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OP ID: MKCOMMERCIAL INSURANCE APPLICATIONDATE (MM/DD/YYYY)APPLICANT INFORMATION SECTION1/11/2018AGENCYNAIC CODECARRIERAloha Insurance Services, Inc.75-5931 Walua Rd.Kailua-Kona, HI 96740TJ Kona, Inc.Golden Bear Insurance CoUNDERWRITER:POLICIES OR PROGRAM REQUESTEDUNDERWRITER OFFICE:POLICY NUMBERFS53050PROPERTYCONTACTNAME:PHONE(A/C, No, Ext):FAX(A/C, No):E-MAILADDRESS:TJ Kona, CODE:XKALAN-2QUOTERENEWBOUND (Give Date and/or Attach Copy):DATETIMEX12:01CANCELVEHICLE SCHEDULEGLASS AND SIGNWORKERS COMPENSATIONINSTALLATION/BUILDERS RISKYACHTOPEN CARGOXPROPERTYTRANSPORTATION/MOTOR TRUCK CARGOPACKAGE POLICY INFORMATIONXISSUE POLICYCHANGEUMBRELLAGARAGE AND DEALERSCOMMERCIALGENERAL LIABILITYCRIME/MISCELLANEOUS CRIMEDRIVER INFO SCHEDULESTATUS OF TRANSACTIONTRUCKERS/MOTOR CARRIEREQUIPMENT FLOATERBUSINESS AUTODEALERSSUB CODE:AGENCY CUSTOMER ID:ELECTRONIC DATA PROCINDICATE SECTIONS ATTACHEDACCOUNTS RECEIVABLE/VALUABLE PAPERSBOILER & MACHINERYENTER THIS INFORMATION WHEN COMMON DATES AND TERMS APPLY TO SEVERAL LINES, OR FOR MONOLINE POLICIES.PROPOSED EFF DATEPROPOSED EXP DATE03/01/1803/01/19BILLING PLANAMPMPAYMENT PLANAUDITDIRECT BILLXAGENCY BILLPACKAGE POLICY PREMIUM: APPLICANT INFORMATIONNAME (First Named Insured & Other Named Insureds)MAILING ADDRESS INCL ZIP 4 (of First Named Insured)c/o Touchstone Properties, Ltd680 Iwilei Rd Ste 777Honolulu, HI 96817Kalanikai Condominiums AOAOFEIN OR SOC SEC #PHONE(of First Named Insured):(A/C, No, DRESS(ES):SUBCHAPTER "S"INDIVIDUALCORPORATIONCORPORATIONNOT FORPARTNERSHIPJOINT VENTUREPROFIT ORGINSPECTION CONTACT:PHONE(A/C, No, Ext):1WEBSITEADDRESS(ES):LLCNO. OF MEMBERSAND MANAGERS808-556-4110BLD #DATE BUSSTARTEDCR BUREAU NAME:X Condo AssocID NUMBER:CindyPREMISES INFORMATIONLOC #808-556-4110ACCOUNTING RECORDS CONTACT:cindy@touchstonepropertiesE-MAILADDRESS: hawaii.comPHONE(A/C, No, hawaii.com808-556-4110ACORD 823 attached for additional premisesSTREET, CITY, COUNTY, STATE, ZIP 475-5681 Kuakini Hwykailua Kona HI 96740HawaiiCITY UPIEDANNUAL NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS BY PREMISE(S)1residental Condos 82 units/5 buildingsACORD 125 (2007/10)Page 1 of 3 1993-2007 ACORD CORPORATION. All rights reserved.The ACORD name and logo are registered marks of ACORD
KALAN-2AGENCY CUSTOMER ID:GENERAL INFORMATIONOP ID: MKEXPLAIN ALL "YES" RESPONSESY/N1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?N1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES?N2.IS A FORMAL SAFETY PROGRAM IN OPERATION?N3.ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?N4.ANY CATASTROPHE EXPOSURE?N5.ANY OTHER INSURANCE WITH THIS COMPANY OR BEING SUBMITTED?N6.ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR THREE (3) YEARS? (Not applicable in MO)N7.ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?N8.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 ANYOTHER 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 oneyear of imprisonment).N9.ANY UNCORRECTED FIRE CODE VIOLATIONS?N10. ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST FIVE (5) YEARS?N11. HAS BUSINESS BEEN PLACED IN A TRUST?IF "YES", NAME OF TRUST:nN12. 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)NREMARKS/PROCESSING INSTRUCTIONS (Attach additional sheets if more space is required)COPY OF THE NOTICE OF INFORMATION PRACTICES (PRIVACY) HAS BEEN GIVEN TO THE APPLICANT. (Not applicable in all states, consult your agent or broker for your state's requirements.)NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT REPORT, MAY BE COLLECTEDFROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION ASWELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRDPARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OFANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST.CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVILPENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR, or VT; in DC, LA, ME, TN, VA and WA, insurance benefits may also be denied)IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR ANAPPLICATION 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 OBTAINTHE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OFHIS/HER KNOWLEDGE.PRODUCER'S SIGNATUREAPPLICANT'S SIGNATUREACORD 125 (2007/10)STATE PRODUCER LICENSE NO(Required in Florida)PRODUCER'S NAME (Please Print)Digitally signed by Bruce D GainerDN: cn Bruce D Gainer,o President, ou Kalanikai AOAO,email bruceg@peak.org, c USDate: 2018.02.28 16:32:42 -10'00'TJ Kona, Inc.308074DATE2/28/18Page 2 of 3NATIONAL PRODUCER NUMBER
LINE12-13CATEGORYCARRIERPOLICY NUMBERPOLICY TYPEKALAN-2AGENCY CUSTOMER ID:PRIOR CARRIER INFORMATION13-14Great DivideGC948025CLAIMSXMADEGreat 3 03/01/1314-15OCCURRENCEGreat DivideGC957577CLAIMSXMADEOP ID: MK15-16OCCURRENCEGreat DivideGC961089CLAIMSxMADE17-18Great DivideCLAIMSMADEOCCURRENCEOCCURRENCERETRO DATEGENECROAMLMELRICAIBAILLITYEFF-EXP ERAL AGGREGATEPRODUCTS COMP OPAGGREGATEPERSONAL & ADV INJEACH OCCURRENCELI FIRE DAMAGEMI MEDICAL EXPENSETS BODILY OCCURRENCEINJURY AGGREGATE03/01/14 03/01/1403/01/15 003/01/16 000PROPERTY OCCURRENCEDAMAGE AGGREGATECOMBINED SINGLE LIMITMODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERAUTOMOBILEPOLICY TYPELIABILITYEFF-EXP DATECOMBINED SINGLE LIMITBODILYINJURYEA PERSONEA ACCIDENTPROPERTY DAMAGEMODIFICATION FACTORTOTAL PREMIUMPOLICY 11POLICY TYPECOMM PROPCOMM PROPEFF-EXP DATE03/01/12CARRIERPROPERTYXBUILDINGAMTPERS PROPAMT03/01/13 Lexington41-LX-027561111PROPPROPERTY03/01/14X 13,457,56703/01/15 03/01/15x 13,457,567Lexington03/01/16 03/01/12x 13,457,56703/01/13x 14,669,360MODIFICATION FACTORTOTAL PREMIUMCARRIERPOLICY NUMBERPOLICY TYPEEFF-EXP DATELIMITMODIFICATION FACTORTOTAL PREMIUMLOSS HISTORYENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMSFOR THE PRIOR 5 YEARS (3 YEARS IN KS & NY)DATE OFOCCURRENCEREMARKSLINETYPE/DESCRIPTION OF OCCURRENCE OR CLAIMNOTE: FIDELITY REQUIRES A FIVE YEAR LOSS HISTORYAMOUNTPAIDXAMOUNTRESERVEDSEE ATTACHEDLOSS SUMMARYCLAIMSTATUSOPEN CLSDATTACHMENTSsee attached summary of exposuresACORD 125 (2007/10)DATEOF CLAIMCHK HEREIF NONESTATE SUPPLEMENT(S) (If applicable)Page 3 of 3
OP ID: MKDATE (MM/DD/YYYY)COMMERCIAL GENERAL LIABILITY SECTIONPHONE(A/C, No, Ext):FAX(A/C, amedInsured)Aloha Insurance Services, Inc.75-5931 Walua Rd.Kailua-Kona, HI 96740TJ Kona, Inc.CODE:AGENCYCUSTOMER ID:EFFECTIVE DATEEXPIRATION DATE03/01/1803/01/19PAYMENT PLANDIRECT BILLXAUDITAGENCY BILLFORCOMPANYUSE ONLYSUB CODE:KALAN-2COVERAGESX1/11/2018Kalanikai Condominiums AOAOLIMITSCOMMERCIAL GENERAL LIABILITYXCLAIMS MADEOCCURRENCEOWNER'S & CONTRACTOR'S PROTECTIVEDEDUCTIBLESPROPERTY DAMAGE BODILY INJURY PERCLAIM PEROCCURRENCEGENERAL AGGREGATE PRODUCTS & COMPLETED OPERATIONS AGGREGATE PERSONAL & ADVERTISING INJURY EACH OCCURRENCE DAMAGE TO RENTED PREMISES (each occurrence) MEDICAL EXPENSE (Any one person) EMPLOYEE BENEFITS MIUMSPREMISES/OPERATIONS PRODUCTS OTHER TOTAL OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137)SCHEDULE OF EXPOSUREPREM/OPS1Residental condos - assocrisk onlyU820051Swimming poolT1005RATING AND PREMIUM BASIS(S) GROSS SALES - PER 1,000/SALES(P) PAYROLL - PER 1,000/PAY(A) AREA - PER 1,000/SQ FTRATETERR(C) TOTAL COST - PER 1,000/COST(M) ADMISSIONS - PER 1,000/ADMPREMIUMPRODUCTSPREM/OPSPRODUCTS(U) UNIT - PER UNIT(T) OTHERCLAIMS MADE (Explain all "Yes" responses)Y/NEXPLAIN ALL "YES" RESPONSES1. PROPOSED RETROACTIVE DATE:2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE3. 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 LIABILITY1. DEDUCTIBLE PER CLAIM:2. NUMBER OF EMPLOYEES:ACORD 126 (2007/05) 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS:4. RETROACTIVE DATE:Page 1 of 4 ACORD CORPORATION 1993-2007. All rights reserved.The ACORD name and logo are registered marks of ACORD
KALAN-2CONTRACTORSOP ID: MKY/NEXPLAIN ALL "YES" RESPONSES (For past or present operations)1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?N2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?N3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?N4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?N5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?N6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?NDESCRIBE THE TYPE OF WORK SUBCONTRACTED PAID TO SUBCONTRACTORS:% OF WORKSUBCONTRACTED:# FULLTIME STAFF:# PARTTIME STAFF:None, if any onlyPRODUCTS/COMPLETED OPERATIONSPRODUCTSANNUAL GROSS SALES# OF UNITSTIME INMARKETEXPECTEDLIFEINTENDED USEPRINCIPAL COMPONENTSincluded0EXPLAIN ALL "YES" RESPONSES (For any past or present product or operation)PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC.Y/N1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?N2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES", attach ACORD 815)N3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?N4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?N5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?N6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?N7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER APPLICANT LABEL?N8. PRODUCTS UNDER LABEL OF OTHERS?N9. VENDORS COVERAGE REQUIRED?N10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?NACORD 126 (2007/05)ATTACH TO ACORD 125
ADDITIONAL INTEREST/CERTIFICATE RECIPIENTINTERESTRANK:ADDITIONAL INSUREDLOSS PAYEEMORTGAGEENAME AND ADDRESSKALAN-2ACORD 45 attached for additional namesXREFERENCE #:CERTIFICATE REQUIREDCertified Management Inc.Susan Gregg75-169 Hualalai RdKailua Kona, HI 96740OP ID: MKINTEREST IN ITEM NUMBERLOCATION: 1BUILDING:VEHICLE:BOAT:SCHEDULED ITEM NUMBER:OTHERLIENHOLDEREMPLOYEE AS LESSORX mgmt agentITEM DESCRIPTION:GENERAL INFORMATIONY/NEXPLAIN ALL "YES" RESPONSES (For all past or present operations)1.ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?N2.ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS?N3.DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, ORTRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc)N4.ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS?N5.MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS?N6.ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED?N7.ANY PARKING FACILITIES OWNED/RENTED?Y8.IS A FEE CHARGED FOR PARKING?N9.RECREATION FACILITIES PROVIDED?N10. IS THERE A SWIMMING POOL ON THE PREMISES?Y11. SPORTING OR SOCIAL EVENTS SPONSORED?N12. ANY STRUCTURAL ALTERATIONS CONTEMPLATED?N13. ANY DEMOLITION EXPOSURE CONTEMPLATED?N14. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?N15. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?N16. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?NACORD 126 (2007/05)Page 3 of 4
KALAN-2GENERAL INFORMATION (continued)OP ID: MKY/NEXPLAIN ALL "YES" RESPONSES (For all past or present operations)17. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?N18. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS?N19. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?N20. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?NREMARKSNone, if any onlyANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANYFACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY: SUBSTANTIAL] CIVILPENALTIES. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR or VT. In DC, LA, ME, TN, VA and WA insurance benefits may also be denied).IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR ANAPPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.ACORD 126 (2007/05)Page 4 of 4
OP ID: MKACORDTMPROPERTY SECTIONPHONE(A/C, No, Ext): 808-334-0044FAX808-334-0115(A/C, No):AGENCYCODE:AGENCYCUSTOMER ID:KALAN-2PREMISES #:1COINS %14,669,360ADDITIONAL WER/HEATINCLCAUSES OF LOSSMININGELEC MEDIAINFLATIONGUARD %BLKTCOVDEDUCTIBLEFORMS AND CONDITIONS TO APPLY100002% HURRDAYSEXTRA EXPENSETUITION FEESOFF PREM POWERDAYS STUDENTSPOWER OTHER EDSERV/INCWATERMO PERIODLIMITORD OR LAW AUDITAGENCY BILLBUSINESS INCOME W/O EXTRA EXPENSEDED180 DAYS% COINSXSPECIALEXT PERIOD 90 DAYSPAYMENT PLANDIRECT BILL75-5681 Kuakini Hwy kailua Kona HI 96740CondosBUSINESS INCOME / EXTRA EXPENSEORDINARY PAYROLLNON MFGEXPIRATION DATESTREET ADDRESS:AMOUNTBUILDINGEFFECTIVE DATEBLDG DESCRIPTION: ResidentalBUILDING #:SUBJECT OF INSURANCEKalanikai Condominiums AOAOFORCOMPANYUSE ONLYSUB CODE:PREMISES oha Insurance Services, Inc.75-5931 Walua Rd.Kailua-Kona, HI 96740TJ Kona, Inc.TYPE OF BUSINESSDATE (MM/DD/YYYY)DEPEND PROP% COINCONT LOCCOMM(DESCR BELOW)REC LOCMAX PERIODMFG LOCDAYSLDR LOC (DESC BELOW)EXTRAEXPENSENAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROPDAYS PERIOD RESTLIMIT LOSS PAY%%# STORIES # BASM'TSYR BUILT%%ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATIONDISTANCE TOHYDRANTFIRE STATCONSTRUCTION TYPESEE NOTES100 FTWIRING, YR:ROOFING, YR:2 MIX0814TAX CODERIGHT EXPOSURE & DISTANCECONDOS0197664,576OTHER OCCUPANCIESNONEWIND CLASSOTHERCONDOSBURGLAR ALARM TYPE3TOTAL AREATSEMIRESISTIVERESISTIVELEFT EXPOSURE & DISTANCEOTHER:5ROOF TYPEPLUMBING, YR: 14HEATING, YR:PROT CLKAILUA KONA/BLDG CODEGRADEBUILDING IMPROVEMENTSXXFIRE DISTRICT/CODE NUMBERHEATING BOILER ON PREMISES?YESIF YES, IS INSURANCE PLACED ELSEWHERE?YESXXNONOREAR EXPOSURE & DISTANCEPARKING/COMMCERTIFICATE #EXPIRATION DATEEXTENTGRADECENTRAL STATIONNONEWITH KEYSBURGLAR ALARM INSTALLED AND SERVICED BY# GUARDS/WATCHMENCLOCK HOURLY0PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)SMOKE DET/EXTING% SPRNKFIRE ALARM MANUFACTURERCENTRAL STATION0LOCAL GONGADDITIONAL INTERESTSRANK:NAME AND ADDRESS:REFERENCE #:CERTIFICATE REQUIREDINTERESTINTEREST IN ITEM D ITEM NUMBER:OTHER:ITEM DESCRIPTION:VALUE REPORTING INFORMATIONREPORTING FORM: PROVIDE AVERAGE VALUES FOR PAST 12 MONTHSSUBJECT OF INSURANCEACORD 140 (2002/09)PREMISES/BUILDINGANY OTHER LOCATION DECLAREDAT INCEPTIONATTACH TO APPLICANT INFORMATION SECTIONANY OTHER LOCATION ACQUIREDAFTER INCEPTIONPREMISES NOT OWNEDOR ACQUIREDLIMIT ACORD CORPORATION 1985
KALAN-2ADDITIONALPREMISES INFORMATIONPREMISES #:STREET ADDRESS:BUILDING #:BLDG DESCRIPTION:SUBJECT OF INSURANCEAMOUNTADDITIONAL INFORMATIONTYPE OF BUSINESSVALUATIONCAUSES OF LOSSBUSINESS INCOME / EXTRA EXPENSEORDINARY PAYROLLNON MFGCOINS %EXCLMFGPOWER/HEATINCLMININGDEDELEC MEDIA90 DAYSDAYSTUITION FEESFORMS AND CONDITIONS TO APPLYEXTRA EXPENSEOFF PREM POWERSTUDENTSPOWER OTHER EDSERV/INCWATERLIMITORD OR LAW BLKTCOVDAYS MO PERIOD180 DAYS% COINSDEDUCTIBLEBUSINESS INCOME W/O EXTRA EXPENSEEXT PERIOD INFLATIONGUARD %OP ID: MKDEPEND PROP% COINCONT LOCCOMM(DESCR BELOW)REC LOCMAX PERIODMFG LOCDAYSLDR LOC (DESC BELOW)EXTRAEXPENSENAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROPDAYS PERIOD RESTLIMIT LOSS PAY%%# STORIES # BASM'TSYR BUILT%%ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATIONDISTANCE TOHYDRANTFIRE STATCONSTRUCTION TYPEFTFIRE DISTRICT/CODE NUMBERBLDG CODEGRADEPLUMBING, YR:ROOFING, YR:HEATING, YR:TAX CODEROOF TYPEOTHER OCCUPANCIESWIND CLASSRIGHT EXPOSURE & DISTANCESEMIRESISTIVELEFT EXPOSURE & DISTANCEBURGLAR ALARM TYPECERTIFICATE #OTHER:TOTAL AREAMIBUILDING IMPROVEMENTSWIRING, YR:PROT CLRESISTIVEOTHERHEATING BOILER ON PREMISES?YESNOIF YES, IS INSURANCE PLACED ELSEWHERE?YESNOREAR EXPOSURE & DISTANCEEXPIRATION DATEEXTENTGRADECENTRAL STATIONWITH KEYSBURGLAR ALARM INSTALLED AND SERVICED BY# GUARDS/WATCHMENPREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)% SPRNKFIRE ALARM MANUFACTURERCLOCK HOURLYCENTRAL STATIONLOCAL GONGADDITIONAL INTERESTSRANK:NAME AND ADDRESS:REFERENCE #:INTERESTCERTIFICATE REQUIREDINTEREST IN ITEM D ITEM NUMBER:OTHER:ITEM DESCRIPTION:REMARKSPremise 1see attached exposure summary by building.ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNINGANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY:SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied)ACORD 140 (2002/09)
POLICY LEVEL INFORMATIONCOV CODEDESCRIPTIONBuilding BlanketKALAN-2LIMIT 1LIMIT 214,669,360.00NAICS:ATTACH TO ACORD PROPERTY SECTIONDEDUCTIBLE10,000.00OP ID: MKCODE 12% HURCODE 2
KALAN-2PREMISES #:ADDITIONALPREMISES INFORMATION1BUILDING #:SUBJECT OF INSURANCESTREET ADDRESS:75-5681 Kuakini Hwy kailua Kona HI 96740BLDG DESCRIPTION:Residental CondosAMOUNTBUILDINGCOINS %14,669,360ADDITIONAL INFORMATIONTYPE OF BUSINESSEXCLMFG10000FORMS AND CONDITIONS TO APPLY2% HURRTUITION FEESDAYSEXTRA EXPENSEOFF PREM POWERDAYS STUDENTSPOWER OTHER EDSERV/INCWATERMO PERIODLIMITORD OR LAW BLKTCOVDEDUCTIBLEBUSINESS INCOME W/O EXTRA EXPENSEDEDELEC MEDIAINFLATIONGUARD %SPECIALEXT PERIOD 180 DAYS% COINSRCPOWER/HEATINCL90 DAYSMINING100CAUSES OF LOSSBUSINESS INCOME / EXTRA EXPENSEORDINARY PAYROLLNON MFGVALUATIONOP ID: MKDEPEND PROP% COINCONT LOCCOMM(DESCR BELOW)REC LOCMAX PERIODMFG LOCDAYSLDR LOC (DESC BELOW)EXTRAEXPENSENAME AND ADDRESS(ES) FOR OFF PREM POWER OR DEPEND PROPDAYS PERIOD RESTLIMIT LOSS PAY%%# STORIES # BASM'TSYR BUILT%%ADDITIONAL COVERAGES, OPTIONS, RESTRICTIONS, ENDORSEMENTS AND RATING INFORMATIONDISTANCE TOHYDRANTFIRE STATCONSTRUCTION TYPESEE NOTES100 FT2 MIWIRING, YR:ROOFING, YR:0814XPLUMBING, YR:RIGHT EXPOSURE & DISTANCECONDOSTAX CODE5ROOF TYPE0197664,576OTHER OCCUPANCIESNONEWIND CLASSSEMIRESISTIVERESISTIVELEFT EXPOSURE & DISTANCEOTHERCONDOSBURGLAR ALARM TYPE3TOTAL AREAT14HEATING, YR:OTHER:PROT CLKAILUA KONA/BLDG CODEGRADEBUILDING IMPROVEMENTSXXFIRE DISTRICT/CODE NUMBERHEATING BOILER ON PREMISES?YESIF YES, IS INSURANCE PLACED ELSEWHERE?YESXXNONOREAR EXPOSURE & DISTANCEPARKING/COMMCERTIFICATE #EXPIRATION DATEEXTENTGRADECENTRAL STATIONNONEWITH KEYSBURGLAR ALARM INSTALLED AND SERVICED BY# GUARDS/WATCHMENCLOCK HOURLY0PREMISES FIRE PROTECTION (Sprinklers, Standpipes, CO2/Chemical Systems)SMOKE DET/EXTING% SPRNKFIRE ALARM MANUFACTURERCENTRAL STATION0LOCAL GONGADDITIONAL INTERESTSRANK:NAME AND ADDRESS:REFERENCE #:INTERESTCERTIFICATE REQUIREDINTEREST IN ITEM D ITEM NUMBER:OTHER:ITEM DESCRIPTION:REMARKSPremise 1see attached exposure summary by building.ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE ORSTATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNINGANY FACT MATERIAL THERETO, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND [NY:SUBSTANTIAL] CIVIL PENALTIES. (Not applicable in CO, HI, NE, OH, OK, OR or VT; in DC, LA, ME, TN and VA, insurance benefits may also be denied)APPLIED 140SCHED (2002/09)
OP ID: MKSTATEMENT OF VALUESDATE (MM/DD/YYYY)1/11/2018PHONE(A/C, No, Ext):FAX(A/C, No):AGENCY808-334-0044808-334-0115Aloha Insurance Services, Inc.75-5931 Walua Rd.Kailua-Kona, HI 96740TJ Kona, Inc.COMPANYSUBCODE:KALAN-2POLICY NUMBEREFFECTIVE DATE1INSURED / APPLICANTKalanikai Condominiums AOAOFS50591OF103/01/18HEADQUARTERS ADDRESS75-169 Hualalai Road Kailua Kona, HI 96740APPLICABLE CAUSES OF LOSS80%AGENCY CUSTOMER IDPAGEGolden Bear Insurance CoCOINS %CODE:NAIC CODE:BASICEARTHQUAKE COV90%BROAD100%SPECIALFLOODSPRINKLERLEAKAGE EXCLSPECIFIC AVERAGE RATEREQUESTEDBLANKET RATE REQUESTEDVANDALISM EXCLAPPLICABLE FORM NUMBERS (Attach completed forms and endorsements that require completion to provide necessary information affecting rates or loss costs)CLASSCODELOC#BLDG#ACV/RCDESCRIPTION AND ADDRESS OF PROPERTYSUBJECT1100% VALUESRATE ORLOSS DRESS:TOTAL N/A INSTRUCTIONSSIGNATURE1. ACV (Actual Cash Value) or RC (Replacement Cost): If other valuation basisapplies, provide necessary information.ALL VALUES AND LOCATION INFORMATION ARE CORRECT TO THE BEST OF MY KNOWLEDGEAND BELIEF2. SUBJECT:B BuildingS StockF Furniture & FixturesM MachineryBPP Your Business Personal PropertyPPO Personal Property of OthersBI Business Income R Rental Income Other - specifyINSURED'SSIGNATURE:3. RATE OR LOSS COST: For class rated property, attach class rate informationform or equivalent information for each location. For specifically rated property,attach specific rate or loss cost information if known.ACORD 139 (2004/03)TITLE:DATE: ACORD CORPORATION 1996
Aloha Insurance Services, Inc. Golden Bear Insurance Co 75-5931 Walua Rd. Kailua-Kona, HI 96740 TJ Kona, Inc. PROPERTY FS53050 TJ Kona, Inc. 808-334-0044 808-334-0115 X ais@alohainsurance.com X KALAN-2 X X 12:01 03/01/18 03/01/19 X c/o Touchstone Properties, Ltd 680 Iwilei Rd Ste 777 Honolulu, HI 96817 Kalanikai Condominiums AOAO 808-556-4110
