Example Enrollment Form and Florida Certificate of Insurance – Last Updated 3/1/2024

OLD REPUBLIC INSURANCE COMPANY
FLORIDA SELF STORAGE TENANT INSURANCE ENROLLMENT FORM
Operator: / Facility Name:
Master Policy Number: / Applicant Name: / Unit or Space #:

IN RETURN FOR THE PAYMENT OF THE PREMIUM AND SUBJECT TO ALL THE TERMS OF THE CERTIFICATE OF INSURANCE, I WANT TO ENROLL IN THE SELF STORAGE TENANT INSURANCE PROGRAM UNDERWRITTEN BY OLD REPUBLIC INSURANCE COMPANY AND ADMINISTERED BY XERCOR INSURANCE SERVICES LLC AS FOLLOWS:

Amount of Insurance: $

Monthly Premium: $

Insurance Start Date:

The Amount of Insurance entered above is the limit, or the most we will pay, subject to a $100 deductible, for damage to your property caused by the Covered Causes of Loss shown in your Certificate of Insurance. In addition, the following Additional Coverages and Additional Covered Causes of Loss are provided and the most we will pay under these coverages are the limits or sublimits shown below, with more detailed descriptions shown in the Certificate of Insurance. Amounts payable under these Additional Coverages and Additional Covered Causes of Loss are part of and not in addition to the Amount of Insurance, and are subject to a $100 deductible.

Additional Coverages / Limit Equals the Following Percentage of the Amount of Insurance Shown Above

• Burglary 100%
• Debris Removal 25%
• Transit 100%
• Extra Rental Space 25%

Additional Covered Causes of Loss / Sublimits

• Flood $1,000
• Rodent, Vermin, Moth or Insect Damage $500
• Mold, Mildew, Fungus, or Wet or Dry Rot $500

I acknowledge that I have elected to purchase insurance from Old Republic Insurance Company. I understand and agree that the Amount of Insurance I have selected above is the maximum limit, unless a limit providing less than 100% of the of the Amount of Insurance or a Sublimit as shown above applies. Any loss paid under the Certificate of Insurance is subject to a $100 deductible. The deductible will be subtracted from the applicable limit or sublimit of insurance. The actual amount paid in the event of loss or damage will be determined by my proof of loss documentation.

I authorize the Owner, landlord, lessor, operator (herein Operator) to collect my Monthly Premium and to submit it to the insurance company on my behalf.

My coverage will begin as of for the Amount of Insurance I have selected above, but only after I have properly completed and signed this Enrollment Form, made the first premium payment, and received a Certificate of Insurance. I understand that my insurance will continue on a month-to-month basis as long as I continue to pay the Monthly Premium shown above. My insurance will be renewed each month until I terminate the insurance or my lease or rental agreement on the storage unit or space is terminated. I understand that the Monthly Premium is due each month on or before the monthly renewal date and that the Monthly Premium is fully earned each month.

Failure to pay any premium in full each month will result in the cancellation of my insurance, without notice.

I understand that the opportunity to purchase insurance for property stored within a building is available to all tenant/occupants who have entered into a rental or lease agreement with the Operator for enclosed storage unit or space. Coverage does not apply to property stored in a commercial office suite, retail space, parking space, other open storage areas or any other locations. Furthermore, certain types of property that I may store in an enclosed storage unit or space are excluded from coverage. It is my responsibility to read the Certificate of Insurance and understand how it may exclude coverage for some of my belongings and for some causes of loss.

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I understand that I will receive 90 days of notice of changes in the premium rates, if any, and the new rate shall be payable as my Monthly Premium beginning the month after the 90 day notice period is exhausted. I have received a Self Storage Tenant Insurance program brochure and Certificate of Insurance. I understand the manager and staff at this facility are NOT insurance agents. Please direct any questions regarding the insurance you purchased to Xercor Insurance Services LLC at:

Xercor Insurance Services LLC
8425 Woodfield Crossing Blvd, Ste 101E, Indianapolis, IN 46240
1-844-769-2904
California License Number: 0L23065

Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree.

I hereby request to enroll in the Self Storage Tenant Insurance program for the Amount of Insurance shown above. I have voluntarily elected to enroll in this Master Policy Insurance program and I have read and completed this Enrollment Form.

PRINTED NAME:

APPLICANT’S SIGNATURE:

DATE SIGNED:

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FLORIDA CERTIFICATE OF INSURANCE
SELF STORAGE TENANT INSURANCE UNDER MASTER POLICY NUMBER:
This is to certify that the tenant named on this Certificate has arranged insurance as hereinafter specified and underwritten by Old Republic Insurance Company.

Tenant Name:

Space:
Customer of:

Date:
Site Address:

IN RETURN FOR THE PAYMENT OF THE PREMIUM, AND SUBJECT TO ALL THE TERMS OF THIS CERTIFICATE AND THE MASTER POLICY, WE AGREE WITH YOU TO PROVIDE THE INSURANCE AS FOLLOWS:

DEFINITIONS: When used in reference to this insurance, “you” and “your” refer to the person(s) named as tenant in the “rental agreement”. “We,” “us” and “our” refer to the insurance company. In addition, certain words and phrases are defined as follows:
AMOUNT OF INSURANCE – means the coverage limit you selected on the “enrollment form” that you signed, which applies to damage caused by any of the Covered Causes of Loss described below, less the Deductible.
ENROLLMENT FORM – means the form titled Self Storage Tenant Insurance Enrollment Form.
BURGLARY – means the act of stealing Covered Property by forcible entry into the self storage unit or space described in the “rental agreement”.
OPERATOR – means the owner, landlord, lessor or “operator” of the self storage facility.
PREMIUM – means the amount shown in the “enrollment form” as premium for your insurance.
RENTAL AGREEMENT – means the lease or rental agreement executed and in effect between the “operator” and you.

EFFECTIVE DATE: This insurance begins on the date shown on the “enrollment form”. This insurance shall remain in effect until terminated or cancelled as provided by this Certificate.

COVERED PROPERTY: We cover your personal property or the personal property of others for which you may be liable or have assumed liability prior to a loss while in storage within the enclosed storage unit or space described in the “rental agreement”.

DEDUCTIBLE: We will not pay for any loss of or damage to Covered Property stored in the Space described above caused by any one occurrence until the amount of adjusted loss or damage exceeds your $100 Deductible. Once the amount of such loss or damage exceeds the Deductible, we will then pay the amount of adjusted loss or damage less the Deductible Amount. However, we will not pay more than the applicable “amount of insurance”, limit, or sublimit of insurance, less the Deductible.

COVERED CAUSES OF LOSS: We will pay up to the “amount of insurance” for direct physical loss of or damage to Covered Property caused by the following:
a. Fire or lightning;
b. Windstorm or hail;
c. Cyclone, tornado or hurricane;
d. Explosion or sonic boom;
e. Strikes, riot or civil commotion;
f. Aircraft, self-propelled missiles or spacecraft;
g. Vehicles;
h. Smoke;
i. Vandalism or malicious mischief;
j. Falling objects, if the building’s exterior containing the Covered Property is first damaged by falling objects;
k. Weight of ice, snow or sleet;
l. Collapse of buildings containing the property insured;
m. Water damage except for loss or damage caused by flood, surface water, waves, tides, tidal waves, tidal surge, tsunami, overflow of any body of water, or their spray, whether driven by wind or not, including but not limited to escape, overflow or discharge, for any reason, of water or waterborne material from a dam, levee, seawall or any other boundary or containment system as provided below under ADDITIONAL COVERAGES, paragraph e. FLOOD;
n. Landslide, including sinkhole collapse;
o. Earthquake;
p. Volcanic eruption; or
q. Certified acts of terrorism.

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ADDITIONAL COVERAGES/ADDITIONAL COVERED CAUSES OF LOSS: We will also provide the following additional coverages and sublimits of insurance for additional covered causes of loss up to the amounts stated below, subject to the $100 Deductible. These additional coverages and sublimits of insurance are part of and not in addition to the “amount of insurance”.
a. BURGLARY: We will pay 100% (one hundred percent) of the “amount of insurance” for loss of or damage to Covered Property caused by “burglary” or holdup. However, this coverage applies only when such self storage unit or space is securely locked at the time of the forcible entry and visible signs of forcible entry must be evident. The absence of a lock will not constitute forcible entry. You must provide a report from law enforcement as verification of such “burglary”.
b. DEBRIS REMOVAL: We will pay up to 25% (twenty-five percent) of the “amount of insurance” shown in the“enrollment form” to cover the necessary expense incurred in the removal of debris of your Covered Property following an insured loss.
c. TRANSIT: We will pay up to 100% (one hundred percent) of the “amount of insurance” shown in the “enrollment form” for loss of or damage to Covered Property by fire or by the collision or overturn of a motor vehicle or trailer upon which Covered Property is being transported while such Covered Property is in transit to or from the self storage facility, provided the Covered Property is in transit within 100 (one hundred) miles of the described storage facility described in the “rental agreement”.
d. EXTRA RENTAL SPACE: We will pay 25% (twenty-five percent) of the “amount of insurance” shown in the “enrollment form” to cover the extra expense necessarily incurred by you for the rental of substitute storage when occupancy of the described storage unit or space is prevented as a result of loss or damage to the storage facility building by a Covered Cause of Loss insured against in this policy.
e. FLOOD: We will pay up to $1,000 for direct physical loss of or damage to Covered Property caused by flood, surface water, waves, tides, tidal waves, tidal surge, tsunami, overflow of any body of water, or their spray, whether driven by wind or not, including but not limited to escape, overflow or discharge, for any reason, of water or waterborne material from a dam, levee, seawall or any other boundary or containment system.
f. RODENT, VERMIN, MOTH OR INSECT DAMAGE: We will pay up to $500 for direct physical loss of or damage to Covered Property caused by rodents, vermin, moths or insects.
g. MOLD, MILDEW, FUNGUS, WET OR DRY ROT: We will pay up to $500 for direct physical loss of or damage to Covered Property caused by mold, mildew, fungus, wet or dry rot.

EXCLUSIONS: Covered Property does not include the following:
a. Accounts, bills, currency, notes, stamps, deeds, evidences of debt, evidence of ownership, contracts and titles, securities, negotiable instruments, money, or lottery tickets;
b. Gold, silver, silverware, goldware, silver-plated or gold-plated ware, semi-precious/precious stones, precious metals or alloys;
c. Animals;
d. Jewelry and watches; furs, or garments trimmed with fur;
e. Breakage of glass or similar fragile articles;
f. Illegal drugs;
g. Food or alcohol;
h. Photographic equipment;
i. Explosives, firearms or ammunition;
j. Cigarettes or other smoking materials; or
k. Vehicles, trailers or watercraft stored in the open or while in transit.

This coverage does not apply to the following:
a. Wear and tear, gradual deterioration, maintenance, inherent vice, latent defect, changes in temperature or atmospheric conditions, delay, loss of use, or loss of market;
b. Neglect by you to use all reasonable means to save and preserve the Covered Property during and after the occurrence of any cause of loss insured against, or when the Covered Property is endangered by a covered cause of loss;
c. Loss of or damage to Covered Property caused intentionally by you or at the your direction;
d. Contraband, or caused by illegal transportation or trade;
e. Activity in violation of the “rental agreement”;
f. Theft, except “burglary” as defined and covered herein;
g. Unexplained disappearance;
h. Loss of or damage to Covered Property due to a pre-existing condition; or

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i. Pollutants

We will not pay for any loss or damage caused directly or indirectly by any of the following. Such loss or damage is excluded regardless of any other cause or event that contributes concurrently or in any sequence to the loss.
a. Hostile or warlike action in time of peace or war, including action in hindering, combating, or defending against an actual, impending or expected attack by any government or sovereign power (de jure or de facto), or by any authority maintaining or using military naval or air forces; or by military, naval or air forces or by an agent of any such government, power, authority or forces, it being understood that any discharge, explosion or use of any weapon of war employing nuclear fission or fusion shall be conclusively presumed to be such a hostile or warlike action by such government power, authority or forces;
b. Insurrection, rebellion, revolution, civil war, usurped power or action taken by governmental authority in hindering, combating, or defending against such an occurrence;
c. Seizure or destruction under quarantine, or customs regulation, confiscation by order of any government or public authority, or risks of contraband or illegal transportation or trade; or
d. Nuclear hazard, including any nuclear reaction, radiation, or radioactive contamination, all whether controlled or uncontrolled or however caused, or any consequence of any of them. Loss of or damage to Covered Property caused by the nuclear hazard shall not be considered loss or damage caused by fire, explosion, or smoke, whether or not these are specifically named or otherwise included as covered causes of loss or damage.

TERMINATION OR CANCELLATION OF THIS INSURANCE: The insurance evidenced by this Certificate of Insurance issued under the Master Policy shall automatically terminate without notice to you on the date the “rental agreement” is terminated.
You may cancel this insurance at any time, upon advance written notice to the “operator” or us.
We may cancel this insurance by mailing or delivering to you, written notice of cancellation at least 10 days before the effective date of cancellation, if we cancel for nonpayment of “premium”.
For reasons other than nonpayment of “premium” as described below, we may cancel this insurance at any time and for any reason permitted by law upon 45 days advance written notice to you at the address set forth in the “rental agreement”. If notice is mailed, proof of mailing will be sufficient proof of notice. In the event of such cancellation, the notice of cancellation will state the effective date of cancellation and the reason for the cancellation. If this insurance is cancelled for any reason other than the nonpayment of “premium”, you may be entitled to a “premium” refund. If so, we will send your refund to the “operator” to give to you. The cancellation will be effective even if we have not made the refund offer.
We may cancel this insurance only for one or more of the following reasons:
a. Nonpayment of “premium”;
b. The insurance was obtained by a material misstatement;
c. In the event of failure to comply, within 90 days after the effective date of coverage, with underwriting requirements established by us before the effective date of coverage;
d. There has been a substantial change in the risk covered by this insurance;
e. The cancellation is for all insureds under such policies for a given class of insureds; or
f. The cancellation of some or all of our policies is necessary to protect the best interests of the public or policyholders and such cancellation is approved by the Florida Office of Insurance Regulation.

VALUATION: The value of the property will be determined at the time of loss of or damage to Covered Property and will be no more than the least of the following amounts:
a. The replacement cost at the time of loss of or damage to Covered Property without deduction for depreciation;
b. The full cost of repair at the time of loss of or damage to Covered Property; or
c. The applicable coverage limit.
Regardless of the valuation of Covered Property, we will pay no more than the applicable limit or sublimit, less the Deductible.

DUTIES YOU HAVE AFTER A LOSS: You will give prompt notice to us, and in case of “burglary”, notify the police. The notice should include:
a. How, when and where the loss of or damage to Covered Property occurred;
b. Proof of Loss for the Covered Property involved and your interest in it; and
c. The names, addresses and telephone numbers of any witnesses.

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IF YOU HAVE A LOSS: Write or telephone:
Xercor Insurance Services LLC
8425 Woodfield Crossing Blvd, Ste 101E, Indianapolis, IN 46240
1-844-769-2904

d. A claim or reopened claim for loss or damage caused by any peril is barred unless notice of claim is given to us in accordance with the terms of this policy within two years after the date of loss. A reopened claim means a claim that we have previously closed but that has been reopened upon your request for additional costs for loss or damage previously disclosed to us. A supplemental claim is barred unless notice of the supplemental claim was given to us in accordance with the terms of the policy within three years after the date of loss. A supplemental claim means a claim for additional loss or damage from the same peril which we have previously adjusted or for which costs have been incurred while completing repairs or replacement pursuant to an open claim for which timely notice was previously provided to us.
For claims resulting from hurricanes, tornadoes, windstorms, severe rain or other weather-related events, the date of loss is the date that the hurricane made landfall or the tornado, windstorm, severe rain or other weather-related event is verified by the National Oceanic and Atmospheric Administration.
This provision concerning time for submission of claim, supplemental claim or reopened claim does not affect any limitation for legal action against us as provided in this policy under the LEGAL ACTION AGAINST US Condition, including any amendment to that condition.
Any inspection or survey by us, or on our behalf, of property that is the subject of a claim, will be conducted with at least 48 hours’ notice to you. The 48-hour notice may be waived by you.

CONCEALMENT, MISREPRESENTATION AND FRAUD: If you commit fraud by intentionally concealing or misrepresenting a material fact concerning:
a. The insurance evidenced by this policy;
b. Covered Property; or
c. Your interest in the Covered Property;
You will void the insurance under this policy.

EXAMINATION UNDER OATH: Before recovering for any loss of or damage to Covered Property, if requested you will:
a. Permit us to inspect the damaged property before it is disposed of or repaired;
b. Send us a sworn statement of loss containing the information we request to settle your claim within 60 days of our request;
c. Agree to examinations under oath at our request;
d. Produce others for examination under oath at our request;
e. Provide us with all pertinent records needed to prove the loss of or damage to Covered Property; and
f. Cooperate with us in the investigation or settlement of the loss or damage.

APPRAISAL: If you and we do not agree as to the amount of loss of or damage to Covered Property, then you and we will select a competent appraiser upon receiving a written request from the other. The appraisers will select an umpire. If they do not agree on an umpire, the appraisers will ask a judge of a court of record of the state in which the appraisal is pending to make the selection. The written agreement of any two of the appraisers and the umpire will be binding and set the amount of loss or damage. You will pay the expense of your appraiser and we will pay for ours. You and we will share equally the other expenses of the umpire and the other expenses of the appraisal.

LOSS PAYMENT: Provided you have complied with all the terms of this insurance, we will pay for covered loss or damage within:
a. 20 days after we receive the sworn proof of loss and reach written agreement with you; or
b. 30 days after we receive the sworn proof of loss and:
1. There is an entry of final judgment; or
2. There is a filing of an appraisal award with us.
We will not be liable for any part of a loss which has been paid or made good by others.

LEGAL ACTION AGAINST US: Legal action against us involving direct physical loss or damage to property must be brought within 5 years from the date the loss occurs.

TRANSFER RIGHTS OF RECOVERY AGAINST OTHERS TO US: If any person or organization to or from whom we make payment under the insurance evidenced by this Certificate has a right to recover damages from another, that right must be transferred to us. That person or organization must do everything necessary to assist us, and must do nothing after the loss or damage to hinder us in our recovery.

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PAIR, SET OR PARTS:
a. Pair or set. In case of loss of or damage to Covered Property to any part of a pair or set we may:
1. Repair or replace any part to restore the pair or set to its valuation before the loss or damage; or
2. Pay the difference between the valuation of the pair or set before and after the loss or damage.
b. Parts. In case of loss of or damage to any part of Covered Property, consisting of several parts when complete, we will pay only for the valuation of the lost or damaged part.

CHANGES: This Certificate and the Master Policy contain agreements between you and us concerning the insurance afforded. The terms of this insurance may be amended or waived only by a written endorsement issued by us, and made a part of the Master Policy.

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