15-0505_Bond_SUR21000014_Pacific Point Dev_TR 16752 Premium: $641.00
SUBDIVISION FAITHFUL PERFORMANCE BOND
(GOVERNMENT CODE 66499.2)
Bond No. SUR21000014
Replaces Bond No. SUR20000344
KNOW ALL MEN BY THESE PRESENTS, that Pacific Paint Development Partners, t_r_C
(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:
Sanitary Sewer subdivision improvements within Tract 16752 as defined within Amendment#1 and
Reinstatement of the Subdivision Improvement Agreement for Tract 16752
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
Eighty Five Thousand Four Hundred Eighty Five Dollars and 00/100 Dollars, ($85,4$5.00 ) 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)
Its: ►.) or`► �� tn - r
SURETY:
Ironshore Indemnity Inc.
(NOTARIZATION AND SEAL)
By: _
Margare . Ginem , Attorney-in-Fact
Surety Phone No 010 WILLIS OF FLORIDA
4211 W.BOY SCOUT BLVD,#1000
TAMPA, FL 33607
@NQU1RIES:(013)261-2095
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 to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California )
County of } )
On 1 before me,
to , Ile serl Nanrle and Title of tae fficer
personally appeared
Name(s)of Sig er(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
5
W,CORE}I is true and correct.
Mi Commisalon#2088325 WITNESS my hand and official seal.
Notary Public-California
Orange County
MY Comm.Expires Oct 31,2018 J
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(ies) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑Corporate Officer — Title(s):,- ❑Corporate Officer — Title(s):
❑ 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 FLORIDA
COUNTY OF HILLSBOROUGH I 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 a4)5�
Anett Cardinale
=ti+Yi ANETT CARDINALE
e. «= Commission#FF 138482
Expires July 28,2018
Bonded Thru Troy Fain Insurance 800385-7019
r
This area for Official Notarial Seal
] estate.IBM. 1'0$0, e>jds -$ectiotis.1-:189 ana 19 'o the:civil,co'db-3nd seaiw 820 of the
GoyerpMeAt.Cod&j,relat�ngio'no'i es;pAbjfev�'TlYd lielpformat of e new.diosure
nqo ce,is anempple;.forpur ao pf illus#xatior
A riatat+ ,4f is off`other dffider coiij iptina thl�
certifidate verifiies.onlythe identity-6f the
individual vrho_signed the dauine�at Io wftl7s
cerxif tate.is attached,and not the trrathfulnessi
Aeci#raOy,or VUil ty of tba;_dc,�upient
Si*bf Ca'lifornia-
.61inty of
0r1
fere
insert name and'title of efficer�,'personally appeared Who
prraVedto o oti-the,basis.of' atisfatc>ry.eviderice to G '#he'pexxom( }'Whost nanie(s)Is/ sulscribed to
%6- Nvithin nistmment and ,acknowledged to me,'that,helshelthey exeouted the saner.in his/herltheit
avt7tpril�d .capacrty es},. it n[.1 y is iet Iie is �3 atute(s) `4tl;tl e insttrufn llt e son(S),.or,' the
'entity,upoii-behalf of--wliieh'the pefsoii(I).aded,.ekecoted t}i ,ristrunaent♦
I:. ert 'ittider
PENALITlJRY iiritier Elie law§'of fie.Mateo Gal%fonEaia f at the'fc i of i
paragraph is true and correct
Wn NESS 4,ymhAnd and officiak seal'.
Sig afore —_ (Sea]).
POWER OF ATFORNEY
Ironshore Indemnity Inc. III- 21000014
KNOW ALL MEN BY THESE PRESENTS,that 12ONSHORE 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 an behalf of the Company any bonds,undertakings,policies,contracts of indemnity or other writings obligatory
in nature of a bond not to exceed$7,500,000 dollars,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 itis 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.
ycSotP°k.,'.
A
9EI1L
, 7979
By:
Da L.Suss n
Director
ACKNOWLEDGEMENT
On this 7th 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.
,,„`, YGs,•- AMV L TAYLOR d, f.
Nolary Publlc-Slate-'ennessee
% ' Davltlson counry -
qqMy commisslon Ex°fires o4°&7a 4A.Y�. ay
,''.; •`'�l Notary Publlc
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 191h Day of MayZp 15
LONF°ssy.
SenL'� .
tfl14
Paul 5.GI dano 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.”
IRONSNORE iNDEMNITY WC
FINANCIAL STATEMENT SUMMARY
As of December 31,2014
ASSETS
LIABIUiIES
Bonds
$179,240,947 tosser
$63,584,066
Preferred stocks 0 Reinsurance payable on paid losses and loss ad)ustenent expenses 0
Common stocks
31,840,141 Loss adjustment expenses $10,384,957
Mortgage loans on real estate:{ant Iens 0 Commisshons payable,contingent eommis cwts and other similar charges $1,020,805
Mortgage Irons on real estate,DOW than first liens 0 Other expenses(exquding taxes.licenses and fees) $5,435,126
Properties occupied by the company 0 Taxes,licenses and fees(excluding federal and foreign Income taxes) $2,383,909
Properties held for the production of income 0 Current federal and foreign Income taxes $2,434,392
Properties hold for We 0 Na deferred tax liability
Cash,cash equivalents and short-term investments $15,632,951 6
� Unearned premiums $29,158,576
Contract lom 0 Advance premium
Derivatives 0 Ceded reinsurance premiums payable(net of ceding commissions) $58,222,187
Other invested assets 0 Funds held by company under reinsurance treaties 0
Rece Iva Wes for securities 0 Amounts withheld or retained by company for account of others
Securities lending reinvested coliatervassets 0 Remittances and items not allocated
Aggregate write-ins forinvested assets 0 Provision for reinsurance $1,545,075
Sublotals.cash and Invested assets $216,61039 Net adjustments inassets and LabllHles due to foreign exchange rates
Title plants leis$6,Charged off 0 Drafts outstanding
Investment Income due and accrued $990,960 Payable to parent,subsidiaries and of118ates
Uncollected premiums and agents'balances in the course of collection $73,567,547 $12,458110
7 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 recoveraVe from reinsurers $33,586,257 LiablBry for amounts held under uninsured plans 0
Funds held by or deposited vdth reinsured companies 0 Aggregate wrlte-Ines for liabilities
$4,185,928
Other amounts receivable under reinsurance contracts 0 Total liabilities excluding protected ce011abllltles $190,811,131
Amounts receivaWe relating to unlruured plans 0 protected cell liabllitles
Current federal and foreign income tax recoverable and interest thereon 0
Net deferred tax asset $5,530,837 Tod liabilities
$190,811,131
Guaranty funds recelvsbk ex on depasht
0
Furniture and equipment,including health are delivery assets 0 POLICY1401DERSS SURPLUS
Net adjustment In assets and liabilities due to forBgn exchange rates 0 Aggregate wntrlos for special surplus funds 0
Receivables from parent,subsidiaries and affiliates 0
Health care and other amounts receivable 0 Common ap tal stock 5 000 000
Aggregate write-Ins for other than Invested assets $7124,971 Preferred capital stock
Total assets excluding rate Accounts, $347,414,611
g Sspa Segregated Account and Protected Cel Aggregate wrlte+rq faother than special surplus 0
Accounts
from Separate Accounts,Segregated Accounts and Protected Cell Accounts 0 Surplus Notes
TOTALS $347 414 611 Gross paid In and contributed surplus
$156,938,671
Unassigned funds jaurplusi ($5,335,190)
Surp`ui as regards policyholders $156,603,481
TOTALS
$347,414,611
SUBSCRIBEDandxworn toren this rdayofl�/thy
My commis-n expires 7.70
Notary Public
CERTIFICATE moi" ^• Prigted Name ALYSSA TURKOVIIZ
Not Public,State of N
I certNy that the above financial statements to the bestaf my � 9YV York
knowledge are a true and accurate reflection of the Onarclal ALY5SATURKCNM No.01 TU6044514
condition of the Company as of December 31,2014, j QIJf]iilie3Cl In Westchester County
Additionally,I certify that the above financial statements are u _ f r, ,Z Cf17fTt6ltX1apirer.July 10.2016
in agreement wlth the Statutory Financial Statements fated with the Texas Nobe bile,State of New York '7
Department of Insurance as of the same date, ,
No.OITU6044514
W81lam J Gleason Qualified In Westchester County
CftY.VP g`RILWUL Coramissfon Expires July 10,2014
SUBDIVISION LABOR AND MATERIAL BOND
(GOVERNMENT CODE 66499.2)
Bond No. SUR21000014
Replaces Bond No. SUR20000344
KNOW ALL MEN BY THESE PRESENTS, that Pacific Point Development Partners rwt_c
(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:
Sanitary Sewer subdivision improvements within Tract 16752 as defined within Amendment#1 and
Reinstatement of the Subdivision Improvement Agreement for Tract 16752
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
Eighty Five Thousand Four Hundred Eighty Five Dollars and 00/100^Dollars (U5,485.00 ) 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 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.
224- r / C_ (NOTARIZATION AND SEAL)
13y:
Margaret Ginem , Attorney-in-Fact
�,'/0 MLLIS OF FLORIDA
Surety Phone No. 411 pry,Spy SCOUT MVD,MOO
TAMPA, FL 33607
NQUIRIES:(813)2812095
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 to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document.
State of California )
County f )
On G before me,
Elate Here Insert N e an �-ntlfe Officer j
personally appeared IT I I � .
Names)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
r of the State of California that the foregoing paragraph
W. CORDI is true and correct.
Commission#2088325 WITNESS my hand and official seal.
Z �+ Notary Public-Czlifornia
Z Orange County
My Comm.Ex liras Oct 31,2018 Signature
S gnature 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(lies) Claimed by Signer(s)
Signer's Name: Signer's Name:
❑Corporate Officer — Title(s):,......__
El Corporate Officer — Title(s):
❑ Partner — ❑ Limited ❑General ❑ Partner — ❑ Limited ❑General
❑ Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: ❑ Othr:
Signer Is Representing: Signe7is Representing:
02014 National Notary Association -www.NationaiNotary.org - 1-800-US NOTARY(1-800-876-6827) Item#5907
ACKNOWLEDGEMENT BY SURETY
STATE OF FLORIDA
COUNTY OF HILLSBOROUGH I 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
ANETT CARDINALE
=; = Cammission#FF 138482
'4= Expires July 28,2018
",JJ „°�` Bonded Th.Troy Fein IneureM 800-3857078
This area for Oficial Notarial Seal
'Senate l3ill 1105:0, 4nehoo :Sections.1--189 a dad :l 195-of'fhe:C-i-Vl l'Cp&e amici Seo.t Oxi 8.10 of Iii,
c Yeijnkzte f.Coe felatin910 xtO "res:P4bJfb..no:b.elow.oypi.cal format of jtie.lew disclosiire
xxotice.js an+exatnpIL-,for Purpoewf iuu4ra*F4.
F.fib pbi lic of other oiii-ccf coiaipletirtg
cerEifioate verifies only the identity cif the
individual who:sided the do -0 wvli Clt. is
.cer ficato is attached,and not the truthfulness;
pLccuracy,Or yalldxty of t.ha:d uttterit.
St W of Ca)iforimia.
C.Qunty.of
Oh �.befi?re ine,
insert name anal title d-officer),penonally Appwod - who
fErQ�+� t o uri tfte`b sis.of° a S#a ,Ory evidence to I} `t o;persari(s)'i lion rianie{s}Woe suly crEbedip:
:tlie.Whirr-instrument and acknowledged to my lhat- hoshefthey excou#ed the,.same,° in- hislherJtheir-
autlYortW .capactty0e0, d'.that by.)iisi'herltlic:it`M ature(s) on,tbe."Wtlllhoiot e-Vbrson(s),;cif the
entity,ti.pcirt.behaif of whickl 6 persoti(`s)acted,ekecuted tlae'snstrwubnt
1�e. if I-9der PEN;A ,T�'`-OfFER.JURX finder tlae ]atvs'of tie.Siad of California that the faiipgoing
paragraph is true and correct.
WUNESS iii:}+liand and.official'sear, ;
St�at��e• . . ,. --- Sea]).
POWER OF ATTORNEY
Ironshore Indemnity Inc. III- 21000014
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 Attorneys)-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
in nature of a bond not to exceed $7,500,000 dollars,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,2D13
IRONSHORE INDEMNITY INC.
idab
r s"oavoa�P
.ce F3.
SEAL
3. 1919
By:
Ilan a Lr Suss n
Director
ACKNOWLEDGEMENT
On this 7 t 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.
AMY LAYLOR
Nolary Public-Stale of Tennessee
My
Dan County
�r. Comvidsomission EXDlfee 01.09-16 4AmyL. ayl l
"s
*�.�wa `�• - Notary Public
tr.rrum'+',
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 May 20 15
r"woe,.
•; eVi:G 1'
1919
• k,A�T
1
PauIS.Gi tfano
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 INDEMN11Y INC
FINANCIAL STATEMENT SUMMARY
As of December 31,2014
ASSETS
LIABILfT1ES
Bonds
$179,140,947 "'es
$63,582,066
Preferred stocks
p Reinsurance payable on paid losses and Inas atdJystment expenses
Common stocks 0
31,840,141 Lass adjustment expenses $10,384,957
Mortgage loans on real estate:First pens 0 Commissions payable,contingent commissions and other similar charges $1,020 0S
Mortgage loans on real estate,'Otherthan first liens 0 Other expenses(excluding taxes.llcensesand fees) $5,435,126
Properties occupied by the company 0 Taxes,licenses and fees(excluding federal and foreign Irimme taxes) $2,383,909
Properties held for the production of income 0 Current federal and foreign Income taxes
$2,434,392
Properties held for We 0 Net deferred tax liability 0
Cash,cash equivalents and short-term Investments $15,632,951 Unearned premiums $29,158,576
Contract loans 0 Advance premium
Derivatives 0 Ceded reinsurance prendums payable{net of ceding commissions) $58,222,187
Other invested assets 0 Funds held by company under reinsurance treaties
0
Receivables for securities 0 Amounts withheld or retalrled by company for amount of others
Securities lending reinvested collateral assets 0 Remittances and items not allocated
Aggregate write-Ins forinvested assets 0 Provision for reinsurance $1,545,075
Subtotals.cash and Invested assets $226,614,039 Net adjustments In assets and labllitlesdue toforeign exchange rates
True plants less$..,Charged off 0 Drafts outstanding
Investment Income due and accrued $990.960 Payable to parent,subsidiaries and efBNates $12,458,110
Uncollected press urns and agents'balances len the course of collection $73,567,547 Derivatives
0
Deferred premiums,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 recoverable from reinsurers $33,586,257 UsblNty foramounts held under uninsured plans 0
Funds held by or deposited with reimuredcompanies 0 Apgregatawrite4nsfor Nabllliks $4,185,928
Other amounts receivable under reinsurance contracts 0 Total liabilities excluding protected call liabilities
$190,811,131
Amounts receivab:e relating to unlrutired plans 0 Protected cell liabilities
Current federal and foreign income tax recoverable and interest thereon 0
Net deferred tax asset $5,530,837 Total liabilities
$190,811,131
Guaranty funds receivable or on deposit 0
Furniture and equlpmerrt,Including health care deBveryassets 0 POUCYHOLDERSSSiJRPLUS
Net adjustment In assets and llablUdes due to foreign exchange rates 0 Aggregatewtite•ins for special surplus funds 0
Receivables from parent,subsidiaries and affillates 0
Health care and other amounts receivable 0 Common capital stock 5,000 000
Aggregate write-Ins fa other than Invested assets $7,124,971 Preferred capital stock
Total assets excludingSeparate Accounts, $347,414,611
pa Segregated Accounts and protected Cel. Aggregate write=.m for other than special surplus p
Accounts
From Separate Accounts,Segregated Amounts and Protected Cell Accounts 0 Surplus Notes
TOTALS $347,41*611 Gross paid in and contributed surplus $156,938,671
Unassigned funds(;surplus; ($%33S,190)
Surp in as regards Policyholders $156,603,481
TOTALS $347,414,611
SUBSCRIBED and sworn to me thlsy-'fdsy of H'q�l .'G'%5
Mycommisscnexpires: 7./0-IT
19�.r�+- _.._. Notary Public
CERTIFICATE Printed Name ALYSSA TURKOVITZ
1 certify that the above financial statements to the best of my Notary Public,State of New YorkNO.01 TU6044.5�4
knowledge area true and accurate reflection of the flna tial ALYSSAWRXOVCT2
condition of the Company as of December 31,2014, _ ; , Quallfied h1 Westchwer Cwnty
Additionally,I certify that the above financial statements are x.4 1;:e/.,-1�;s,,:� ��„��.. �aion f:�Sf.]ir'Q'a JUIY 10.2010
in agreement with the Statutory Financial Statements filed with the Taxai Noor IrMir,Stele of New yolk__,--. j
Department of Insurance as of the same date. r
No.01TU6044514
WNHem J Gleason qualified In Westchester County
LfS7+-Y Tfaplkifii- Cornmission Expires July 10,2014