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SEND BIND REQUEST TO: Pam Falcione <br />Fax: (727) 528-8703 <br />or <br />Email: tboley@bassuw.com <br />Agent: Starbright Insurance Agency Corp <br />INSURED: <br />NUNEZ CONSTRUCTION, INC <br />Quote # <br />4120795A <br />Renewal of: <br />Insurer: <br />Benchmark Specialty Insurance Company <br />Coverage: <br />BRK-General Liability -Magnolia <br />PLEASE BIND EFFECTIVE: <br />TOTAL PREMIUM, FEES & TAXES: <br />TRIA: ( ) Accepted ( ) Declined <br />Agent Contact: _ <br />Contact Phone #: <br />Inspection Contact: <br />Inspection Phone #: <br />Producer License info: <br />Name <br />*"Producing Agent must sign Acord <br />Authorized Signature: <br />License #: <br />"By signing the above, agent acknowledges collection of all related fees and costs." <br />Coverage can not be backdated or assumed to be bound without written confirmation from an authorized <br />representative of Bass Underwriters. <br />ATTACHMENTS: <br />Please see attached for terms and conditions. <br />The signed application is required via email or fax at time of binding. We request that you do not mail additional copies. <br />