Filing Number: 788155
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| Filing Accepted: 10/22/2024 |
| Last/Business Name
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WARDEN
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First Name |
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RAMONA WEAKLAND |
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| Street Address
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9716 SEAFARER'S WAY |
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NAVARRE,
FL
32566
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| Email Address
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RAMONAWW@GMAIL.COM |
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Insured |
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| Last/Business Name* |
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WARDEN |
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First Name |
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RAMONA WEAKLAND |
| Policy # * |
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7384826062 |
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Claim #* |
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01000112523 |
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Attorney is Applicable
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| Last Name* |
ROSS
First Name *
VANESSA
Initial
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1800 2ND STREET, SUITE 892 |
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SARASOTA
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FLORIDA
34236
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| Email Address * |
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ESERVICE@ROSSLEGALFL.COM |
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| Insurer Type
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 Authorized Insurer
 Unauthorized Insurer
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| Insurer Name |
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| Insurer Name* |
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FIRST PROTECTIVE INSURANCE COMPANY
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NAIC Company Code 10897 |
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| Name of individual responsible for violation (if any):*
MICHELLE PERKINS FL LICENSE #W608891, MIKE PEYTON, FL LICENSE #W122720, JONATHON WOODARD, P.E. FLORIDA ENGINEERING LICENSE #73750, AND ALL OTHER ADJUSTERS, SUPERVISORS, MANAGEMENT AND INDIVIDUALS ASSOCIATED WITH OR RETAINED BY US COASTAL PROPERTY AND
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| Type of Insurance
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Residential Property & Casualty
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| Reason for Notice
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Claim Denial
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Claim Delay
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Unsatisfactory Settlement Offer
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Unfair Trade Practice
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Other
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Failure to properly investigate claim and with due regard to Insured’s interest.
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Other
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Failure to acknowledge and act promptly to communications regarding claim
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Other
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ADDITIONAL STATUTES VIOLATED §627.70131(7)(a) - Within 60 days after an insurer receives notice of
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Statutory provision(s) which the insurer allegedly violated.
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| 624.155(1)(b)(1) |
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Not attempting in good faith to settle claims when, under all the circumstances, it could and should have done so, had it acted fairly and honestly toward its insured and with due regard for her or his interests.
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| 624.155(1)(b)(3) |
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Except as to liability coverages, failing to promptly settle claims, when the obligation to settle a claim has become reasonably clear, under one portion of the insurance policy coverage in order to influence settlements under other portions of the insurance policy coverage.
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| 626.9541(1)(i)(3)(a) |
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Failing to adopt and implement standards for the proper investigation of claims.
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| 626.9541(1)(i)(3)(d) |
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Denying claims without conducting reasonable investigations based upon available information.
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| 626.9541(1)(i)(3)(g) |
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Failing to promptly notify the insured of any additional information necessary for the processing of a claim.
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| 626.9541(1)(i)(3)(h) |
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Failing to clearly explain the nature of the requested information and the reasons why such information is necessary.
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Specific policy language that is relevant to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
The Insureds may not be in possession of a complete copy the applicable policy of insurance, however, the specific policy language relevant to the violations outlined below is contained within First Protective Insurance Company d/b/a Frontline Insurance Company’s Homeowners policy, Policy No. 7384826062, issued to the Insureds including, but is not limited to, the following:
Coverage A-Dwelling provisions
Coverage B-Other Structures provisions
Coverage C-Personal Property provisions
Coverage D-Loss of Use provisions - Additional Living Expenses
Additional Coverages provisions - Debris Removal - Reasonable Repairs - Ordinance Or Law Limited Fungi, Wet or Dry Rot, or Bacteria Coverage endorsement
The Declarations Page
Loss Payment or Loss Settlement provisions
Duties in Event of Loss Policy provisions
The insurance policy's definition sections
The insurance policy's exclusion of coverage provisions
Policy Forms and Endorsements
FIM NDR (03 22)
WELCOME LETTER E (06 23)
FP 00 02 (10 08)
FP 00 01 (10 08)
FP 00 03 (10 08)
IL P 001 (01 04)
FIM-FL-HO-DEC (03 22)
NCPT HO (07 23)
FIM-WLR (04 10)
FIM-OC3 (06 15)
HO 00 03 (05 11)
FIM 00 23 (05 23)
FIM 00 13 (06 21)
FIM 00 17 (05 21)
FIM 00 19 (08 23)
FIM 00 24 (08 23)
FIM 00 33 (05 21)
FIM 00 39 (05 21)
FIM 00 42 (05 21)
FIM 00 49 (05 21)
FIM 03 51 (05 23)
FIM SEN (01 12)
HO 04 96 (10 00)
HO 05 99 (05 13)
HO 23 86 (05 13)
HOMEOWNERS 3 – SPECIAL FORM – HOMEOWNERS HO 00 03 05 11
AGREEMENT
We will provide the insurance described in this policy
in return for the premium and compliance with all
applicable provisions of this policy.
***
SECTION I – PROPERTY COVERAGES
A. Coverage A – Dwelling
1. We cover:
a. The dwelling on the "residence premises" shown in the Declarations, including structures attached to the dwelling; and
b. Materials and supplies located on or next to the "residence premises" used to construct, alter or repair the dwelling or other structures on the "residence premises".
2. We do not cover land, including land on which the dwelling is located.
B. Coverage B – Other Structures
1. We cover other structures on the "residence premises" set apart from the dwelling by clear space. This includes structures connected to the dwelling by only a fence, utility line, or similar connection.
2. We do not cover:
a. Land, including land on which the other structures are located;
b. Other structures rented or held for rental to any person not a tenant of the dwelling, unless used solely as a private garage;
c. Other structures from which any "business" is conducted; or
d. Other structures used to store "business" property. However, we do cover a structure that contains "business" property solely owned by an "insured" or a tenant of the dwelling, provided that "business" property does not include gaseous or liquid fuel, other than fuel in a permanently installed fuel tank of a vehicle or craft parked or stored in the structure.
3. The limit of liability for this coverage will not be more than 10% of the limit of liability that applies to Coverage A. Use of this coverage does not reduce the Coverage A limit of liability.
C. Coverage C – Personal Property
1. Covered Property
We cover personal property owned or used by an "insured" while it is anywhere in the world.
After a loss and at your request, we will cover personal property owned by:
a. Others while the property is on the part of the "residence premises" occupied by an "insured"; or
b. A guest or a "residence employee", while the property is in any residence occupied by an "insured".
***
E. Additional Coverages
***
2. Reasonable Repairs
a. We will pay the reasonable cost incurred by you for the necessary measures taken solely to protect covered property that is damaged by a Peril Insured Against from further damage.
b. If the measures taken involve repair to other damaged property, we will only pay if
that property is covered under this policy and the damage is caused by a Peril
Insured Against. This coverage does not:
(1) Increase the limit of liability that applies
to the covered property; or
(2) Relieve you of your duties, in case of a
loss to covered property, described in
C.4. under Section I – Conditions.
***
5. Property Removed
We insure covered property against direct loss
from any cause while being removed from a
premises endangered by a Peril Insured
Against and for no more than 30 days while
removed.
This coverage does not change the limit of
liability that applies to the property being
removed.
***
SECTION I – PERILS INSURED AGAINST
A. Coverage A – Dwelling And Coverage B –
Other Structures
1. We insure against direct physical loss to property described in Coverages A and B.
2. We do not insure, however, for loss:
***
c. Caused by:
(6) Any of the following:
(a) Wear and tear, marring, deterioration;
(b) Mechanical breakdown, latent defect, inherent vice or any quality in property that causes it to damage or destroy itself;
(c) Smog, rust or other corrosion, or dry rot;
(d) Smoke from agricultural smudging or industrial operations;
(e) Discharge, dispersal, seepage, migration, release or escape of pollutants unless the discharge, dispersal, seepage, migration, release or escape is itself caused by a Peril Insured Against named under Coverage C.
Pollutants means any solid, liquid, gaseous or thermal irritant or contaminant, including smoke, vapor, soot, fumes, acids, alkalis, chemicals and waste. Waste includes materials to be recycled, reconditioned or reclaimed;
(f) Settling, shrinking, bulging or expansion, including resultant cracking, of bulkheads, pavements, patios, footings, foundations, walls, floors, roofs or ceilings; (g) Birds, rodents or insects;
(h) Nesting or infestation, or discharge or release of waste products or secretions, by any animals; or
(i) Animals owned or kept by an "insured".
Exception To c.(6)
Unless the loss is otherwise excluded, we cover loss to property covered under Coverage A or B resulting from an accidental discharge or overflow of water or steam from within a:
(i) Storm drain, or water, steam or sewer pipe, off the "residence premises"; or
(ii) Plumbing, heating, air conditioning or automatic fire protective sprinkler system or household appliance on the "residence premises". This includes the cost to tear out and replace any part of a building, or other structure, on the "residence premises", but only when necessary to repair the system or appliance. However, such tear out and replacement coverage only applies to other structures if the water or steam causes actual damage to a building on the "residence premises".
We do not cover loss to the system or appliance from which this water or steam escaped.
For purposes of this provision, a plumbing system or household appliance does not include a sump, sump pump or related equipment or a roof drain, gutter, downspout or similar fixtures or equipment.
***
***
NOTICE OF CHANGE IN POLICY TERMS
SPECIAL PROVISIONS POLICY CHANGE HOMEOWNERS - NCPT HO 07 23
***
SECTION I – PERILS INSURED AGAINST
A. COVERAGE A – DWELLING and COVERAGE B – OTHER STRUCTURES
Paragraph 2.c.(5) is deleted and replaced by the following:
(5) Repeated seepage or leakage of water or the presence or condensation of humidity, moisture, or vapor, that occurs or develops over a period of 14 or more days, whether hidden or not.
The Exception to c.(6) second paragraph is deleted and replaced by the following:
Exception to c.(6)
The cost that we will pay for the tear out and repair above is only that cost necessary to access and
repair only that specific point of that system or appliance that caused the covered loss, whether the
system or appliance, or any part or portion of the system or appliance, is repairable or not. However, such tear out and repair coverage only applies to other structures if the water or steam causes actual damage to a covered building on the “residence premises.”
***
B. COVERAGE C – PERSONAL PROPERTY
12. Accidental Discharge Or Overflow Of Water Or Steam
The following paragraph 12.b.(4) is replaced by the following:
(4) Caused by repeated seepage or leakage of water or steam, or the presence or condensation of humidity, moisture or vapor that occurs or develops over a period of 14 or more days, whether hidden or not.
In the event this exclusion applies, we will not pay for any damages sustained starting from the first day and instant the repeated seepage or leakage of water or steam, or the presence or condensation of humidity, moisture, or vapor began.
***
SECTION I – EXCLUSIONS
11. Existing Damage, meaning:
a. Damages which occurred prior to policy inception regardless of whether such damages were apparent at the time of the inception of this policy or discovered at a later date; or
b. Claims for damages arising out of workmanship, repairs or lack of repairs arising from damage which occurred prior to policy inception. However, any ensuing loss, which occurs during the policy period, arising out of workmanship, repairs or lack of repairs, caused by a Peril Insured Against, to property described under Section I – Property Coverages, is covered unless the loss is otherwise excluded in the policy.
This exclusion does not apply in the event of a total loss caused by a Peril Insured Against.
(This is exclusion A.11. in the HO 00 03)
12. Repeated seepage or leakage of water or steam, or the presence or condensation of humidity moisture or vapor that occurs or develops over a period of 14 or more days, whether hidden or not.
In the event this exclusion applies, we will not pay for any damages sustained starting from the first day and instant the repeated seepage or leakage of water or steam, or the presence or condensation of humidity, moisture, or vapor began.
(This is exclusion A.12. in Form HO 00 03)
14. Accidental Discharge or Overflow of Water or Steam from:
a. Within a plumbing, heating, air conditioning or automatic fire protective sprinkler system;
b. Within a household appliance for heating water; or
c. Within a household appliance.
This exclusion applies only while the dwelling is vacant or unoccupied for more than 30 consecutive days or being constructed; unless you have used care to:
a. Shut off the water supply; and
b. Drain the system and appliances of water.
System and appliances of water do not include outdoor swimming spas, or outdoor irrigation wells.
***
The following Conditions have been updated:
SECTION I – CONDITIONS
C. Duties After Loss is deleted and replaced by the following:
C. “Your” Duties After Loss.
An assignment agreement does not change the obligations to perform the duties required under this Policy.
In case of a loss to covered property, you must see that the following are done. These duties must be performed either by you, an “insured” seeking coverage, or a representative of either:
1. Give immediate notice to us or our agent.
a. Any claim or “reopened claim”, as those terms are defined in Florida Statute 627.70132, is barred unless notice of the claim was given to us in accordance with the terms of the policy within one year as specified in the Florida Statute 627.70132(3). Any “supplemental claim”, as that term is defined in Florida Statute 627.70132 is barred unless notice of the “supplemental claim” was given to us in accordance with the terms of the policy within eighteen months as specified in the Florida Statute 627.70132(3).
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 tornado, windstorm, severe rain, or other weather-related event is verified by the National Oceanic and Atmospheric Administration.
b. Except for Reasonable Emergency Measures taken under Additional Coverages 2., there is no coverage for repairs that begin before the earlier of:
(1) 72 hours after we are notified of the loss;
(2) The time of loss inspection by us; or
(3) The time of other approval by us.
If you unreasonably deny us access to inspect the loss during the period in a. above, coverage for
repairs beyond Reasonable Emergency Measures begins the earlier of when we are given access to inspect the loss or when we fail to appear at a scheduled loss inspection.
2. To the degree reasonably possible, retain the damaged property and any photographs of the damaged property; and
Allow us to inspect, subject to the paragraph above, all damaged property prior to its removal from the “residence premises” and make copies of the photographs.
3. Notify the police in case of loss by theft.
4. Notify the credit card or fund transfer card company in case of loss under Credit Card or Fund Transfer Card coverages.
5. Protect the property from further damage. The following must be performed:
a. Take reasonable emergency measures that are necessary to protect the covered property from further damage, as provided under Additional Coverage 2.
A reasonable emergency measure under 2.e. above may include a permanent repair when necessary to protect the covered property from further damage or to prevent unwanted entry to the property. To the degree reasonably possible, the damaged property must be retained for us to inspect.
b. Keep an accurate record of repair expenses. To the degree reasonably possible, take pictures prior to repairs commencing.
6. Cooperate with us in the investigation of a claim.
This includes speaking to and sharing information with us or any person authorized to act on our behalf, and providing documents which can be reasonably obtained by you, to facilitate our investigation of the claim.
You, any “insured” seeking coverage, or a representative of either of these:
a. Must cooperate with our investigation;
b. Must not act in any manner that prevents us or any person authorized to act on our behalf, from investigating the claim; and
c. May not act in any manner to obstruct our investigation.
7. Prepare an inventory of damaged personal property showing the quantity, description, actual cash value and amount of loss. Attach all bills, receipts, and related documents that justify the figures in the inventory.
8. As often as we reasonably require:
a. Show us the damaged property and the cause of loss and the condition it was in at the time of loss, if reasonably possible, except as to any repairs performed under SECTION I – PROPERTY COVERAGES, Additional Coverages, 2. Reasonable Emergency Measures;
b. Provide us with records and documents we request and permit us to make copies;
c. You, and any and all “insureds;” and
Any member, officer, director, partner, or similar representative of the association, corporation, or other entity, if you are the association, corporation, or other entity, who is an “insured;” must:
(1) Submit to examination under oath and recorded statements at the location insured or other reasonable location designated by us, while not in the presence of each other or any other “insured;”
(2) Provide government issued photo identification. If you do not possess government issued photo identification, a signed sworn statement identifying who you are may be provided; and
(3) Sign any transcript of the examinations under oath and recorded statements;
At our request, the examinations will be conducted separately and not in the presence of any other persons except legal representation;
Such examinations and recorded statements must either be in-person or utilize video and audio technology, or both, as determined by us;
d. Permit us to take samples of damaged and undamaged property for inspection, testing, and analysis; and
e. Any and all “insureds” must execute all authorizations for the release of information when requested by us, which we deem relevant to the investigation of your loss.
f. Allow us or any person authorized on our behalf:
(1). Access to the “residence premises;”
(2). To inspect the “residence premises” and to inspect, subject to 2. above, all damaged property prior to its removal from the “residence premises;” and
(3). To require an “insured” or their representative, or both if reasonably possible, to be present at our inspection and to assist in identifying the damaged property during the inspection;
g. At our request, identify the person or persons with knowledge of how the loss occurred and the extent of damage;
h. For losses covered under Coverage A and B, allow us to re-inspect, including but not limited to taking photographs and/or video of the property to confirm repairs invoiced by third parties were completed, or following a supplemental or re-opened claim.
9. After notifying us of the loss, submit to us, within 30 days after notification, your signed, sworn proof of loss which sets forth, to the best of your knowledge and belief:
a. The description of the loss, including the date and time of the loss, the cause of loss, a description of how the loss occurred, when the loss was discovered, and who discovered the loss;
b. The names of all persons who resided at the insured location at the time of the loss;
c. The interest of all “insureds,” assignees if any, and all others in the property involved and all liens on the property;
d. Other insurance which may cover the loss;
e. Changes in title or occupancy of the property during the term of the policy;
f. Specifications of damage to the dwelling and other structures, including;
(1) Detailed descriptions of the damage to the property;
(2) Repair estimates which show the extent of damage to each item or property;
(3) Estimated amount(s) to repair or replace each item of property; and
(4) Amount(s) of payment made for any temporary or permanent repairs.
Photographs and other supporting documentation that exists should be included to the extent it is reasonable and practical to obtain;
g. The inventory of damaged personal property described in C.7. above;
h. Receipts for additional living expenses incurred and records that support the fair rental value; and
i. Evidence or affidavit that support a claim under the Credit Card, Fund Transfer Card, Forgery and Counterfeit Money coverage, stating the amount and cause of loss.
10. Produce any updates to the documents and information described above, including revised descriptions of loss, scope of loss, estimates, or other supporting information:
a. As this information becomes available, and if additional loss or damage is discovered or incurred; and
b. If you are provided with new estimates or invoices regarding the losses submitted or not submitted in the proof of loss.
The duties above apply regardless of whether you, an “insured” seeking coverage, or a representative of either retains or is assisted by a party who provides legal advice, insurance advice or expert claim advice, regarding an insurance claim under this Policy.
C. 2. Assignee(s) Duties After Loss has been deleted.
D. Loss Settlement.
In Forms HO 00 03 and HO 00 06, the following paragraphs are added at the beginning of D. Loss Settlement:
We will settle covered property losses according to the following, unless otherwise stated in this policy.
However, the valuation of any covered property losses does not include, and we will not pay, any amount for “diminution in value.”
You may disregard the replacement cost loss settlement provisions and make claim under this policy for loss to buildings on an actual cash value basis. You may then make claim for any additional liability according to the provisions of this Condition D. Loss Settlement, provided you notify us of your intent to do so within 180 days after the date of loss.
In Forms HO 00 03:
The following is added to Paragraph D.1.:
e. Fences.
Paragraph D.2.a. is deleted and replaced by the following:
a. We will pay the cost to repair or replace with similar construction and for the same use on the premises shown in the Declarations, the damaged part of the building property covered under Coverage A or B at replacement cost without deduction for depreciation except for fences, subject to the following:
(1) We will pay at least the actual cash value less any applicable deductible at the time of the loss prior to repair or replacement of the damaged part of the property, up to the applicable limit of liability shown in the Declarations, not to exceed the cost to repair or replace the damaged part of the property;
(2) In addition, we will pay any remaining covered additional amounts you actually and necessarily incur to perform such repair or replacement as work is performed and expenses are incurred and submitted, or an amount up to the applicable limit of liability shown in the Declarations, whichever is less. There will be no deduction for depreciation;
(3) if a total loss occurs of a dwelling occurs, we must pay the replacement cost coverage without reservation or holdback of any depreciation in value, pursuant to s 627.702. There will be no deduction for depreciation.
The following is added to D.2.:
f. We will repair or replace undamaged property due to mismatch between undamaged material and new material in adjoining areas, if repairs or replacement are reasonable. In determining the extent of the repairs or replacement of items in adjoining areas, we will consider:
(1) The cost of repairing or replacing the undamaged portions of the property; and
(2) The degree of uniformity that can be achieved without such cost; and
(3) The remaining useful life of the undamaged portion; and
(4) Other relevant factors
The total limit of liability for Coverage A and B is 1% of the Coverage A limit of liability for repairs or replacement of any undamaged part of the building or its components solely to match repairs made to damage as a result of a coverage loss.
This limit does not increase the Coverage A or Coverage B limits of liability shown on the Declarations page, nor does it apply to damage otherwise limited or excluded.
***
W. Notice
A company employee adjuster, independent adjuster, attorney, investigator, or other persons acting on our behalf that needs access to you or a claimant or to your property must provide at least 48 hours notice to you or a claimant, public adjuster, or legal representative before scheduling a meeting with the claimant or an onsite inspection of your property.
You or a claimant may deny access to the property if notice has not been provided. You or a claimant may waive the 48 hour notice.
***
LIMITED FUNGI, WET OR DRY ROT, OR BACTERIA COVERAGE - FIM 00 13 06 21
(FOR USE WITH FORM HO 00 03)
SCHEDULE *
1. Section I – Property Coverage Limit of Liability For $25,000 Each Covered Loss the Additional Coverage “Fungi”, Wet Or Dry Rot, Or
Bacteria $50,000Policy Aggregate
2. Section II – Coverage E Aggregate Sublimit of
Liability for “Fungi”, Wet Or Dry Rot, Or Bacteria $50,000
* Entries may be left blank if shown in the policy Declarations.
DEFINITIONS
The following Definition is added:
“Fungi”
a. “Fungi” means any type or form of fungus, including mold or mildew, and any mycotoxins, spores, scents or byproducts produced or released by fungi.
b. Under Section II, this does not include any fungi that are, are on, or are contained in, a good or product intended for consumption.
SECTION I – PROPERTY COVERAGES
ADDITIONAL COVERAGES
The following Additional Coverage 13. is added:
13. “Fungi”, Wet Or Dry Rot, Or Bacteria
a. The amount shown in the Schedule above is the most we will pay for:
(1) The total of all loss or costs payable under Section I – Property Coverages caused by “fungi”, wet or dry rot, or bacteria;
(2) The cost to remove “fungi”, wet or dry rot, or bacteria from property covered under Section I – Property Coverages;
(3) The cost to tear out and replace any part of the building or other covered property as needed to gain access to the “fungi”, wet or dry rot, or bacteria; and (4) The cost of testing of air or property to confirm the absence, presence or level of “fungi”, wet or dry rot, or bacteria, whether performed prior to, during or after removal, repair, restoration or replacement. The cost of such testing will be provided only to the extent that there is a reason to believe that there is the presence of “fungi”, wet or dry rot, or bacteria.
b. The coverage described in 13.a. only applies when such loss or costs are a result of a Peril Insured Against that occurs during the policy period and only if all reasonable means were used to save and preserve the property from further damage at and after the time the Peril Insured Against occurred.
c. The Each Covered Loss amount shown in the Schedule for this coverage is the most we will pay for the total of all loss or costs payable under this Additional Coverage resulting from any one covered loss; and
The Policy Aggregate amount shown in the Schedule for this coverage is the most we will pay for the total of all loss or costs payable under this Additional Coverage for all covered losses, regardless of the number of locations insured under this endorsement or number of claims made.
d. If there is covered loss or damage to covered property, not caused, in whole or in part, by “fungi”, wet or dry rot, or bacteria, loss payment will not be limited by the terms of this Additional Coverage, except to the extent that “fungi”, wet or dry rot, or bacteria causes an increase in the loss. Any such increase in the loss will be subject to the terms of this Additional Coverage.
This coverage does not increase the limit of liability applying to any of the SECTION I – Property Coverages shown in the Declarations to which this coverage applies.
SECTION I – PERILS INSURED AGAINST COVERAGE A – DWELLING and COVERAGE B – OTHER STRUCTURES
Paragraph 2.c.(5) is deleted and replaced by the following:
(5) Repeated seepage or leakage of water or the presence or condensation of humidity, moisture, or vapor, that occurs or develops over a period of time, whether hidden or not.
In the event this exclusion applies, we will not pay for any damages sustained from the first day and instant the repeated seepage or leakage of water or steam, or the presence or condensation of humidity, moisture, or vapor began.
Paragraph 2.c.(6)(c) is deleted and replaced by the following:
(c) Smog, rust or other corrosion;
Paragraph 2.c.(6)(g) is deleted and replaced by the following:
(g) Birds, rodents, insects, “vermin,” amphibians, or reptiles;
The Exception to c.(6) is deleted and replaced by the following:
Exception to c.(6)
If any of these cause water damage not otherwise excluded or limited elsewhere in the policy, from a plumbing, heating, air conditioning, or automatic fire
protective sprinkler system or household appliance, we cover loss caused by the water including the cost
of tearing out and repairing only that particular part of a building or only that particular part of an other structure covered under Coverage A or B on the “residence premises” necessary to access and repair that specific point of that system or appliance from which the water escaped.
The cost that we will pay for the tear out and repair above is only that cost necessary to access and repair only that specific point of that system or appliance that caused the covered loss, whether the system or appliance, or any part or portion of the system or appliance, is repairable or not.
However, such tear out and repair coverage only applies if the water or steam causes actual damage to a covered building on the “residence premises.”
In the event that additional tear out and repair are required beyond the coverage provided for access and repair in the provision immediately above, we will still pay only for our portion of the access and repair cost required to repair only that specific point
of that system or appliance that caused the covered loss as described above.
However, we do not cover loss:
a. To the system or appliance from which this water or steam escaped;
b. On the “residence premises” caused by accidental discharge or overflow which occurs off the “residence premises;”
c. To a plumbing system, whether above or below the ground, caused by:
(1) Age, collapse, obsolescence, wear, tear;
(2) Fading, oxidization, weathering;
(3)Deterioration, decay, marring, delamination, crumbling, settling, cracking;
(4)Shifting, bulging, racking, sagging, bowing, bending, leaning;
(5)Shrinkage, expansion, contraction, bellying, corrosion;
(6) The unavailability or discontinuation of a part or component of the system; or
(7) Any other age or maintenance related issue;
d. To a plumbing system, whether above or below ground, caused by the impairment, state or condition of the system which prohibits repair or replacement including access, necessary to connect the adjoining parts of appliances, pipes, or system; or
e. Otherwise excluded or limited elsewhere in the Policy.
For the purposes of this provision, a plumbing system or household appliance does not include:
i. A sump, sump pump, irrigation system, or related equipment; or
ii. A roof drain, gutter, down spout, or similar fixtures or equipment.
This coverage does not increase the limit of liability that applies to the damaged covered property.
COSMETIC AND AESTHETIC DAMAGE TO FLOORS LIMITATION FIM 00 42 (05 21)
(Forms HO 00 03 and HO 00 06)
The total limit of liability for Coverages A and B
(Coverage A in form HO 00 06) combined is
$10,000 per policy term for cosmetic and
aesthetic damages to floors.
1. Cosmetic or aesthetic damage includes
but is not limited to:
a. Chips;
b. Scratches;
c. Dents; or
d. Any other damage to less than 5%
of the total floor surface area and
does not prevent typical use of the
floor.
2. This limit includes the cost of tearing out
and replacing any part of the building
necessary to repair the damaged
flooring.
3. This limit does not increase the
Coverage A or Coverage B limits of
liability shown on the Declarations.
4. This limit does not apply to cosmetic or
aesthetic damage to floors caused by a
Peril Insured Against as named and
described for Coverage C – Personal
Property.
All other policy provisions apply.
Please advise if there are other applicable policy provisions that are not cited above that would provide coverage to the INSURED for the on or about May 13, 2024, accidental and/or fortuitous water discharge.
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Facts and circumstances giving rise to the violation.
Enter all words or phrases (one at a time) that should be used to filter.
1) failure to pay claim in full;
2) failure to properly investigate claim;
3) failure to adjust loss;
4) failure to act in due diligence and good faith to resolve claim;
5) placing financial interest of insurer before that of policy holders and claimants;
6) failure to properly train, evaluate and manage adjusters;
7) the reasons for this may be attributed to improper training, supervision, and/or motivation of adjusters and claims supervisors to promptly and fairly investigate, adjust and pay full benefits available to all beneficiaries. The insurer may have failed to adopt proper standards of investigation and adjustment of losses, or is otherwise not implementing those standards because full payment and prompt payment for the loss is not occurring.
In Florida, the work of adjusting insurance claims engages the public trust. First Protective Insurance Company d/b/a Frontline Insurance Company (“INSURER”) has breached the public’s trust by its adjustment of Ramona Weakland Warden (“INSURED”) claim of loss. First Protective Insurance Company d/b/a Frontline Insurance Company’s mailing address is P.O. Box 958405, Lake Mary, FL 32795.
INSURER has failed to create and implement adequate guidelines for the proper investigation and evaluation of claims, claims handling, and for training and supervision of employees resulting in statutory violations as set forth above. INSURER has failed and/or refused to thoroughly, accurately, and completely investigate and evaluate the INSURED’S insurance claim for damages.
INSURER has failed to promptly settle the INSURED’S insurance claim when the obligation to settle the insurance claim had become reasonably clear.
To date, notwithstanding the INSURED’S pleas otherwise, INSURER has continued to refuse to acknowledge its obligation to conduct a proper investigation, and to tender the full amount of insurance monies due and owing its INSURED under the policy.
This claim involves the INSUREDS’ property located at 9716 Seafarer's Way, Navarre, FL 32566 which sustained significant damage from an accidental discharge or overflow of water or steam and/or fortuitous Water Loss discharge on or about on or about May 13, 2024.
This complaint is made on behalf of the Insureds, Ramona Weakland Warden (“INSURED”). Further, this complaint is a statement that notice is hereby given in order to perfect the right to pursue the civil remedy authorized and pursuant to Florida Statute §624.155.
In consideration of the premium paid to it by INSURED, INSURER issued a Homeowner’s residential insurance policy, Policy No. 7384826062, (hereinafter referred to as “The Policy”), to INSURED wherein the insurance policy provided coverage for all losses, including an accidental discharge or overflow of water or steam and ensuing damages, except those losses which were expressly excluded. (See attached, Policy).
The policy was in full force and effect at the time the damage occurred as a result of an accidental discharge or overflow of water or steam and the ensuing damages as a direct result thereof, to the insured premises located at, at 9716 Seafarer's Way, Navarre, FL 32566, on or about May 13, 2024.
On or about on or about May 13, 2024, the INSURED’S home sustained damages when a pipe in the common area of the half bathroom room burst. The accidental water discharge resulted in damages to: the hallway bathroom and ensuing losses throughout the interior of the INSURED’S home. The damages to the INSURED’S property were not a result of a water leak as misclassified by INSURER.
The INSURED timely notified INSURER of the damages and opened a claim pursuant to the terms and conditions of the Policy, which was opened under Claim No. 01000112523. The INSURED recalls in the three to four days prior to the loss not having heard any unusual sounds throughout the insured property. When the loss occurred, the INSURED recalls hearing a hissing noise coming from the wall of the common area hall bathroom and shutting the water supply to the home and the hissing sound stopping. INSURED mitigated their damages and immediately contacted a plumber to assess and provide temporary repairs.
In response, INSURER assigned the claim to its representative, Michelle Teresa Perkins FL Adjuster License #W608891 (license issued May 17, 2024) to adjust and investigate the loss, as well as a field adjuster, Michael E Peyton FL License #W112720 (license issued July 3, 2014), to inspect and adjust the loss as well as third-party representatives and expert(s), Jonathan Woodard, P.E. FL Engineering License #73750, visited the insured property and performed a cursory and inadequate investigation of the damaged property.
Following the May 16, 2024, inspection, by Michael E Peyton, FL License #W122720 INSURER advised INSURED that their damages only totaled $9,360.55 Actual Cash Value, and after depreciation and Policy deductible, undisputed insurance benefits in the amount of $6,860.55 would be tendered. (See attached, Carrier Letter). INSURER’S estimate was severely deficient in damage assessment and repair/replacement value. This estimate did not consider all of the INSURED’S damages and undervalued the extent of damage in the remainder of the property. This is unfair claims handling practices.
Sometime between May 13, 2024, and May 31, 2024, INSURER dispatched its vendor, PuroClean to the INSURED’S property to perform water mitigation and remediation services. PuroClean provided demolition and dry out of the affected areas at the direction of the INSURER. INSURER relied on PuroClean as its preferred vendor to perform emergency services to protect the property from further damage yet has failed to restore the property to its pre-loss condition, therefore leaving the property in a state of disrepair. INSURER has failed to pay INSURED sufficiently to cover the cost to put the property in pre-loss condition as well.
Concerned that INSURER had no intention to fairly investigate and adjust their claim, INSURED retained the services of an insurance claim professional, Noble Public Adjusting Group, to assist in submitting their claim to INSURER which would adequately and fairly detail all the damages sustained as a result of the loss.
INSURER has admitted that INSURED sustained covered damages as a result of loss but misclassified the loss as a water leak and denied coverage for the ensuing losses as a result of the accidental water discharge and ensuing damages loss that occurred on or about on or about May 13, 2024, but has denied tendering all owed insurance benefits to INSURED. Thus, INSURER has wrongfully denied coverage. (See attached, Carrier Letter).
On or about June 13, 2024, INSURER’S representative, Michelle Perkins FL License #W608891, called INSURED, Ramona Weakland Warden to discuss the coverage determination on the claim. During the call, the INSURED inquired how Michelle Perkins FL License #W608891 was able to do her job as it must be so difficult to handle these situations and Michelle Perkins FL License #W608891 advised INSURED the INSURER provided “special training” to its representatives on how to handle “these types of calls” on denying claims under the policy changes that took effect on INSURED’S policy in February 2024, and stated the policy changes were the reason for the coverage determination issued by the INSURER. INSURER’S representative Michelle Perkins FL License #W608891,at the direction of INSURER and the INSURER have failed and/or refused to settle the claim when it could and should have done so had it acted fairly and honestly towards INSURED and has failed to take into account the information and evidence provided that contradict its decisions.
In correspondence dated June 13, 2024, Michelle Perkins FL License #W608891, authored the attached Coverage Determination letter which accepted coverage for the loss but did not provide the full scope of repairs required to place the property in pre-loss condition. The denial letter stated the reason for the denial as follows:
“Frontline evaluated the claim you reported on May 14, 2024, for water damage. As part of that evaluation, Frontline inspected the insured location on May 16, 2024. The inspection revealed water damage to flooring and baseboards in several rooms due to a leaking pipe.
Based upon Frontline’s current and ongoing evaluation, as well as the information you have provided to date. Enclosed is the check in the amount of $7,230.84 for interior repairs, the estimate of covered loss, and Statement of Loss providing a breakdown of the payment.
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Respectfully, we are unable to pay for the repair to your plumbing as your Homeowners Policy excludes coverage for wear, tear or deterioration. Your policy, HOMEOWNERS 3 – SPECIAL FORM HO 00 03 05 11 as modified by SPECIAL PROVISIONS – FLORIDA FIM 00 23 05 23, states in relevant part:
SECTION I – PERILS INSURED AGAINST
1. We insure for sudden and accidental direct physical loss to covered property described in Coverages A and B unless the loss is otherwise excluded or limited in this policy. However, loss does not include, and we will not pay for, any “diminution in value.”
2. We do not insure, however, for loss:
…..
(6) Any of the following:
(a) Wear and tear, marring,
deterioration; …..
The aforementioned policy provisions are only excerpts from your policy. All policy terms and conditions continue to apply to your claim.
Our denial of your claim for plumbing repairs does not relieve you of any duty to maintain your property, and you should move forward with any repairs necessary to protect the property from further damage.”
See, Coverage Determination Letter dated June 13, 2024, attached hereto.
The coverage determination letter failed to provide the areas affected by the accidental water discharge and ensuing damages that were excluded from coverage as a result of “wear and tear, marring, deterioration;…..”
On August 2, 2024, INSURED submitted their estimate of damages to INSURER, along with the documentation in support thereof and INSURED advised INSURER they were in disagreement with INSURER’S claim evaluation.
On August 5, 2024, INSURER acknowledged receipt of INSURED’S dispute of the amount and scope of loss.
On August 28, 2024, INSURER’S preferred vendor, Donan Engineering, visited the insured property and performed a cursory and inadequate investigation of the damaged property in order to provide INSURER with an outcome oriented engineering report. In the report authored by Jonathan Woodard, P.E. FL License #73750, determined, the cause of loss to be:
“Water is rapidly released when a pipe or tubing bursts, splits, is cut open, or separates at a joint of a pressurized supply line (Figure 1). The breached pipe or tubing discharges large quantities of water quickly that can be noticed almost immediately by its sound and/or by the visual evidence of flooding or wetting a nearby area. If such failures are undetected and not quickly mediated, significant damages can result.”
See attached, Donan Report dated September 6, 2024. Further, the report recommended the removed flooring be replaced and cabinetry be removed and reset, as well as as follows:
“The repair recommendations provided below are based on an engineering opinion of the work that is expected, based on the indicated extent of damage, to return the structure to its pre-damaged condition. These recommendations do not constitute engineering design work, nor are they based on estimating or cost analysis of the work to be performed. All repair or replacement work should be completed by a qualified and licensed contractor, using materials of comparable quality and strength to existing materials, and in accordance with state and local building codes and permit requirements. If the complexity of the repair or replacement work is beyond the ordinary services provided by a contractor, it is recommended that a registered professional engineer be consulted to advise the contractor on an appropriate scope of work and construction details.
The removed engineered wood flooring can be replaced. Where the laminate wood flooring is removed, wood underlayment, floor leveling compound, or similar means can be used to create an even floor elevation prior to replacing the engineered
wood flooring. The kitchen cabinets are not damaged and can be removed and reset if replacing portions of the flooring beneath them is required.”
See attached, Donan Report dated September 6, 2024.
Despite INSURER being in receipt of the Donan Report dated September 6, 2024, the INSURER sent the INSURED correspondence dated September 11, 2024, and continued its wrongful denial of the INSURED’S claim for accidental water discharge and continued to refuse to issue and additional undisputed payments. See attached, Stand On Denial Letter dated September 11, 2024.
Since the beginning of the claim, INSURER has engaged in a pattern of delay, denial, and reckless disregard for INSURED’S rights. The actions of INSURER listed herein have been continuing in nature and given the totality of the circumstances, which includes INSURER’S adjustment, actions and/or omissions post the filing of this CRN. INSURED contend that given the past experience in this matter with INSURER, it is reasonably foreseeable that INSURER’S current actions will extend to its entire conduct in the handing of their claim, including the acts or omissions of INSURER and/or its representatives, until the final resolution of their claim. As such, INSURED contend adequate notice has been given should INSURER’S actions and violations listed herein continue after the expiration of this notice. INSURER has failed and/or refused to settle the claim when it could and should have done so had it acted fairly and honestly towards INSURED and has failed to take into account the information and evidence provided that contradict its decisions.
INSURER’S conduct has been reckless and unfair to INSURED and has caused and continues to cause additional damages throughout the property. This is evidenced by the delay in paying the claim and the failure of INSURER to evaluate the claim in total.
To date, INSURER has failed and/or refused to provide INSURED with all the necessary insurance benefits due and owing and has not tendered the full amount needed to repair the Property despite knowing that INSURED have sustained covered damages to their insured property.
As INSURER must admit, it is implied within every insurance policy a duty of good faith and fair dealings. In an insurance contract, each party is prevented from interfering with the other’s right to benefit from the contract. The obligations of good faith and fair dealings encompass qualities of decency and humanity inherent in its responsibilities as a fiduciary. INSURER is bound to conduct itself with the utmost good faith for the benefit of INSURED. However, INSURER has failed to comply with the obligations in connection with this claim and has never looked at the claim or the contract for insurance with good faith and fair dealing. Instead, INSURER has looked for ways not to pay the claim in full, or pay the claim at all, and these actions have been to the detriment of INSURED.
The adjusters assigned to this claim have a duty to adjust and treat all claims equally. Since the beginning of this claim the representatives on behalf of INSURER have approached this investigation in a manner prejudicial to INSURED. INSURER is using either untrained or improperly trained adjusters in connection with this claim. INSURER should have been adjusting the loss with INSURED but instead, it was looking for ways not to pay the claim at all, or pay the claim in full. If INSURER handles all the claims in the manner in which INSURED’S claim was adjusted, then it is improperly handling all claims.
INSURER has refused and/or failed to comply with The Policy’s cooperation and/or “Loss Payment” provision. Under The Policy, INSURER was to timely tender undisputed insurance benefits to INSURED. INSURER has failed and/or refused to timely tender owed insurance benefits, undisputed or otherwise. This is a breach of The Policy.
INSURER has refused and/or failed to cooperate and/or “Adjust the Loss” by cooperating with INSURED during the claims adjustment process in compliance with The Policy’s “Loss Payment” provision. This is a breach of The Policy.
Accordingly, INSURER has a contractual and statutory obligation to investigate all possible bases which might support INSURED’S claim and cannot deny a claim without thoroughly investigating the foundation for its denial or basis for withholding insurance benefits. INSURER violated its obligations here.
- INSURER has a contractual and statutory obligation to make a perfunctory investigation, not ignoring evidence that would support INSURED’S claim. INSURER violated its obligations here.
- INSURER has a contractual and statutory obligation not to look the other way when confronted with facts revealing the possibility of coverage and resisting reasonable interpretations of its policy. INSURER violated its obligations here.
- INSURER has a contractual and statutory obligation not to deny the claim based on standards known to be impermissible or on an interpretation contrary to established law. INSURER violated its obligations here.
These actions and violations were either done intentionally or as the result of INSURER’S failure to adopt and implement the proper standards of the investigation and adjustment of claims.
Overall, INSURER’S investigation of the claim was inadequate and contrary to its obligations under the insurance policy and Florida law.
INSURED have done everything legally requested by INSURER to date. To cure the violations set forth in this Civil Remedy Notice, INSURER must now agree to acknowledge its duties and obligations under the law in adjusting its Insureds’ claim, and tender rightfully owed insurance benefits to return INSURED to their pre-loss condition.
Therefore, demand is hereby made as follows:
Estimate $107,031.03
Less Prior Payments $6,860.55
Less Deductible $2,500.00
TOTAL $97,670.48
Further, to cure the violations set forth in this Civil Remedy Notice, INSURED hereby request that INSURER tender at this time, or prior to the expiration of the statutory cure period, the amount of INSURED’S damage estimate and demand which accurately reflects the true nature and extent of INSURED’S damages. Therefore, INSURER should tender $107,031.03 (less depreciation, prior payments, excess policy limits, and/or deductible) in insurance benefits at this time.
Although INSURED have made a demand for payment in the amount of $107,031.03 (less depreciation, prior payments, excess policy limits, and/or deductible) and have provided INSURER with all the necessary documentation in support thereof, they may still be willing to consider and to potentially accept any reasonable counter-offer made by INSURER. Therefore, if INSURER is not in agreement with INSURED’S reasonable demand for payment of their rightfully owed insurance benefits being submitted at this time, INSURED hereby request that INSURER now make a reasonable counter-offer before the expiration of the cure period. INSURED still hope that their claim can be resolved amicably.
The concept of insurance is that the insurer will investigate and grant timely and prompt indemnity or security against a contingent loss. Florida Statute §624.02 defines “insurance” as a contract whereby one undertakes to indemnify another or pay or allow a specified amount or a determinable benefit upon determinable contingencies. Inherent in that definition is the fact that payment must be made timely and promptly so that the INSURED may mitigate their damages and be put back into the position they were in prior to the loss as quickly as possible. INSURER has breached this duty.
The INSURED was, and still is, forced to expend out of pocket monies to submit her insurance claim, e.g., retaining an attorney and other experts to force INSURER to honor its obligations under the insurance policy and to pay all the insurance proceeds due and owing to them.
INSURER has refused and/or failed to tender all the insurance proceeds due and owing to the INSURED. INSURER’s refusal and/or failure to settle the insurance claim when under all circumstances it could have and should have done so had it acted fairly and honestly towards the INSURED is wrongful conduct. Furthermore, the INSURED contends that INSURER’s adjusters and/or representatives financially benefit from such wrongful conduct.
It is clear that INSURER’S adjusters have also failed to adhere to insurance industry rules and guidelines when adjusting a first party claim. It is also evident that INSURER violated the Florida unfair claims practices, the adjuster’s ethical code of conduct, and acted irresponsibly in the handling of its Insureds’ claims. In this case, INSURED paid a premium for a service, the service of claims adjusting
The claim professional must dispense his or her knowledge and skill for the benefit of society. The general public expects claims representatives to pay all legitimate claims promptly and fairly. The claim professional must harness all of his or her knowledge and expertise to accomplish the objectives of the claim function. He or she must also adhere to the highest degree of ethical conduct. In addition to interacting with other insurance personnel and service providers in a professional manner.
This notice is given in order to perfect the right to pursue the civil remedy authorized by Fla. Stat. §624.155.
Therefore, to cure the defects outlined in this Civil Remedy Notice, INSURER must:
(1) Create and implement adequate guidelines for the proper investigation and evaluation of claims and for the training and supervision of employees, which will avoid future statutory violations as set forth above, and prevent this from occurring in the future;
(2) INSURER must create and implement adequate guidelines for the proper investigation and evaluation of these types of claims and for the training and supervision of employees with regard to these claims to ensure that the claims handling procedure with regard to these types of losses are adequate to prevent other Insureds from being treated unfairly and wrongfully;
(3) INSURER must assist INSURED in mitigating their damages;
(4) INSURER must pay INSURED the fair value of their insurance claims;
(5) INSURER must act fairly and honestly towards INSURED and with due regard for their interests in attempting to settle INSURED’S claim
(6) INSURER must agree to reimburse INSURED for their expenses incurred by having to retain a public adjuster to present their claim;
(7) INSURER must tender to the INSURED $107,031.03 (less depreciation, prior payments, excess policy limits, and/or deductible), which accurately reflects the true nature and extent of their damages, as set forth above; and,
(8) INSURER must act fairly and honestly towards its INSURED and with due regard for her interests in attempting to settle its INSURED’S claim.
Or, in the alternative, should INSURER not be in agreement with INSURED’S reasonable demand for payment of their rightfully owed insurance benefits being submitted at this time, INSURED may still be willing to consider and potentially accept a reasonable counter-offer made by INSURER. As such, INSURED hereby request that INSURER now make a reasonable counter-offer before the expiration of the cure period. INSURED still hope that their claim can be resolved amicably.
Attachments:
1. Coverage Determination Letter 06.13.24
2. Carrier Estimate
3. Insured Estimate 07.03.24
4. Photos – PA 07.03.24
5. Donan Report 09.06.24
6. Stand on Denial letter 09.11.24
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The submitter hereby states that this notice is given in order to perfect the rights of the
person(s) damaged to pursue civil remedies authorized by Section 624.155, Florida Statutes.
Before submitting a Notice using this system, please verify that all text has been entered
correctly and completely. Once the Notice has been submitted, the text cannot be changed
or deleted.
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DFS-10-363
Rev. 10/14/2008
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