park Street McCall ID 83638 City of McCall FINANCE Date Number Page Phone: (208) 634-2103 11/03/2015 3772 1 Bill To: Wooten Family Trust Customer No. 16.1 c/o Gaylin Wooten 890 E Valli Hi Road Contact: Eagle, ID 83616 Terms: Net 30 Days III'I'I'I'lllllll'III'illlllllll'I'I'lll'lllllllllllll'llll'lllll Quantity Description Unit Price Net Amount :1 '{ 1 Annual Lease-Oct. 2015 thru Sept. 2016 - Hangar 207 5,510.15 5,510.15 DEC -s�o•�S s } Amount 5,510.15 Freight Balance Due 5,510.15 Hangar Lessee Contact and Aircraft Information Form DEC J 2 2 jib 0 Mailing address is not correct or has changed to the following: Name: WO(4eh Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: (208) Phone 2: Email: Aircraft N Number(s) for aircraft stored in your hangar(s): .A.1 25Z3—7-CO If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. F CITY OF MCCALL INVOICE 216 E. Park Street McCall ID 83638 City of McCall FINANCE Date Number Page Phone: (208) 634-2103 11/03/2015 3817 1 I l Bill To: Evergreen Forest Products Customer No. 87.8 I Robert Hitchcock Contact: P.O. Box 950 McCall ID 83638 Terms: Net 30 Days f Quantity Description Unit Price Net Amount 1 Annual Lease-Oct. 2015 thru Sept. 2016 - Hangar 602C 1,469.31 1,469.31 k DEC 0 1 20i5 ., � t Amount 1,469.31 Freight Balance Due 1,469.31 i 1 �—Cu12015 Hangar Lessee Contact and Aircraft Information Form a,q(p O Mailing address is not correct or has changed to the following: q&9'3 Name: r �-t to ar Prd ' Mailing address: City, State, Zip: Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. '= Phone l: pp / Phone 2: �O��G 3 1�//3 s Email: &512 (',aw f Aircraft N Number(s) for aircraft stored in your hangar(s): If no aircraft is stored in the hangar, please explain what actions you are taking to use the hangar for aircraft storage. Y D C l 2015 Hangar Lessee Contact and Aircraft Information Form �5�22�gZ O Mailing address is not correct or has changed to the following: 5�6 Name: 5'NEarn,a+j f,qO,,,P t t_L Mailing address: SW Emw- AVE Sp a Ztl� City, State, Zip: ?61zsu4wp D Z 9"1204, Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: Ap &P 503 Po. ais Phone 2: (A*tt)k II�Ct-t-EtZ So?a `�'SZ 4 3102. Email: Apapr4(? ME tNt.Lc..elcrw. a0�'1�4�\�°� MEN r.t.c .e-owe. Aircraft N Number(s) for aircraft stored in your hangar(s): 3T� Rpt If no aircraft is stored in the hangar,please explain what actions you are taking to use the hangar for aircraft storage. 2 i a } Hangar Lessee Contact and Aircraft Information Form ilEC 17 2015 Ljz1�2-7 O Mailing address is not correct or has changed to the following: ?` Z Name: - �- --t Mailing address: PSW (,J A5 F-A City, State, Zip. �r-- 'e --T D � 6 Please provide a current phone number and email address, if it is OK to contact you by email. This information will not be released or distributed to outside parties. Phone 1: C eP a Phone 2: Email: �' I SM 0 a. l c ra Aircraft N Number(s) for aircraft stored in your hangar(s): a� 7` 75 rJ C e ss r ;t If no aircraft is stored in the hangar,please explain what actions you are taking to use the hangar for aircraft storage. 2 CITY OF MCCALL INVOICE 216 E. Park Street McCall ID 83638 City of McCall FINANCE Phone: (208) 634-2103 Date Number Page11/03/2015 $797 1 Bill To: Charles and Mott n. Y Schneider n,� �, Customer No. 109.4 P.Q. Box 2304 McCall ID 83638 �, ' Contact: /� Terms: Net 30 Days Quantity Description Unit Price Net Amount 1 Annual Lease-Oct 2015 thru Sept.2016-Hangar 541 542.32 542.32 DEC 1 7 2015 Amount 542.32 Freight Balance Due 542.32 +Y A y y 7g X u z�' ------------------- .�hE 0 as 0. Customer Number 47162 WWI- Your Agent x � Aircraft insurance CorArr>ei m Michael W. Schaffer Po Box 554 New Meadows, Id x Limits of Liability $1,000,000 Total Liability for Bodily Injury and Property Damage Hull Deductibles $100,000 Each Passenger(Included Within Total Liability) $NIL Not-In-Motion $5,000 Each Person, Medical Payment Coverage Including Crew $NIL In-Motion Aircraft N # Year/make/model Seats Hull Value Coverage Hangared Airport Aircraft Use 757ML 2013 CHAMPION 2 $215,000 Full Flight Hangared _MIYL) Pleasure&Business Named Pilots I } MIdvW Schaffer Open Pilot Warranty Aii Other Pilots N Not Named Above Must Meet The Following Requirements. License/Ratings prime Total Time 500 Hours in Type 100 Tw Make/Model 25 Add al Insureds wmi BR1AW WAFFwry• wrt►+so wvs NO=OFCMrCEU A"N FAVOR OF LIGHTHAW K 1 PO BOX 653 3 1 LANDER WY 82520 2 2 4 ! . . -051 ' Signed _,I Date 4/24/2015 r The Cincinnati Specialty Underwriters Insurance Company A Stock Insurance Company C THE I N C I N NATI Headquarters: 6200 S. Gilmore Road, Fairfield, OH 45014-5141 SPECIALTY UNDERWRITERS Mailing address: P.O. Box 145496, Cincinnati, OH 45250-5496 INSURANCE COMPANY www.cinfin.00m■ 513-870-2000 COMMON POLICY DECLARATIONS POLICY NUMBER: CSU0025741 PREVIOUS POLICY NUMBER: CSU0025741 NAMED INSURED AND MAILING ADDRESS: Sherman Group LLC; Refer to Named Insured Schedule CSIA409 838 SW 1ST AVE STE 201 PORTLAND OR 97204 s PRODUCER-Your contact for matters pertaining to this policy: 46-008 Broker: 336097 West Coast Insurance Services, Inc. dba Biggs Insurance Se CSU Producer Resources, Inc. 916 Main St 6200 South Gilmore Road Vancouver WA 98660 Fairfield, OH 45014-5141 Scott Hintze Policy Period: From 09/21/2015 To 09/21/2016 AT 12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE. Form of Business: _ ❑ Individual ❑ Partnership❑ Corporation ❑ Joint Venture ® Limited Liability Company ❑ Other Business Description'Warehouse Hangar IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. COVERAGE PARTS PREMIUM DEPOSIT PREMIUM Commercial General Liability $ 814.00 Terrorism Risk Insurance Extension Act $ 12 .00 Broker Fee $ 35.00 TOTAL POLICY PREMIUM $ 861.00 CANCELLATION MINIMUM EARNED PREMIUM IS 25.o%OF TOTAL POLICY PREMIUM. Surplus Lines Taxes $ 12.92 Stamping Fee $ 2 .16 Other Taxes or Fees N/A TOTAL $ 876.08 Premium is subject to annual audit: ❑ Yes ❑x No NOTICE TO POLICYHOLDER: This surplus line contract is issued pursuant to the Idaho insurance laws by an insurer not licensed by the Idaho Department of Insurance. There is no coverage provided for surplus line insurance by either the Idaho Insurance Guaranty Association or by the Idaho Life and Health Insurance Guaranty Association. Includes copyrighted material of ISO Page 1 of 2 rRIA sm n7 14 Properties. Inc.. with its permission t FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY AT TIME OF ISSUE: Refer to Forms and Endorsements Schedule CSIA406 THIS COMMON POLICY DECLARATIONS AND THE SUPPLEMENTAL DECLARATION(S)TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORM(S) AND ENDORSEMENT(S), IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. Signed by: Date (Authorized representative or countersignature, where applicable) Includes copyrighted material of ISO CSIA 5010714 Properties, Inc., with its permission Page 2 of 2 The Cincinnati Specialty Underwriters Insurance Company A Stock Insurance Company C THE i I N C I N NATI Headquarters: 6200 S. Gilmore Road, Fairfield, OH 45014-5141 S SPECIALTY UNDERWRITERS Mailing address: P.O. Box 145496, Cincinnati, OH 45250-5496 INSURANCE COMPANY www.cinfin.com ■ 51M70-2000 s COMMON POLICY DECLARATIONS POLICY NUMBER: CSU0025741 PREVIOUS POLICY NUMBER: CSU0025741 NAMED INSURED AND MAILING ADDRESS: Sherman Group LLC; Refer to Named Insured Schedule CSIA409 838 SW 1ST AVE STE 201 PORTLAND OR 97204 PRODUCER-Your contact for matters pertaining to this policy: 46-008 Broker: 336097 West Coast Insurance Services, Inc. dba Biggs Insurance Se CSU Producer Resources, Inc. '= 916 Main St 6200 South Gilmore Road Vancouver WA 98660 Fairfield, OH 45014-5141 Scott Hintze Policy Period: From 09/21/2015 To 09/21/2016 AT 12:01 A.M. STANDARD TIME AT YOUR MAILING ADDRESS SHOWN ABOVE. Form of Business: _ ❑ Individual ❑ Partnership❑ Corporation ❑ Joint Venture ® Limited Liability Company ❑ Other Business Description:Warehouse Hangar ` IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS STATED IN THIS POLICY. THIS POLICY CONSISTS OF THE FOLLOWING COVERAGE PARTS FOR WHICH A PREMIUM IS INDICATED.THIS PREMIUM MAY BE SUBJECT TO ADJUSTMENT. b -- COVERAGE PARTS PREMIUM DEPOSIT PREMIUM Commercial General Liability $ 814 .00 Terrorism Risk Insurance Extension Act $ 12 .00 Broker Fee $ 35.00 TOTAL POLICY PREMIUM $ 861.00 CANCELLATION MINIMUM EARNED PREMIUM IS 25 .o%OF TOTAL POLICY PREMIUM. Surplus Lines Taxes $ 12.92 Stamping Fee $ 2 .16 Other Taxes or Fees N/A TOTAL $ 876.08 Premium is subject to annual audit: ❑ Yes ❑x No NOTICE TO POLICYHOLDER: This surplus line contract is issued pursuant to the Idaho insurance laws by an insurer not licensed by the Idaho Department of Insurance. There is no coverage provided for surplus line insurance by either the Idaho Insurance Guaranty Association or by the Idaho Life and Health Insurance Guaranty Association. Includes copyrighted material of ISO CSIA 501 0714 Properties, Inc., with its permission Page 1 of 2 FORMS AND ENDORSEMENTS ATTACHED TO THIS POLICY AT TIME OF ISSUE: Refer to Forms and Endorsements Schedule CSIA406 THIS COMMON POLICY DECLARATIONS AND THE SUPPLEMENTAL DECLARATION(S) TOGETHER WITH THE COMMON POLICY CONDITIONS, COVERAGE PART DECLARATIONS, COVERAGE PART(S), COVERAGE FORM(S) AND FORM(S) AND ENDORSEMENT(S), IF ANY, ISSUED TO FORM A PART THEREOF, COMPLETE THE ABOVE NUMBERED POLICY. Signed by: Date (Authorized representative or countersignature, where applicable) Includes copyrighted material of ISO CSIA 501 0714 Properties, Inc., with its permission Page 2 of 2