15-0505_Bond_SUR21000004_Pacific Point Dev_TR 16751 Premium: $1,062.00
SUBDIVISION FAITHFUL PERFORMANCE BOND
(GOVERNMENT CODE 66499.2)
Bond No. SUR21000004
Replaces Bond No. SUR20000341
KNOW ALL MEN BY THESE PRESENTS, that Pacific point Development Partners LLC
(hereafter designated as "Principal"), and Ironshore_Indemnity Inc. ,
as Surety (hereinafter called "Surety") agree to install and complete certain designated
public improvements as conditioned by City Council Resolution No's. 92-6-16-4 and
03-09-16-06.
WHEREAS, said Principal is required to furnish a bond pursuant to Municipal
Code Section 9-5.101 and 9-5.109 et seq., for the faithful performance to guarantee
certain work, more particularly described as follows:
Landscape subdivision improvements within Tract 16751 as defined within Amendment#1 and
Reinstatement of the Subdivision improvement Agreement for Tract 16751
NOW, THEREFORE, we, the Principal and Surety are held firmly bound unto the
City of San Juan Capistrano, (hereafter called "Obligee") in the penal sum of
One Hundred Fort One Thousand Five Hundred Sevent Eight Dollars and 001100 Dollars, ($141,578.00 ) lawful money
of the United States, for the payment of which sum well and truly to be made, we bind
ourselves, our heirs, successors, executors and administrators, jointly and severally,
firmly by these presents.
NOW, THEREFORE, the condition of this obligation is such that, if Principal shall
promptly and faithfully perform said improvement obligations within the fully executed
and recorded subdivision improvement agreement, then the obligation shall be null and
void; otherwise it shall remain in full force and effect.
Page 1 of 3
BE IT FURTHER RESOLVED:
1. As a part of the obligation secured hereby, and in addition to the face
amount specified, there shall be included costs and reasonable expenses and fees,
including reasonable attorney's fees, incurred by City in successfully enforcing such
obligation, all to be taxed as costs and included in any judgment rendered.
2. Said Principal, for value received, hereby stipulates and agrees that no
change, extension of time, alteration, or modification of the contract documents or of the
work to be performed thereunder, shall in any way affect its obligations or this bond, and
it does hereby waive notice of any such change, extension of time, alteration, or
modification of the contract documents or of work to be performed thereunder.
IN WITNESS WHEREOF, this instrument has been duly executed by the
Principal herein named on the 19th day of May , 2015 , the name and
corporate seal of each corporate party being hereto affixed and these presents duly
signed by its undersigned representatives pursuant to authority of its governing body.
PRINCIPAL:
Pacific Point Development Partners, LLC
(NOTARIZATION AND SEAL)
By:
Its:
SURETY:
Ironshore Indemnity Inc.
(NOTARIZATION AND SEAL)
B y: At 0'�
, a
Marga-0-
. Ginem r , Attorney-in-Fact
Surety Phone No. 010 WILLIS OF FLORIDA
4211 W,BOY SCOUT BLVD,#1000
PAMPA, FL 33607
NQUIRIES:(813)281-2095
Page 2 of 3
APPROVED AS TO FORM:
By:
NOTE: Please attach Acknowledgement and Power of Attorney
Page 3 of 3
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
document te,%A^ }" z;;2attached, -mt-the-truthfuhess accu
xacy;-or vafiditWtttat-dot.
State of C )
County alifornia f tI • �,'lr �r' USG{ r(�/
On A before me,
Date Here Insert e qn Title o thb Officer
personally appeared i E
Name(s)of Signer(s)
who ,proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) Is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(ies),and that by his/her/their signature(s)on the instrument the person(s),
or the entity upon behalf of which the person(s)acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
W.CORDI is true and correct.
M+
Commission#2088325 WITNESS my hand and official seal.
-* Notary Public•California
x Orange County -
My Comm.Ex Tres Oct 31,2016 Signature_
Signature of Notary Public
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: Document Date:
Number of Pages: Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑Corporate Officer — Title(s): ❑Corporate Officer —Title(s):
❑ Partner — ❑ Limited ❑General ❑ Partner — ❑ Limited ❑General Y
❑ Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: ❑ Other:
Signer Is Representing: Signer Is Representing:
RN
+. u. - - .> : - `L,.C"+" - _. _. ,._ "�'r,4y+aL a.-•r rHrm".[ -seerzca— .�,r '. ...r--0,,,.`-.._
02014 National Notary Association - www.NationaiNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907
ACKNOWLEDGEMENT BY SURETY
S)TATE OF FLORIDA
COUNTY OF HILLSBOROUGH SS-
On this 19th day of May, 2015 before me, personally came
Margaret A. Ginem, who is personally known to me (or proved
to me on the basis of satisfactory evidence) to be the person
who executed the within Instrument as Attorney-In-Fact on
behalf of Ironshore Indemnity Inc., and acknowledged to me
that he/she executed the within instrument on behalf of said
surety company and was duly authorized to do.
In witness whereof, I have signed and affixed my official seal on
the date in this certificate first above written.
Signature
Anett Cardinale
:?
�:P''V4 ANETT CARDINALE
._ Commission#FF 1313482
Expires July 28,2018
Bonded Thru Troy Fein Irxurenoe 900-385.7019
This area for Official Notarial Seal
s ec, ans aa b-OL Cort� ect o 't e
�rQ.v e .Code;tea tc� noun es.publfo:'Thb;be].Qtoys cA format-of�jie., ew.disclosure
vo ice:is-an.exa xfrle; dor .ptu poses a zTluStrat nrt
nrff ja iblic of other Officer caftiplefind#fifs:
cerfiffaate.verifses,onlythe identity ofthe
indi!r0ii4i who.signed,the docuimerit,tO wbidh
certificate.is attached,and not the truthfulness,
cci r Cy,or vatid,pe of th4;donrt ent
Stale'of 4 aliforinia
C,6unty_of
Ori ;beford ine,
insert name andtitle of offrcerj,Personally app red Who..
pravt ra to nig oil fho'bas':s.of'wisfactcrry.byiOg.hOo to be#lie p�xsori(s�.Whose naaie6-)is/ore si 4scribed tp:
thewilhid-ifisvuznent and acknowledged -to -me•'that: Wshe/they exenuted the same.in his/her/their c pac�tj+(ies), til At.by.,his/'her/thp* S#Rhatu a-W `t tfie'itistrfRof �e'v0son(s),:cif ,the
-entity, upon.hehalf of wbjpp the per'sbfi(s).acted,cxecuted ffk6 nstrurnent
1; Citi y'uYider ]'EN;AP_,`l -OF.'P R7UR wider the laws of the. t w ofCalifomia tho,the f rf-$oiriR,
para"h is true and correct
W TNES-9 iiiy.l and and,6fficral seal, r
Sgriatute fi�ealj�
POWER OF ATTORNEY
Ironshore Indemnity Inc. III- 21000004
KNOW ALL MEN BY THESE PRESENTS,that IRONSHORE INDEMNITY INC.,a Minnesota Corporation,with its principal office in New York,NY does
hereby constitute and appoint:David H.Carr,Anett Cardinale,Margaret A.Ginem its true and lawful Attorney(s)-In-Fact to make,execute,seal and
deliver for,and on its behalf as surety,any and all bonds,undertakings or other writings obligatory in nature of a bond.
This authority is made under and by the authority of a resolution which was passed by the Board of Directors of IRONSHORE INDEMNITY INC.on the
22nd day of April,2013 as follows:
Resolved,that the Director of the Company is hereby authorized to appoint and empower any representative of the company or other person or
persons as Attorney-In-Fact to execute on behalf of the Company any bonds,undertakings,policies,contracts of indemnity or other writings obligatory
xceec+-$_ 600-ftCompany might execute through its duly elected officers, and affix the seal of the
Company thereto. Any said execution of such documents by an Attorney-In-Fact shall be as binding upon the Company as if they had been duly
executed and acknowledged by the regularly elected officers of the Company,Any Attorney-In-Fact,so appointed,may be removed for good cause and
the authority so granted may be revoked as specified in the Power of Attorney.
Resolved,that the signature of the Director and the seal of the Company may be affixed by facsimile on any power of attorney granted,and the
signature of the 'Secretary,and the seal of the Company may be affixed by facsimile to any certificate of any such power and any such power or
certificate bearing such facsimile signature and seal shall be valid and binding on the Company.Any such power so executed and sealed and certificate
so executed and sealed shall,with respect to any bond of undertaking to which it is attached,continue to be valid and binding on the Company.
IN WITNESS THEREOF, IRONSHORE INDEMNITY INC. has caused this instrument to be signed by its Director,and its Corporate Seal to be affixed this
7th day of August,2013
IRONSHORE INDEMNITY INC.
r�1 $FkL
1917
By.
Dane L,Suss n
Director
ACKNOWLEDGEMENT
On this 71h Day of August,2013,before me,personally came Daniel L.Sussman to me known,who being duly sworn,did depose and say that he is the
Director of Ironshore Indemnity, Inc.,the corporation described in and which executed the above instrument;that he executed said instrument on
behalf of the corporation by authority of his office under the By-laws of said corporation.
ANIy L TAYLOR - Q,
Notary Public-stale of Tennessee
Davidson County
q, My—misslon E%olres 0t-09-16 4A.yL8
•'.,,"�eawwF.+`�� - Notary Public
CERTIFICATE
I, the undersigned, Secretary of IRONSHORE INDEMNITY INC., a Minnesota Company, DO HEREBY CERTIFY that the original Power of Attorney of
which the foregoing is a true and correct copy,is in full force and effect and has not been revoked and the resolutions as set forth are now in force.
Signed and Sealed at this 19th Day of.MayZD 15
Y�µp,60Rgr y
-
SEAL
$015
- � A
Paul S.Zal dark r
secretary
"WARNING:Any person who knowingly and with intent to defraud any insurance company or other person,files and application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent
insurance act,which is a crime and subjects such person to criminal and civil penalties."
IRONSHORE MDEMNITY INC
FINANCIAL STATEMENT SUMMARY
As of December 31,2014
ASSETS LIABILITIES
0onds
$179,140,947 lasses
$63,582,066
Preferred stocks Ps Reinsurance
D sable on paid losses and loss tsdjustment expenses p
Cominco stocks 31,844 141 Inas adjustment expenses $10,384,957
Mortgage loans on real atate.first tens 0 Commissions payable,contingent commissiorss and otherslmilar charges $1,020,805
Mortgage loans on real estate;Other than first Bens 0 Other expenses(eva"rigtaxes.licenses and fees) $5,435,126
Properties occupied by the company 0 Taxes,licenses and few(excluding federal and foreign Income taxa) $2383909
Fropernes heFd for the production of Income 0 Current federal and fosellinIncome taxes
$2,434,392
Properties held for sale 0 Net deferred taxllablllty 0
Cash.cash equivalents and short-term investments S15,632,9S1 Unearned premlums $29,158,576
Contract loans 0 Advance premium
Derivatives 0 Ceded reinsurance premiums payable(net of coding commissions) $58,222,187
other invested assets 0 Funds held by company under reinsurance treaties 0
Recclvablts for securitlts 0 Amounts withheld or retained by company for acwUntof others
Securities lending reinvested collateral assets 0 Remittances and Items not allocated
Aggregate wrlWns forinvested assets 0 Provision for reinsurance
$1,545,075
Subtotals.rash and Inresltd assail $226,614,039 Net adjustments In assets and labllRlw due to foreign exchange rates
Title plants less S.•,Charged off 0 Drift outstandka
Investment Income due and accrued $990„960 Payable to parent,subsidiaries and affiliates
$12,456,110
Uncollected preW ums and agents'balances In the course of collection $73,567,547 Derivatives
0
Deferred premlums,agents'balances and Installments booked but deferred and not 0
yet due Payable for securities 0
Accrued retrospective premiums 0 Payable for securities lending 0
Amounts recoverstaefrom reinsurers $33,586,257 Liability for amounts held under uninsured plans 0
Funds held by or deposited with otinsured companies 0 Aggregate write-Ins for liabilities $4,185,928
Other amounts receivable under reinsurance contracts 0 Total liabilities excluding protected Bell liabilities $190,811 131
Amounts receintKe relating to uninsured plans 0 Protected call liabilities
Current federal and foreign income tax recoverable and interest thereon 0
Nct dtfane6 Ws assts $5,530,837 Totalliabllltles
$190,811,131
0
Guaranty funds receivable or on deposit
Furrdtureand equipment Including health core delivery as" 0 POUCYMDERVS SURPLUS
Net adjustment In assets and liabilities due to foregn exchange rates 0 Aggregate wnte-Ins for special surplus funds
0
Receivables from parent subsidlarles and affllhtes 0
Health care and other s mounts receivable 0 Common capital stock
5,000.000
Aggregate write-ins for other than Invested asset $7„124,971 Preferred capital stock
Total assets excluding Separate Accounts,Segregated Accounts and Protected Cat $347,414,611
Aggregate write;res for other than special surplus p
Accounts
From Separate Accounts.Segregated Accounts and Protected Call Accuunts 0 Surplus Notes
TOTALS $347,414611 Gross paidlnandcontributedsurplus
. •._^_ r $156,938,671
l.inasslgned fundsjsurplus; ($5335,190)
Surp us as regards policyholders $156,603,481
TOTALS / $347,414,611
SUBSCRIBED and sworn tome INsxday of
...... �'�_ Notary Public
CERTIFICATE Pri,,ted Name ALYSSA TURKOVITZ
I certify that the above financial statements to the heNotary Public,State of NOW Yo*
tet my NO.t)1TUfi0445t 4
knowledge are atrueandaccurate reflectionofthefinwlal ALYSSATURKOVICI (�LT811fIeC1IFt ITU604 51 �`,CSl1
condition of the Company as of December 31,2014, ''
Additionally,I certify that the above financial statements are 4 .`•�, ,� I`lt�9 ,.. ybion i:.xPIft$8 July 10,2018
In agreement with the Statutory Financial Statements filed with the Texas Notatl;�+ubllc,State of Hew York _
Department of Insurance as of the same date- r
No.01YU6044514
WHIlamJ Gleason tluafified In Westchester County
MU—P&Ire85S9er Commission Expires July 10,2014
SUBDIVISION LABOR AND MATERIAL BOND
(GOVERNMENT CODE 66499.2)
Bond No. SUR21000004
Replaces Bond No.SUR20000341
KNOW ALL MEN BY THESE PRESENTS, that pacific Point Development Partners LLC
(hereafter designated as "Principal"), and Ironshore Indemnity Inc. ,
as Surety (hereinafter called "Surety") agree to install and complete certain designated
public improvements as conditioned by City Council Resolution No's. 92-6-16-4 and
03-09-16-06.
WHEREAS, said Principal is required to furnish a bond pursuant to Municipal
Code Section 9-5.101 and 9-5.109 et seq., for the faithful performance to guarantee
certain work, more particularly described as follows:
Landscape subdivision improvements within Tract 16751 as defined within Amendment#1 and
Reinstatement of the Subdivision Improvement Agreement for Tract 16751
NOW, THEREFORE, we the Principal and Surety are held firmly bound unto the
City of San Juan Capistrano, (hereafter called "Obligee") in the penal sum of
One Hundred Forty One Thousand Five Hundred Seventy Eight Dollars and 00/100 Dollars ($141,578,00 ) lawful
money of the United States, for the payment of which sum well and truly to be made, we
bind ourselves, our heirs, successors, executors and administrators, jointly and
severally, firmly by these presents.
NOW, THEREFORE, the condition of this obligation is such that if the above
bound Principal, his or its heirs, executors, administrators, successors or assigns, shal
in all things stand to and abide by and well and truly keep and perform the covenants,
conditions and provisions per City Council Resolution No's. 92-6-16-04 and 03-09-16-
06, on his or their part, to be kept and performed at the time and in the manner therein
specified, and in all respects according to their true intent and meaning, and shall
indemnify and save harmless the City, its offers, agents and employees as therein
stipulated, and, as necessary enter into a Subdivision Agreement, then this obligation
shall become null and void; otherwise it shall be and remain in full force and effect.
Page 1 of 3
BE IT FURTHER RESOLVED:
1. As a part of the obligation secured hereby, and in addition to the face
amount specified therefore, there shall be included costs and reasonable expenses and
fees, including reasonable attorney's fees, incurred by City in successfully enforcing
such obligation, all to be taxed as costs and included in any judgment rendered.
2. Said Principal hereby stipulates and agrees that no change, extension of
time, alteration, or modification of the terms of the agreement or of the work to be
performed thereunder, shall in any way affect its obligations or this bond, and it does
hereby waive notice of any such change, extension of time, alteration or modification of
the terms of the agreement or of the work or to the specifications.
IN WITNESS WHEREOF, this instrument has been duly executed by the
Principal herein named on the 19th day of Mav 2015 , the name and
corporate seal of each corporate party being hereto affixed and these presents duly
signed by its undersigned representatives pursuant to authority of its governing body.
PRINCIPAL:
Pacific Point Development Partners, LLC
(NOTARIZATION AND SEAL)
By:
Its: �, -
SURETY:
Ironshore Indemnity Inc.
(NOTARIZATION AND SEAL)
Marg et A. Ginem , Attorney-in-Fact
C10 WILLIS OF FLORIDA
Surety Phone No, 4211 W,Boy SCOUT 8t.W,VIMO
TAMPA, FL 33607
iNQUIRIES,(813)281-2095
Page 2 of 3
APPROVED AS TO FORM:
By:
NOTE: Please attach Acknowledgement and Power of Attorney
Page 3 of 3
CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE § 1189
A notary public or other officer completing this certificate verifies only the identity of the individual who signed the
do cum ent to wiGla thiscertificate is allaghed,and not tha 1rtrtlt#tlfless,-a=rW Gt-vafidity of tl at dauumUS11.
State of Califord )
County o )
r
On III before me,
Date ,Here Ins Nam d Toile 6f t e lbfflcer
personally appeared
{s) of Signer(s)
who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) Is/are
subscribed to the within instrument and acknowledged to me that he/she/they executed the same in
his/her/their authorized capacity(fes),and that by his/her/their signature(s)on the instrument the person(s),
or the entity_upon behalf of which the person(s)acted, executed the instrument.
I certify under PENALTY OF PERJURY under the laws
of the State of California that the foregoing paragraph
W.CORDI is true and correct.
Commission#2088325 WITNESS my hand and official seal.
Notary Public-California
Orange County
5 Comm. x Tres Oct 31,2018 Signature
lard
Signature of Notary Public
Place Notary Seal Above
OPTIONAL
Though this section is optional, completing this information can deter alteration of the document or
fraudulent reattachment of this form to an unintended document.
Description of Attached Document
Title or Type of Document: Document Date:
Number of Pages: Signer(s) Other Than Named Above:
Capacity(les) Claimed by Signer(s)
Signer's Name: Signer's Name: _
❑Corporate Officer — Title(s): ❑Corporate Officer — Title(s)-
El Partner — ❑Limited ❑General ❑ Partner — ❑ Limited ❑General
❑ Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑ Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: ❑ Other:
Signer Is Representing: Signer Is Representing:
02014 National Notary Association -www.NationalNotary.org - 1-800-US NOTARY(1-800-876-6827) Item#5907
ACKNOWLEDGEMENT BY SURETY
STATE OF FLORID
COUNTY OF HILLSBOROUGH SS.
On this 191h day of May, 2015 before me, personally came
Margaret A. Ginem, who is personally known to me (or proved
to me on the basis of satisfactory evidence) to be the person
who executed the within Instrument as Attorney-In-Fact on
behalf of Ironshore Indemnity Inc., and acknowledged to me
that he/she executed the within instrument on behalf of said
surety company and was duly authorized to do.
In witness whereof, I have signed and affixed my official seal on
the date in this certificate first above writte
Signature fr
Anett Cardinale
ANETT CARDINALE
Commission#FF 138482
Expires July 28,2018
Bonded Thni Troy Fein Ineumnee 800.38&7019
This area for Oficial Notarial Seal
e3. , amen. 's ec#�ori <189 acid I o :t] b Czvi ou 'Section 822 of the
3 !e ei i.fade;-Ye�ating fi{ ript ie . The-:beipphysIcal forinat of thenew di sclosure
-4p. 4ce.zs. example".forpm .0fiRusiratj ;
A notary'public off'other 6ff�d, 6*pipt ng tws
cert fcatevedfies only the identity of the
individual Whv signect the do uinerit.t K+i7IC ltllis
zertificate-is attached,and not the tTUth'fulness,
Y
�.eciira�r�.;o;validity��' �-dcicu�tcnt,
.Staff'Of4Mifornia.
Chanty.bf
faceme,
-ihsert name and�title of~-officer persv'nally appeared
Who
Proved tO II1;q,on tho basis ofsaftisffado�Y OviCl'dh6i to die th ptrsoo(g)wk�5t nan e(s�1s/arsCyto,
alae within-Wtrument and acknowledged to me'that;belshelthey ex4muted the-same an his/her/their,
autiao izefl ruapacity(ies}, tsd:that,F y. is;!l ez I# teior tutu.Ta) -qn.:oe iastr�Eta n't ire rsoia(S),. ifie
fitity ti ,it.behalf of rvhiP]i the person(§ , fd;eitecu'ted#iiOttsfiruniaent,
I; �rti Y Vider PENALT�C Or PER1U�Y undO.Oe )avvs of tie.�fia�t�gxt✓alifast�ia fat'the far�goisza
paragraph i's true and correct
WnNESSmy Rand and official seal,
Si.gafu're Sea]
POWER OF ATTORNEY
Ironshore Indemnity Inc. 1111- 21000004
KNOW ALL MEN BY THESE PRESENTS,that IRONSHORE INDEMNITY INC.,a Minnesota Corporation,with its principal office in New York,NY does
hereby constitute and appoint:David H.Carr,Anett Cardinale,Margaret A.Ginem its true and lawful Attorney(s)-In-Fact to make,execute,seal and
deliver For,and on its behalf as surety,any and all bands,undertakings or other writings obligatory in nature of a bond.
This authority is made under and by the authority of a resolution which was passed by the Board of Directors of IRONSHORE INDEMNITY INC.on the
22nd day of April,2013 as follows:
Resolved,that the Director of the Company Is hereby authorized to appoint and empower any representative of the company or other person or
persons as Attorney-In-Fact to execute on behalf of the Company any bonds,undertakings,policies,contracts of indemnity
nature of a bond not to exceed$7,500;0OU dollarsp which the Company might execute through its duly elected officers, and affix the seal of the
Company thereto. Any said execution of such documents by an Attorney-In-Fact shall be as binding upon the Company as if they had been duly
executed and acknowledged by the regularly elected officers of the Company.Any Attorney-In-Fact,so appointed,may be removed for good cause and
the authority so granted may be revoked as specified in the Power of Attorney.
Resolved,that the signature of the Director and the seal of the Company may be affixed by facsimile on any power of attorney granted,and the
signature of the Secretary, and the seal of the Company may be affixed by facsimile to any certificate of any such power and any such power or
certificate bearing such facsimile signature and seal shall be valid and binding on the Company.Any such power so executed and sealed and certificate
so executed and sealed shall,with respect to any bond of undertaking to which it is attached,continue to be valid and binding on the Company.
IN WITNESS THEREOF,IRONSHORE INDEMNITY INC.has caused this instrument to be signed by its Director,and its Corporate Seal to be affixed this
7th day of August,2013
IRONSHORE INDEMNITY INC.
=4 P
fiEAt
57l9
By:
Dart a L,Suss n
Director
ACKNOWLEDGEMENT
On this 71h Day of August,2013,before me,personally came Daniel L.Sussman to me known,who being duly sworn,did depose and say that he is the
Director of Ironshore Indemnity, Inc.,the corporation described in and which executed the above instrument;that he executed said instrument on
behalf of the corporation by authority of his office under the By-laws of said corporation.
j AM L TAYLOR
NOWry Publlc-Slate WTonnessee
Davldson County
m 4WD.E.Nes 97.09.76
MY GaAmy L,78
�•.,?a � t�r _ Nalury PuNk
CERTIFICATE
I, the undersigned, Secretary of IRONSHORE INDEMNITY INC., a Minnesota Company, DO HEREBY CERTIFY that the original Power of Attorney of
which the foregoing is a true and correct copy,is in full force and effect and has not been revoked and the resolutions as set forth are now in force.
Signed and Sealed at this 19th Day of_May20 15
- V$FURL sfi
1919
Pauls.Gi ,lona +
Secretary
'WARNING:Any person who knowingly and with intent to defraud any insurance company or other person,files and application for insurance or statement of claim
containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent
insurance act,which is a crime and subjects such person to criminal and civil penalties."
IRONSHORE INDEMNITY INC
FINANCIAL STATEMENT SUMMARY
As of December 31,2014
ASSETS
LIABILITIES
Bonds
$179,140,947 lasses
$63,582,066
Preferred stocks
p Reinsurance payable on paid losses and loss axijustmmt expenses
0
Common stocks 31,840,141 Loss adjustment expenses
$10,384,957
Mortgage loans on real estate;Antfms 0 Commissions payable,contingent commissions and other slm8archarges $1,020,805
Mortgage loans on real estate;Other then first liens 0 Other expenses(excluding taxes.licenses and(ees( $5,435,126
Properties occupied by the company 0 Taxes,licenses and fees(excluding federal and foreign kseometaxes) $2,383 909
rrupernes held For the production ofincome 0 Current federal and foreign income taxes $2,434,392
Properties held for We 0 Not deferred hu liability 0
Cash,cash equivalents aril short-term Investments $15,632,951 Uneamed premiums $29,158,576
Contract bans 0 Advance premium
Derivatives 0 Ceded reinsurance premiums payable(net of ceding commissions) $58,24187
Other invested assets 0 Funds held by company under relnsurancetreatles
0
Receivables for securities D Amounts withheld or retained by company for account of others
Securities lending reinvested collateral assets 0 Remittances and Nems not allocated
Aggregate write-Ins forinvestedassets 0 Provision for reinsurance $1,545,075
Subtotals.cash and invested assets $226,614,039 Net adjustments In assets and tabllttles due to foreign exchange rates
Thie plants less$.„Charged off 0 Drafts outstanding
Investment Income due and accrued $990,960 payable to parent,subsidiaries and affiliates
$12,458,110
Uncollected prom umsand agents'balances In the course of collection $73,567,547 Derivatives
u
yDeferred
eeff er ed premiums.agents'balances and Installments booked but deferred and not 0 Payable for securities 0
Accrued retrospective prerniums 0 Payable for securities lending 0
Amounts recoverable from reinsurers $33,586,257 Liability for amounts held under uninsured plans 0
Funds held by or deposited with reinsured companies 0 Aggregate write-Ins for liabilities $4,185,928
Other amounts receivable under reinsurance contracts 0 Total Ilabllitles excluding protected cell liablllties 5190,811,131
Amounts receive"relating to uninsured plans 0 Protected cell liabilities
Current federal and foreign Income ax recoverable and interest thereon 0
Net deferred tax asset $5,530,837 Total galblities
$190,811,131
Guaranty funds receivable or on deposit 0
Furniture and equipment,including health care delivery assets 0 POUCYHOLDEWS SURPLUS
Net adjustment In assets and liabilities due to foreign exchange rates 0 Aggregate write-Ins for special surplus funds
0
Receivables from parent'subsidiaries and affiliates 0
Health are and other amounts receivable 0 Common capital stock 5000000
Aggregate write-Ins for other than invested assets $7,124.971 Preferred capital stock
Total assets excluding Separate Accounts,Segregated Accounts and protected Cel; $347,414,511
Accounts Aggregate write dru for other then special surplus p
From Separate Accounts.Segregated Accounts and Protected Cell Accounts 0 Surplus Notes
TOTALS $347,414,,11 Gross paid In and contributed surplus
$156,930,671
Unassigned funds(surplusj ($5,335,1901
Surp us as regards polleyhoiders $156,603,481
TOTALS $347,414,611
SUBSCAMED and awom to con thisydad of MJ jY��7 j
�. Myromrmsacnex{xFes: 7 le)
}/ Notary Public
CERTIFICATE r" ^^ Printed Name ALYSSA TURKOVITZ
1 certify that the above0nancial statements to thebestof my Notary Public,State Of NOW York
knowledge are a true and accurate reflection of the financial ALYSSA TURKOVIIZ No.0171,16044514
condition of the Company as of December 33,2014, f Cluelf1ied in S Westchester cour y
Additionally,lcertify that the above financial statements are ti r.y�,`gr��� / / {.'i3iTtmlas1L7f1EY im July 10,2016
M agreement with the Statutory Financial Statements flied with tie`:Texan Nota44ubtl0tate of New York
Department of Insurance as of the some date s
No.OlIU6044514
WHllam J Gleason Qualified In Westchester County
JL4.V P&Tr4asvT[cr Conamissksn Explres July 10,2014