15-0505_Bond_SUR21000015_Pacific Point Dev_TR 15609 Premium: $225.00
SUBDIVISION FAITHFUL PERFORMANCE BOND
(GOVERNMENT CODE 66499.2)
Bond No. SUR21000015
Replaces Bond No. SUR20000321
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:
Monument subdivision improvements within Tract 15609 as defined within Amendment#1 and
Reinstatement of the Subdivision Improvement Aqreement for Tract 15609
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
Fifteen Thousand Five Hundred Dollars and 00/100 Dollars, ($15,500.00 ) 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: n
SURETY:
Ironshore Indemnity Inc.
(NOTARIZATION AND SEAL)
By: le - W.
MargareOk Ginem , Attorney-in-Fact
Surety Phone No.
C/O WILLIS OF FLORIDA
4211 W.BOY SC OUT BLVi),#1000
TAMPA, FL 33607 Page 2 of 3
INQUIRIES:(813)281-2095
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 )
C o u ntyof )
On �/
before me i ((�
fl
Dae Here lbsett Ncime Aand Title Officer
personally appeared
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(les),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.COROI is true and correct.
Commission#2088325 WITNESS my hand and official seal.
Notary Public•CelOornis
Orange County
'LID
Comm.E Ires Oct 31,2018
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
❑ Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: _ ❑ Other:
Signer Is Representing: Signer Is Representing:
j c'��-w4._-..�' _-.,^ ...." -_-'_ .�. ..G.5�-'.{."�iG --,�`Sr�SS�*t�"E:�u'z:�''z_.'�r'�aec:�;..r.��z�.,��xv.•.,,.,.,,.=,. .. _ _... .
02014 National Notary Association •www.NationalNotary.org • 1-800-US NOTARY(1-800-876-6827) Item#5907
i
`SCtiatc.Dill 1050; Alheil&;Sections-11$9 Widl 110'cid°tl�ie'Civil.tp& tad SeCt;O�i tO. of the
jQbYemmC*-Code,rClattinvo r�p#ar eS:*Ife;.�T13e'.lielp'w Pbysical format of tie.rim di§elosure
oface sxangle, for piaras°ctilustratm;
A.hOtg*.pb�lie of other 6fflGef coihplietirtg this;
cettifibate verifies only the i&mtity'of the
ind lv dual)vhv signed.the dbotnerit.to which fills
certifieate.is attached and not the trdth'fulness;
VA
'
accur40y,of realydtty of th4r docuptela't.
State ofCaiiforbia
.G.ounty.of
ifrsert name an,&title 6fofficer5,personally appwetl �;ho
proved t�3ri�orS�h�basis,of'satsfaGtbry.e►+idesice�ti�•#1ae.:persoit(�} vvlr�se'narie(s) sl$rc suliscrj bed:to
f b& withiri.-i6� ent and ackrxowledged to -me-'that:b0shelthey executed the.same:.in .hisllieritheirs
auth'Orized .capacity(0), utid fiat;by�is]her/their`-t!glxatur*) on.the'itistruiite tt a rersoi�(5}, vir Shq
�eritity upon.behalf of.�wliiCfltlie lier'snri(§,acted,exeac�,rted tIr�.Trlstnrruent,
1;edit(•y'ilnder PENAL.I` `C'l ? � RTIJRY wilder The laws of e.Mate v alj dmia hot the far-goiri
paragraph is true and:correct
WITNESS ii,y%hAnd aiid.0fiic al-sei
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
AgETT CARDINALE
Commission#FF 138482
. Expires.fufy 28,2418
Bonded Shw coy Fein k Mrenca BA0�3�3�t4i6
This area for Official Notarial Seal
POWER OF ATTORNEY
III- 21000015
Ironshore Indemnity Inc.
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
22"d 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 eleel.0 ufficers, and affix the seat 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.
F.AL
o.:919
By:
Dane L.Susffr
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.
Y �L
AMY L.TgYLOR
Nolary PuWlo-51ale of Tennessee
Davidson County
My Commission ExDlres 01-08-15 kmy L.Tp
���'t'.�s•' --- Notary Puldlc
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 MaV20 15
. uM.
" Fi EIL
tn14
Paul s.6i dart
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."
IRO NSNORE SNOEMNITY INC
FINANCIAL STATEMENT SUMMARY
its of December 31,2014
ASSETS LIABILITIES
Bonds
$179,140,947 losses $63,582,066
Preferred stocks 0Reinsurance payable on paid losses and Inas adJustment expenses O
Common stocks 31,M,141 loss adjusboent expenses $10,384,957
Mortgage loans on real estaw.11rsttens 0 Commissions payable,contingent commssionsand othersimilar,charges $1,020,805
Mortgage loans on real estate;Other than tint liens 0 Otherexperaes(excluding taxes.Il am es and fees) $5,435,126
Properties occupied by the company 0 Taxes,licenses and fe"(excluding federal and foreign Income taxes) $2,383,909
Properties held for the production of Inconrc 0 Current federal and foreign income taxes
$2,434,392
Properties held forsa.e 0 Net deferred tax liability
0
Cash.cash equivalents and short-term investments $15,632,9S1 Unearned premiums $29,158,576
Contract loans D Advance premium
Derivatives D Ceded reinsurance premiums payable(veto(ceding commissions) $58,222,197
Other invested assets 0 Funds held by company under reinsurance treaties 0
Rice l va N es far%ecu,Itles 0 Amounts withheld or reralned by company for account of others
Securities lending reinvested colbtera3 assets 0 Remittances and items not allocated
Aggregate wrlteansforinvestedassets 0 Provision for reinsurance
$1,545,075
Subtotals.cash and invested assets $226,624,039 Net adjustments In assets and tabllltles due to foreign exchange rates
Tide plants less$,.,Charged off 0 Drafts outstanding
Investment Income due and accrued $990,960 Payable to parent,subsidiaries and affillates $12,458,110
Uncollected prem urns and agents'balances In the course of collection $73,567,547 Derivative:
U
Deferred premium;agents'balances and Installments booked but deferred and not 0
yet due Payable for securities 0
Accrued retrospective prerniums 0 Payable for securities lending 0
Amounts recoverah€e from reinsurers $33,58k,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
Otharamounts receivable under reinsurance contracts 0Total flabillUes excluding protected can liabilities $190,811,131
Amounts reaivab;e relating to uninsured plans 0 Protected cell hablIM"
Current federal and foreign Income tax recoverable and interest thereon 0
Nei deferred tax asset $5,530,837 Total liabilities
$190,811,131
Guaranty funds receivable or on deposit 0
Furniture and equipment,Including health are delivery assets 0 POUCYNOLDEWS SURPLUS
Net adjustment In assets and IlabiBties due to foregn exchange rates 0 Aggregate write-Ins for special surplus funds 0
Receivables from parent,subsidiaries and aflflllates 0
Nealth care and other a mounts receivable 0 Common caotal stock 5 000 000
Aggregate write-Ins for other than Invested assets $7,124,971 Preferred capital stock
Tolal assets excluding Separate Accounts,Segregated Accounts and Protected Cel $347,414,611Aggregate v,Ylthm forothar than special surplus p
Accounts
From Separate Accounts,Segregated Accounts and Protected Cell Accounts 0 Surplus Notes
TOTALS 5347,414,611 Gross paid In and eontnbuted surplus $155,938,671
Unassigned funds jsurplus; ($5,335,190)
Sure us as regards policyholders $156,603,481
TOTALS
$347,414,611
SURSCRIaED and sworn to W..-t IW.5
MNy ._ifs
mycomrrusscnexpires •�{)—/
Z?
Nota Public
CERTIFICATE Priited Name
ALYSSA TURKOVITZ
1 certify that the above financial statements to the blit of my
Notary Public,State of New York
knowledge are a true and accurate reflection of the Onsx:lal
TURKOM No.01TU6044514
condition of the Company as of December 31,2014, / l J Quelifled{f1 Westchester CQL my
Additionally,I certify that the above financial statements are �;.y.• f i�.�) ; �- - COT"ftfb M EXPIM JU1y 10,20tS
in agreement with the Statutory Finwclal Statements filed with the Taxat Nvtn bllc,Stale of thw York
Department of Insurance as of the same date.
No.OITU6044514
William J Gleason QluaORed In Westchester County
M,.YR-AjGlasurer Commission Explres July 10,2014
SUBDIVISION LABOR AND MATERIAL BOND
(GOVERNMENT CODE 66499.2)
Bond No. SUR21000015
Replaces Bond No. SUR20000321
KNOW ALL MEN BY THESE PRESENTS, that Pacific Poin# [7eveloment Par#ners LLC
(hereafter designated as "Principal"), and Ironshore Indemnity Inc. 1
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:
Monument subdivision improvements within Tract 15609 as defined within Amendment#1 and
Reinstatement of the Subdivision Improvement Agreement for Tract 15609
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
Fifteen Thousand Five Hundred Dollars and 00/100 Dollars ($15,500.00 ) 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, shat
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: � \>4 c r iJ
SURETY:
Ironshore Indemnity Inc.
Ile (NOTARIZATION AND SEAL)
By: .
Margars A. Ginem , Attorney-in-Fact
Surety Phone No.
C/O VUILLIS OF FLORIDA
4211 W BOYSCQUTBLVI) #10W Page 2 of 3
TAMPA, FL 33507
INQUIRIES:(813)281-2095
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 efore me,
Date , Were ert t4a e and Titleoft a fficer ,
personally appeared
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.
O4nnnlsIIon M 2088325 x WITNESS my hand and official seal.
Lot Nofary Public-California
Orange County
Comm.Expires Oct 31,2018.. Signature
Signature of Notary Public
Place Notary Seal Above
j 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
❑ Individual ❑Attorney in Fact ❑ Individual ❑Attorney in Fact
❑Trustee ❑Guardian or Conservator ❑Trustee ❑Guardian or Conservator
❑Other: ❑ Other:
Signer Is Representing: Signer Is Representing:
i
02014 National Notary Association • www.NationalNotary.org 1-800-US NOTARY(1-800-876-6827) Item#5907
w ' Y
S '
1
[ate Bill 10$0 afids• Sections: 1 l80 till'
I c :j> 5:Df thte:Civil bodextd Sectir SQ oi"the.
GO.Y'erin io t t.Code; l ting to i? ?E . ut ii : 'r'kIe:l el v h sical format of ifi new cii.sclosure
notice:js=an ex pplc-,,for purpssses o f_Ru*ai�
tYot ty public of othdr officer coftipi,e€ing this;
+ceriifzcate verifies only the identity of the
individual who.sighed the do4tmrit.tp►►hkkt.
certificate,is attached.,and not the trathfulness�.
acctlraOY,Ot vlawo oft
Swd()fWforinid
County.of
On before"me,
-ihsert name andiffle oi`,Officer3,personally o'ppeored Who
trotted t¢jrt oiy'tl~te basis of atisfactofy-ey d ce to he e'.p rsoia{s) whnse nanie(s) slate,sul3scribedtt7,
thin wlthixi.-Ais umeut.and acknowledged -to me� that'hehhelthey executed 'the:same; .in-hislherltheir,
authoiixeti capacrtj± ; sj, ci that,]iyas�ier� °strature( 7 Ott the. .struttteeisbit(S),:of Vie:
'W tiix raPOn.behalf of.-whict lh6 pefsot('s).act'ed exdcu edtb&itistruru6nt,
t.ireitifder PENAJ,`I' Vii? f' t'NRX ii.rid�r :0. Jags of t e,Sta(e cif'�alifcrrraia})lat the for goui
pasag.rap i's true and',correct.
WITNESS,Myi h"4 Ahkoffi6W seal, i
Sigatre (Sea]).
r
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 writte
Signature
Anett Cardinale
1411A
r' +rs■•lwg,, ANETT CARDINALE
Commission#FF 138482
1s.y. r Expires July 28,2018
fly,41 Bonded Thru Troy Fein Iheurence 800-385.1018
This area for Official Notarial Seal
POWER OF ATTORNEY
Ironshore Indemnity Inc. 111- 21000015
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
22"d 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 writ}ngs obligatory
in nature of a bond not to exceed$7,500,000 dollars,which the Company night 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 goad cause and
the authorlty 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.
y�.'9po on„"ii
`low
By:
Dan 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.
AMYL TAYLOR
— NOL3ry
Public—Slate of Tennessee
Davidson County
%r, �..••°„+��` My Commission Expires 01-09-16
Amy L TO
Notary Wbde
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 ZD 15
RIFAL t
1919
2aul �G� 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."
IAONSNORE§NDEMNRY INC
FINANCIAL STATEMENT SUMMARY
As of December 31,2014
ASSETS LIABILITIES
Bonds
$179,140,947 losses $63,SB2,056
Preferred stocks 0 Reinsurance payable on paid losses and loss*4ostment expenses 0
Common stocks 31,840,141 loss adjustment expenses $10,384,957
Mortgage loans on real estate:first kens 0 Commissions payable,contingent commissions and other similar charges $1,020,805
Mortgage Irons on real estate;Other than first liens 0 Other expenses(excluding taxes.licenses and fees) $5,435,125
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 fedenN and foreign Income taxes
$2,434,392
Properdes he4d for safe 0 Net deferred tax liability 0
Cash,cash equivalents and short-term Investments $15,632,951 Unearned premiums $29,158,576
Contract bans 0 Advance premium
Derivatives 0 Ceded reinsurancepremiurro payable(net of codingcommisslons) $S812221187
Other invested assets 0 Funds field by company under reinsurance treaties
0
Receivables for securities 0 Amounts withhold or retained by company for account of others
Securities lending reinvested collateral,assets 0 Remittances and Items not allocated
Aggregate wrlte-Ins foOnvested assets 0 Provision for reinsurance $1,545,075
S ublatals.cAih a n d l nvestrd With $226,614,039 Net adjustments In assets and labilltlas due to foreign excfnnge rates
Tide plants less$...Charged off 0 Drafts outstanding
investment Income due and accrued $990,960 Payable to parent,subsidiaries andoffiflates $12,458,110
Uncollected prem urns and agents'balances in the course of collection $73,567,547 Derivatives
0
Deferred premiums,egen&balances and Installments booked but deferred and not 0
yetdue Payable for securities 0
Accrued retrospective prerr@ums 0 Payable for securities lending 0
Amounts recovemblefrom reinsurers $33,586,257 Liability for amounts held under uninsured plans 0
Funds held by or deposited with relmured companies 0 Aggregate write-Iris for liabilities $4,385,928
Other amounts receivable under reinsurance contracts 0 Total flabil)ties excluding protected cell fiabilides $190,iimm
Amounts receivab�e relating to uninsured 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
0
Guaranty funds receivable or on depoatt
Furniture and equipment,including health are delivery assets 0 POUCYI%DEBTS SURPLUS
Net adjustment In assets and flableties due to foregn exchange rates 0 Aggregate write-Ins for special surplus funds 0
Receivables from parent,subsidiaries and affiliates 0
Health care and other amounts receivable 0 Common apltal stock 5000,000
Aggregate write-lnsfor other than invested assets $7,124,971 Preferred capital stock
Total assets excluding Separate Accounts,Segregated Accounts and Protected Cat $347,414,611Aggregate wrlWm for other than special surplus p
Accounts
From Separate Accounts.Segregated Accounts and Protected Cell Accounts 0 Surplus Notes
TOTALS $347,414,611 Gross paid in and contributed surplus. $156,931,671
Unassigned funds(surplus; ($5,335,190)
Surp"us as regards policyholders $156,603,481
TOTALS $347,414,611
SUBSCRIBEDand mom to me this'ysday of M}J1!. j rj
MYcommiss-znexpires 7./El—/Sj.
CERTIFICATE NoOrypubllc
ALYSSA TURKOVITZ
Priced Name Notery Public.State of New York
1 certify that the above financial statements to the best of my NO.U1TU6044,514
knowledgeareatrue and accurate reflection ofthe financial ALYSSATURX0Vf12 [�UEII{I�t?Ct InWestchesterIT5CoLIli
AddMconditan of the Company the as the
December ial 2014, ' �+ Z. Coftu Vosion Expires July 10,?.Q t C
AddlUonally,I certify that the above financial statements aro t_:.'st!y� /O+.�i!{c.�`J.—��'
in agreement with the Statutory Financial Statements filed with Use Texae N0 CW'Ic,Seta of New York
Department of Insurance as of the same date.
No.OITU6044514
William Gleason Qualified In Westchester County
Commission Expires July 10,2014