25 1 DOCUMENTS QUOTES Quotes You're one chat away from & coverage Matthew Morris Hello! I'm Matthew, your personal agent and U.S. BASED LICENSED AGENT insurance expert. To ask a question or finalize your coverage, please send me a message or Direct line: give me a call at 973-939-2605 8.30am - Spm | ee MONDAY - FRIDAY. We can also discuss 8.30am - 5pm | MONDAY - FRIDAY financing or payment options. EFTA00308028

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Workers' Compensation AmTrust Insurance Company of Kansas, Inc. HBB Best Rating: N/A Quote #: 1593659 Quote Coverage Details Bodily Injury by Accident, Each Accident $500,000 Bodily Injury Disease, Policy Limit $500,000 Bodily Injury Disease, Each Employee $500,000 These quotes are only estimates and are not a contract, binder or agreement to extend coverage.Your actual rates may be different depending on the underwriting criteria of each insurer and the specific characteristics of your business.Insurance taxes or other mandated premium surcharge may be billed in addition to the premium quotes.These preliminary quotes are available for your review for 30 days. $2,566 sensi EFTA00308029

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1184574 Neptune LLC ACORD 130 FL (Page 1 of 3) 3/12/2019 5:27:50 PM FLORIDA WORKERS COMPENSATION APPLICATION Automatic Data Processing Insurance Agency, Inc. 1 ADP Bivd. aoe =a | # | STREET, city, COUNTY, STATE, zIP CODE it 358 El Brillo Way, Palm Beach, FL 33480 ‘SPECIFY ADDITIONAL COVERAGES / ENDORSEMENTS [peeuencenconcmnon | is [mooreommemum | ig SS a ACORD 130 FL (2015/02) Page 1 of 3 © 1991-2015 ACORD CORPORATION. All rights reserved. EFTA00308030

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ACORD 130 FL 3/12/2019 5:27:50 PM GIVE COMMENTS AND DESCRIPTIONS OF ALL BUSINESSES, OPERATIONS AND PRODUCTS (INCLUDING OTHER STATES): MANUFACTURING - RAW MATERIALS, PROCESSES, PROOUCT, EQUIPMENT; CONTRACTOR - TYPE OF WORK, SUB-CONTRACTS; MERCANTILE - MERCHANDISE, CUSTOMERS, DELIVERIES; SERVICE - TYPE, LOCATION; FARM - ACREAGE, ANIMALS, MACHINERY, SUB-CONTRACTS. NUMBER. IF CONTRACTOR, PROVIDE LICENSE GENERAL INFORMATION EXPLAIN ALL “YES” RESPONSES 1. DOES APPLICANT OWN, OPERATE OR LEASE AIRCRAFT / WATERCRAFT? 2. DO/ HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(O) OTHER BISURANCE WATH THUS INBURER? STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING At ANY msl Tus OF HAZARDOUS MATERIAL? (e.g, lands, wastes, vel tanks, etc 18, ANY PRIOR COVERAGE DECLINED / CANCELLED / NON-RENEWED 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? 19. ARE EMPLOYEE HEALTH PLANS PROVIDED? 20. 1S THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS / SUBSIDIARY? 4 ANY WORK PERFORMED ON BARGES, VESSELS, DOCKS, BRIOGE OVER WATER? |_&. ARE SUB-CONTRACTORS ANDOR INDEPENDENT CONTRACTORS USED? |_| | ANY WORK SUBLET WITHOUT CERTIICATESOFING? || | 4. DOEMPLOYEES TRAVELOUTOFSTATE? ACORD 130 FL (2015/02) Page 2 of 3 EFTA00308031

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1184574 Neptune LLC ACORD 130 FL {Page 3 of 3) 3/12/2019 5:27:50 PM ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE OR AS OTHERWISE PUNISHABLE AS PROVIDED UNDER THE LAW. | UNDERSTAND THAT AS THE EMPLOYER, | MUST UPDATE THE APPLICATION MONTHLY TO REFLECT ANY CHANGE IN THE REQUIRED APPLICATION INFORMATION; (THE FLORIDA WORKERS COMPENSATION CHANGE SHEET WILL BE USED FOR THIS PURPOSE ) IF | FILE AN APPLICATION OR APPLICATION UPDATE CONTAINING FALSE, MISLEADING, OR INCOMPLETE INFORMATION WITH THE PURPOSE OF AVOIDING OR REDUCING THE AMOUNT OF PREMIUMS FOR WORKERS COMPENSATION COVERAGE IT IS A FELONY OF THE THIRD DEGREE OR AS OTHERWISE PUNISHABLE AS PROVIDED UNDER THE LAW. | SHALL SUBMIT TO THE CARRIER, A COPY OF THE EMPLOYERS QUARTERLY REPORT AND SELF-AUDITS SUPPORTED BY THE EMPLOYERS QUARTERLY REPORT, AS REQUIRED BY CHAPTER 443, AT THE END OF EACH QUARTER. IF | OMIT THE NAME OF AN EMPLOYEE FROM THIS EMPLOYERS QUARTERLY REPORT, FLORIDA STATUTES STATE THAT | WILL REMAIN LIABLE AND WILL REIMBURSE THE CARRIER FOR ANY WORKERS COMPENSATION BENEFITS PAID TO THIS OMITTED EMPLOYEE; | AGREE TO MAKE AVAILABLE, ALL RECORDS NECESSARY FOR THE PAYROLL VERIFICATION AUDIT AND PERMIT THE AUDITOR TO MAKE A PHYSICAL INSPECTION OF OUR OPERATIONS. | UNDERSTAND FAILURE TO DO THIS SHALL RESULT IN A $500 PAYMENT TO THE CARRIER TO DEFRAY THE COST OF THE AUDITS; THAT, IN ACCORDANCE WITH FLORIDA STATUTES 440.381(6), IF | (WE) UNDERSTATE OR CONCEAL PAYROLL, OR MISREPRESENT OR CONCEAL EMPLOYEE DUTIES SO AS TO AVOID PROPER CLASSIFICATION FOR PREMIUM CALCULATIONS, OR MISREPRESENT OR CONCEAL INFORMATION PERTINENT TO THE COMPUTATION AND APPLICATION OF AN EXPERIENCE RATING MODIFICATION FACTOR, | (WE) SHALL PAY A PENALTY OF TEN (10) TIMES THE AMOUNT OF THE DIFFERENCE IN PREMIUM PAID AND THE AMOUNT | (WE) SHOULD HAVE PAID, AND REASONABLE ATTORNEY'S FEES. FORMER NAMES AND OWNERS FOR THE LAST 5 YEARS, LIST THE CURRENT BUSINESS NAME AND ANY FORMER NAMES OR PREDECESSOR COMPANIES FOR ALL COMPANIES TO BE COVERED BY THE POLICY. INCLUDE THE FEIN FOR EACH COMPANY. FOR EACH COVERED COMPANY, LIST ANY CURRENT OWNER WHO HAS MORE THAN 5% OWNERSHIP INTEREST. FOR EACH COVERED COMPANY OR PREDECESSOR COMPANY, LIST ANY OWNER WHO HAD MORE THAN 5% OWNERSHIP INTEREST IN THE LAST 5 YEARS. OWNERSHIP / COMBINABILITY DOES THIS BUSINESS OR ANY OF THE OWNERS OF THIS BUSINESS, EITHER INDIVIDUALLY OR IN COMBINATION WITH OTHER OWNERS OF THIS BUSINESS, OWN MORE THAN 50% OF ANY OTHER BUSINESS, WHICH OPERATED AT ANY TIME DURING THE FIVE YEARS PRIOR TO THIS APPLICATION? Clves (Jno OR, DOES THIS BUSINESS OWN A MAJORITY INTEREST IN ANOTHER ENTITY, WHICH IN TURN OWNS A MAJORITY INTEREST IN ANY ENTITY THAT OPERATED AT ANY TIME IN THE FIVE YEARS PRIOR TO THIS APPLICATION? im CL YES NO IF THE ANSWER TO EITHER OF THE ABOVE QUESTIONS IS YES, COMPLETE THE FOLLOWING SUPPLEMENTAL OWNERSHIP / COMBINABILITY QUESTIONS: 1. IDENTIFY BY NAME, ADDRESS, AND FEIN EACH BUSINESS WHICH IS RELATED BY COMMON OWNERSHIP TO THE APPLICANT BUSINESS. 2. SET FORTH THE DATES EACH BUSINESS WAS IN OPERATION, THE INSURANCE COMPANY THAT PROVIDED WORKERS’ COMPENSATION INSURANCE, THE POLICY NUMBER AND THE EXPERIENCE MODIFICATION FACTOR APPLIED TO EACH SUCH POLICY. 3. IF THE POLICY WAS WRITTEN WITHOUT AN EXPERIENCE MODIFICATION FACTOR, PLEASE STATE. THE APPLICANT HEREBY AUTHORIZES AND REQUESTS EACH RATING ORGANIZATION WITH EXPERIENCE RATING INFORMATION RELATED TO THE APPLICANT AND THE BUSINESS SET FORTH ABOVE TO RELEASE SUCH INFORMATION TO THE INSURER, FWCJUA, OR OTHER RATING ORGANIZATION SO THAT THE CORRECT EXPERIENCE MODIFICATION FACTOR CAN BE DETERMINED. AS AGENT / PRODUCER, | HEREBY ATTEST THAT | HAVE GIVEN THE | HEREBY ACKNOWLEDGE THAT I HAVE READ THE ABOVE STATEMENTS AND APPLICANT/SIGNATORY THE OPPORTUNITY TO READ THE APPLICATION AND I PERSONALLY SWEAR THAT THE INFORMATION CONTAINED IN THE Tern ine pa, AS At Fe nan | cane Me Cuno reese PT | TO S100 THES APPLICATION ON BEHALF OF T | CLASSIFICATION CODES THAT ARE USED FOR PREMIUM CALCULATIONS AND TO BIND THE APPLICANT. PURSUANT TO SECTION 440.381 (2), FLORIDA STATUTES. ACORD 130 FL (2015/02) Page 3 of 3 EFTA00308032