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1245 NE 93 St (9)Regular Flood Insurance Program Insurance Competes Mamie= of Application and Declarations Form R REGULAR FLOOD National flood Insurers Association (For Use OMy With the Flood insurance Policy) INSURANCE PROGRAM (le Cooperation with the U.S. Government) Insurance is provided only (1) against the peril of flood as defined in the policy to which this form is attached, (2) with respect to those items specifically described herein and for which a specific amount of insurance is shown below, and (3) for the policy term specified below; and, unless otherwise provided, all conditions and provisions of this form and of the policy to which it is attached shall apply separately to each item covered. Imporgot Notices: This Policy does not cover loss resulting from a flood or mudslide occurrence already In progress on the date of this application. It is a condition of this insurance that property is not in violation of any Flood Plain l-aw or Ordinance. L Policy Term 1 Year, from 8/7/77 to 8/7/78 Inception (Mo. Day Yr.) Expiration (Mo. Day. Yr.) 1201 AM. Standard Time at location of the property involved, and thereafter for successive policy terms of 1 year, provided the then current premium payable by the Insured for each e policy term is paid prior to the expiration of the then current policy term, and if nct so paid this policy shall then terminate; provided, however, with respect ;v any m gagee (or trustee) named below, this insurance shall continue in — force only for the benefit of such mortgagee (or trustee) for 20 days after written notice to Rhe mo '.gee (or steel of termination of this policy, and shall then terminate. Community # 125098B FIRM Zon .�+ Yt A ITEM NO. 81 2. Cents. r Space for Agent's Name and Mating Address (Sticker) MOORE INSURANCE AGENCY, INC. 999 Brickell Avenue, Suite 413 Miami, Florida 33131 AMOUNT OF INSURANCE a) First Layer b) Second Layer a) $ 35,000. b) $ 35.000. $ 70,000. Total Total RATES .10 .10 Notice: The Premium for this Policy has been subsi- dized by the U.S. Government under the National Flood Insurance Act. Mortgagee (Building): Insert name(s) and Mailing Addressles) Second Mortgagee Exists Base Flood Yes ❑ No Elevation from FIRM First Floor Elevation -- Certify Dift. Plus (+1 or Minus ( —) To Nearest Foot NFIA•2 (Ed. 7 - 74) ACTUARIAL RATES AND PREMIUMS PREMIUMS Check Box ❑ If 215 Expense Constant Included. $ 50 It $ 35 $ 1sb Total $ ❑ Total $ 85 A PAYABLE BY THE INSURED RATES a) Payable b) Actuarial a► .10 b) .10 a) b) Grand Total Premium Payable By Insured —� Does Insured Qualify as "Small Business ?" Yes ❑ N Is Structure Single 2-4 Other Family M ; Family p; Residential. ©; All Other Q] Is This a Motel or Hotel Structure with normal occupancy of less than six (6) Months? Yes ❑ Y No EyN Is this "New Construction or Substantial Improvement "? Yes ❑y No qN N/A Date New Construction or Substantial Improvement started Is structure within ( corporate limits or unincorporated area of county. One Story — Basement ❑ 1 No Basement 2 Two or more Stories — Basement 03 No Basement ❑ 4 Split Level — Basement 05� No Basement 0 Mobile Home on Foundation ❑ TRA lkCOMIlfftQl)BY N.F.I.A. SERVICING OFFICE ORLAI;OO FLA 32803 SERV NY NAME AND ADDRESS COUNTERSIGNATURE DATE AUTHORIZED REPRESENTATIVE • FL RENEWAL: TES ❑ NO Xx Policy No. FL 423095 [+ l (IF RENEWAL. USE SAME NUMBER) lum N Name and . Count.. rO / Number, or Town, City or Town, County, State, hp Code) 7 S ANLEY D. KING & MARY KATHERINE'PANNILL KING 1245 N.E. 93rd Street Miami Shores, Dade, Florida 88138 PREMIUMS a) b) $ 85 $ 85 Total a1 $ b) $ $ Total 85 Occupied as Located at On Contents consisting principally of in the Enclosed Building Described Above 0: or Located at Loss Payee (Contents): CITIZENS FEDERAL -.VMS & LOAN ASSOCIATION 999 Brickell Avenue, Miami, Florida 33131 INSLJRED'S COPY Mortgagee pays new and renewal ❑ 1 renewal only�j Masonry walls -slab foundation Masonry walls -other foundation All other walls -slab foundation All other walls -other foundation Contents Rated as: All in Basement — Alt on First Floor — All on First Two Floors — AlI on First Floor & Basement — AlI on First Two Floors & Basement - All above First Floor — All in Mobile Home on Foundation Description aid Location of Property Covered (Location same as mailing address above unless otherwise indicated) dwelling INSERT NAME(S) AND MAILING ADPRESS(ES) LJQ 0 0 0 7/22/77 The above statements ueecorrect to the best of my knn�owledp. DATE OF APPLICATION I understand that any false state may Im puelsiable by Iir.3 or immisonment under 18 U.S. Code, Sec.1(81. any Check only one box Residential ❑ 04 ❑ 05 ❑ 06 ❑ 07 ❑ 08 ❑ 09 ❑ 03 SIGNATURE OF INSURED OR AGENT Agency 'nut's Tax Number 59- 0878054 All Other 0 1 ❑ 14 0 1 16 0 1 0 1 Q 1 Agent Certifies that following matters have been discussed with insured: 1) That loss already in progress on date of application is not covered; 2) Advantages of insuring the single family dwelling to at least 80% of the replacement cost of structure, at the time of loss. a 3