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PAVAN PARIKH
HAMILTON COUNTY CLERK OF COURTS
COMMON PLEAS DIVISION
ELECTRONICALLY FILED
July 31, 2023 10:52 AM
PAVAN PARIKH
Clerk of Courts
Hamilton County, Ohio
CONFIRMATION 1350987
GREENLIGHT PREMIUM A 2303226
FINANCE COMPANY
vs.
CIRCLE O INC
FILING TYPE: INITIAL FILING (OUT OF COUNTY) WITH NO JURY
DEMAND
PAGES FILED: 21
EFR200
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
IN THE HAMILTON COUNTY COMMON PLEAS COURT
HAMILTON COUNTY, OHIO
GREENLIGHT PREMIUM FINANCE)
COMPANY ) CASE NO.:
955 Executive Parkway Dr Suite 216 )
St Louis MO 63166-6501
) JUDGE:
Plaintiff )
Vv.
COMPLAINT
CIRCLE O INC
8044 Montgomery Rd Ste 700-730
Cincinnati OH 45236
And
ABDURAKHMON MAVLYANOV
8044 Montgomery Rd Ste 700-730
Cincinnati OH 45236
Defendant(s).
Now comes Plaintiff, by and through undersigned counsel and for its Complaint
against Defendant states as follows:
INTRODUCTION
1 Plaintiff is a licensed business whose principal place of business is as set
forth in the caption.
2. At all times pertinent herein, Defendant Circle O Inc is and was a licensed
Ohio corporation and Defendant Abdurakhmon Mavlyanov is a principal of Circle O, Inc
and also is a resident of the of Cincinnati, County of Hamilton, and State of Ohio.
3 Plaintiff is in the business of providing financing options to businesses in
need of said financing of their insurance premiums.
4 Plaintiff and Circle O Inc entered into a business relationship whereby
Plaintiff provided financing for the $202,603.99 insurance premium incurred by Circle O
Inc for the Cargo and Physical Damage insurance policy issued by Evolution Insurance
Brokers, LLC for the period of March 23, 2021 to March 23, 2022. Based upon the
actions of Plaintiff, Circle O Inc received and accepted insurance coverage from EIB.
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
COUNTI
(Failure to Pay)
5 Plaintiff incorporates by reference all the foregoing allegations of
Paragraphs | through 4 as if fully rewritten herein.
6 Plaintiff provided said financing and Circle O Inc received said insurance
coverage, however the Defendant has failed to tender payment for said coverage. A copy
of the agreement is attached hereto as Exhibit “A”.
7 As a direct and proximate result of Defendant’s failure to pay, Plaintiff has
been damaged in the amount of $76,097.08, together with accrued interest.
COUNT IT
(Breach of Guarantee)
8 Plaintiff incorporates by reference all the foregoing allegations of
Paragraphs | through 7 as if fully rewritten and restated herein.
9 As a Condition of granting credit terms to Circle O Inc, Plaintiff requested
and Defendant Abdurakhmon Mavlyanov entered into a personal guarantee contract,
whereby Defendant Abdurakhmon Mavlyanov guaranteed payment. The Guarantee
referenced is attached hereto as Exhibit “B”.
10. Defendant breached the guaranty by failing to make payment to Plaintiff
for the amount due and owing.
il. As a direct and proximate result of Abdurakhmon Mavlyanov breach of
the Guarantee, Plaintiff has incurred damages of $76,097.08, plus interest at the statutory
rate, together with costs incurred herein.
COUNT Til
(Unjust Enrichment)
12. Plaintiff incorporates by reference all the foregoing allegations of
Paragraphs 1 through 11 as if fully rewritten herein.
13. Plaintiff conferred a benefit to both Defendants when it extended credit to
Circle O Inc, and upon information and belief said credit benefited Abdurakhmon
Mavlyanov financial position.
14. Defendants knowingly received a benefit when they received the good and
services from Plaintiff.
15. Defendants unjustly retained the benefit of the loan proceeds by failing to
pay the balance due.
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
16. As a direct and proximate result of Defendants’ failure to pay the amount
due, Plaintiff has been damaged in the amount of $76,097.08 plus accrued interest.
WHEREFORE, Plaintiff demands judgment against the Defendant, Circle O Inc
on the first, and third causes of action, in the amount of $76,097.08, plus interest at the
statutory rate of five percent (5%) per annum from the date of judgment, and against
Abdurakhmon Mavlyanov on the second and third causes of action, in the amount of
$76,097.08, plus interest at the statutory rate of five percent (5%) per annum from the
date of judgment, plus its costs incurred herein, and any further relief this Court deems
just and equitable.
Respectfu| mitted,
Jeffrey L. Koberg (0047386)
Law Offices of Timothy M. Sullivan
18013 Cleveland Parkway Suite 180
Cleveland, Ohio 44135
Phone: (216) 762-1700
Email: jkoberg@tmslaw.net
Attorney for Plaintiff
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72
Evolution Insurance Brokers, LC
Wy
8722 S. Harrison St. indy, UT 84070 P.O. Box 4439, Sandy, UT 84091
Phone: 800-257-5580 - Fax: 877-452-6910
Website: ~ bind@eibdirect.com
3/22/2021
GIA Group, LLC.
148 East Street Road Suite 171
Feasterville, PA 19053
Re: Circle O Inc
Please find below an Indication Quote. In orderto accommodate the insurer's underwriting parameters and/or the insured's premium
preference, the Quote may contain coverage options or be based upon factors such as lower limits of liability or a higher self-insured
retention or deductible than what was stated as preferred on the Application. Accordingly, please read the Quote carefully.
INDICATION QUOTE
Quote number: PA2103419-4 ‘Customer number: E21-303419
Underwriter: Pete Andersen Direct phone no. (801) 304-5591 E-mail: petea@orimeis.com
This is an Indication Quote only. The prices listed below are subject to review and change after receipt of any requested additional
information. This Indication Quote is valid for thirty (30) days from today unless the Company withdraws this Indication in writing or issues
a new or revised Indication Quote.
rms of quotec
Unless otherwise specifically indicated herein, or in the policy forms themselves, the following apply to the quoted policy:
a) The quoted policy is a manuscript policy which differs substantially from standard insurance forms, please review this
quote and the policy carefully to ensure that it meets your insurance needs;
(2) This policy is quoted for claims-made-and-reported coverage which includes strict reporting requirements. However,
you have the option of purchasing broader “occurrence coverage" for an additional premium as quoted below;
@) If you are purchasing claims-made-and-reported coverage, you have the option of purchasing broader “retroactive
coverage” as explained and quoted below;
(4) The quoted policy requires any disputes arising out of the policy to be resolved in a Utah court applying Utah law,
(5) The quoted policy may not include all the coverages you have requested in your application and the insurance company has
no obligation to quote all coverage and terms you may have requested. Please review this quote to ensure it meets your
insurance requirement,
(6) The quoted policy may not provide all the insurance you are required to have under federal or focal laws. You, and
your broker/agent if you have one, are solely responsible to ensure that the type and amountof coverage you have selected
meets your needs and the requirements of your operation; and
(7) In the event a court reforms or revises the quoted policy to comply with laws or regulations governing your operations,and
‘such reformation or revisions results in the insurance company providing more or broader coverage than you have selected,
you are required to indemnify the Company for any increased exposure created by your failure to purchase mandated insurance.
Description of risk(s): Long Haul Trucking
Description of coverage: Commercial Auto Liability - Motor Truck Cargo - Trailer interchange
Minimum eared: 40% EXHIBIT
Premium: $383,545.00
Policy/inspection fee: $850.00 Agent commission amount: $38,354.50
State taxes:
SLSC:
$19,177.25
$0.00
Total due: $365,217.75
KL-
Total: $403,572.25
‘TO.BIND COVERAGE: Several other conditions must be met prior to binding coverage, including but not limited to, receipt of payment,
compliance with all stated conditions below, and receipt of all completed forms and requested information. Sevetese ie not bour wil
bouns in prior rite
ome In the event of any material change in underwriting information before coverage is bound, terms may be modified
‘or withdrawn by the underwriter.
EIBI-F-033 16MAY2019 Page
1 of 13 ‘Quote Number: PA2103419-4
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72
INDICATION QUOTE
(cont.}
Commercial Auto:
$1,000,000 Per Accident
$5,000 SIR
$10,000 Property Damage Clean Up Cost Sublimit
$2,500 Trailer Interchange Deductible
Number of Vehicles: 25
[y] Excludes Physical Damage
$50,000 Trailer Interchange limit per unit (25 units) Coverages:
Form Type: [¥] Claims Made (1 Occurrence Composite Rate - Revenue - based on 12,000,000. Rate of $3.2/100.
PoticyType: ¥] Manuscript Oso
Motor Truck Cargo
Motor Truck Cargo Units: 25 Value: $250,000
with Refer
Breakdown
[_ Deductibie $2,500
_
EIBI-F.033 16MAY2019 Page
2 of 13 ‘Quote Number: PA2103419-4
-
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72
INDICATION QUOTE
(cont.)
——
Other coverages availablo: (additional underwriting required and an increase in premium, if accepted)
Retroactive coverage: One year of retroactive coverage is available for an additional premium of. $153,418. Additional
years are available, but require additional underwriting (See "Explanation of retroactive coverage" below).
Occurrence coverage: Unless otherwise stated herein, the policy is quoted on a claims-made-and-reported basis. However,
you may purchase broader occurrence coverage for an additional: 40% of the quoted premium.
———
Explanation of retroactive coverage: Ifthe quoted policy is a claims-made-and-reported policy, you should consider purchasing
broader “retroactive coverage". A “claims made and reported” policy provides coverage only for incidents that occur during the policy
period where the claim is also made and reported during that same coverage period. If an accident occurs during a different policy
period than the policy period during which the claim is first made against you, or reported to the insurance company, there would be no
coverage. "Retroactive coverage” broadens coverage so that an accident occurring before the policy will be covered if the claim is
made and reported during the next policy period year. As such, retroactive coverage provides continuous uninterrupted coverage for
claims made against you during the new coverage period but which result from an accident that happened before the new coverage
period. If you have questions regarding retroactive coverage, please contact us or your broker/agent.
m
Optional coverages available for additional premium — additional underwriting information required: 1. Pandemic Liability; 2. Active
Shooter/Workplace Violence Liability. Insured is required to submit a written copy of policies/procedures: all must be above the standard of
care set by governing authorities (local, state, federal government) and proactively evolve as needed based on the direction of authorities.
Any fraudulent activities on any policy, will be reported to the Department of Transportation, Departmentof Insurance and any Certificate/Al
holders.
Any unreported vehicles discovered will result in additional premium and the policy wil! be put under Notice of Cancellation.
Quote based on 25 Tractor/Trailers units and 12,000,000 Annual Revenue for the next 12 months.
Defense coverage is within the limits of liability.
If Higher Liability Limits are required by the insured, please contact underwriting for a formal quote.
If using outside finance companies, the underwriter must be notified priorto binding - sample policy forms will be sent.
PICIPPCI Deregulation: Excludes coverage for pollution costs or expenses. Terms can be offered for additional premium,
‘Subject to the insured’s completion of a discussion call with aur Risk Management Department within 30 days of binding coverage. Toll
Free 877-585-2851
Insured driver contract may not have wording that promotes a driver, owner/operator or any employee to break or be penalized for the
FMSCA tules and regulations (ex: penalties for late deliveries causing HOS violations etc.).
Signed UMIUIM/PIP selection / rejection form required.
Towing & Labor Costs are excluded - terms can be offered for additional premium, physical damage coverage must be purchased.
‘Only scheduled drivers are covered and premiums for additional drivers must be paid before coverage is in force. Premium (including
taxes/fees) for each additional driver is $50 (not including MVR surcharges) and is 100% fully earned.
All Drivers are subjectto Driver Premium Charges: processing charge, 5 years MVR, and CDL experience. MVR charges are fully earned.
Personal Guarantee and Indemnity Agreement with a Claims Fund Agreement required along with approved security prior to binding
Claims Fund Agreement with prefunded retention of $5,000 required to bind.
Agent/broker may not charge any kind of fee to the Insured that is different from or exceeds the premiums and fees set forth in the quote,
unless specifically authorized by us in writing.
‘Subject to an unlimted radius
Only carrier can issue vehicle identification cards.
The Policy Receipt Form (PRF) must be signed and returned to us within 10 days of the receipt of the Policy. In the event the PRF is not
timely retumed, we reserve the right to issue a Notice of Cancelation (NOC).
Covered Pollution Cos/Expense/PD Cleanup:max payment for costs to clean up, remove or mitigate damage, debris, spilled cargo, or any
other impediment or impairment to property not owned by an insured, caused by a covered Accident.
PIC/PPCI Deregulation - Physical damage coverage excludes diminution in value and loss of use. May consider offering for additional
premium.
Provide a government issued document evidencing the exact name of the legal entity to be insured, including any DBA’s or alternative
names
All owner operators are required to carry bob-tail / non-trucking liability coverage and the insured is required to maintain proof of active
coverage. Proofof active coverage must be available upon request.
uote excludes Additional Insureds (Als) unless specifically outlined in the quote documents. Als can be added for additional premium
Approved Driver Endorsement: Only drivers that meet the endorsement guidelines are automatically covered, drivers outside of the
endorsement guidelines require a driver surcharge and must be specifically scheduled.
Approved Driver Endorsement: Specifically scheduled drivers (fall outside of Approved Driver Endorsement guidelines) included in this
quote: NONE
ADE: If expiring policy is scheduled drivers, current scheduled drivers will NOT be renewed. Insured must submit a list of drivers that fall
outside of the guidelines, driver is not covered until the additional driver premium is paid & scheduled.
Any Accident or Claim brought forth may have multiple SIR’s owed for each loss (review the full policy language). Sample policy language
is available upon request.
MTC includes Refer Breakdown
EIBI-F-033 18MAY2019 Page 3 of13 ‘Quote Number: PA2103419-4
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72
ito Liability: Composite Rate used - vehicles are not required to be scheduled. Insured is required to maintain an up to date excel
‘spreadsheet of vehicles (make, model, year, VIN), drivers, and dates - must be available upon request
Composite Rate includes 50,000 Physical Damage coverage non-owned trailers while attached to a Tractor Unit on dispatch from the
insured.
Composite Rate includes 250,000 Motor Truck cargo coverage while hauled by a Tractor Unit on dispatch from the insured.
AUDITABLE exposure: Quarterly reports required: 1.Revenue 2. Number of power units, additional premium may be required at the time of
audit
Current composite rate for auto liability only: $3.2 per $100 in trucking revenue.
‘UW to review all audits and advise if additional premium is needed. - add condition as needed.
All audit information is due the 5th of the month on a Quarterly basis. Audit dates will be as follows:
Motor Truck Cargo Coverage excludes claims due to theft from an unattended or unsecured vehicle.
EIBI-F-033 16MAY2019 Page
4 of 13 ‘Quote Number: PA2103419.4
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
DocuSign Envelope ID: 034C9E95-0786-4ED3-95BC-AE40682CBC72
Greenlight Premium Financing Options
Quote date: 3/22/2021
Company name: Circle O Inc
Customer number: E21-303419 Total premium due (includes taxes and fees): _ $403,572.25
If you want to finance, INITIAL the option containing the finance terms of your choice.
Choose ONLY ONE option otherwise 100% of the total premium is due.
25% Down Payment~ | 30% Down Payment | 40% Down Payment
$100,893.06 $121,071.68 $161,428.90
“Auto draft monthly payments
are required
3.Monthly Payments
Initial Here initial Here __ Initial Here
3@ $102,591.31 : 3@ $95,752.78 3@ $82,075.71
Interest Rate 10.00% 10.00% 10.00%
Finance Charge $5,094.74 $4,757.76 $4,083.70
Final APR™* 10.08% 10.08% 10.1%
Amount Financed $302,679.19 $282,500.58 $242,143.35
Total of Payments $307,773.93 $287,258.33 $246,227.14
+
5 Monthly Payments
Initial Here Initial Here Initial Here
=
s@ seam02 o
: 5@ “$58,214.42 ae 5@ $49,899.22
|
Interest Rate 12.00% 2.00% 12.00%
Finance Charge $9,180.91 $8,571.52 $7,362.73
Final APR** 12.08% 12.06% 12.07%
Amount Financed $302,679.19 $282,600.58 $242,143.35
Total of Payments $311,860.10 $201,072.09 $249,496.08
Monthly Payments
Initial Here Initial Here Initial Here
- woe
7@ $45,139.51 7 7 @ “$42,130.59 7@ $36,4 12.75 : i
Interest Rate 13.00% 13.00% 13.00%
Finance Charge $13,207.36 $12,413.53 $10,645.88
Final APR** 13.04% 13.05% 13.05%
‘Amount Financed $302,679.19 $282,500.58 $242,143.35
Tolal of Payments $315,976.54 $294,914.10 $252,789.23
DS.
9 Monthly Payments
AM. initial Here Initial Here __ Initial Here
- ~
51.62
Interest Rate XROIGAX 14.00% 14.00%
Finance Charge $17,958.61 $16,764.03 $14,374.89
Final APR™* 14.03% 14.03% 14.04%
‘Amount Financed $302,679.19 $262,500.58 $242,143.35
Total of Payments $320,637.80 $299,264.61 $256,518.24
Check this box if you would like to setup your monthly payments to be auto drafted (this option Is for 30 & 40% down,
all 25% down payments will automatically be setup up for auto drafts).
After initialing an option listed above, sign the agreement on the next page and attach a
check for the down payment amount shown in your selected option above.
*Note: All 25% down payment options require an automatié draft from your bank account monthly.
“Note: Final APR is based on the annual percentage ‘rate plus fees for the duration of the numberof monthly payments selected,
This is nol a foan document and is not binding on any premium finance company to accept any loan for the undersigned.
‘The first payment is due in 30 days after the coverage effective date.
a
EIBI-F-033 16MAY2019 Page
5 of 13 ‘Quote Number: PAZ103419-4
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72
Greenlight Premium Financing Request (Continued)
Yes, | want to finance according to the option selected on the previous page (please sign and see down payment methods below)
(Note: All 25% down payment options require an automatic draft from your bank account monthly.)
The undersigned insured/member requests that, EIB International, LLC. (EIB) a Utah company, arrange the financing for its premium in
monthly installments and hereby imevocably appoints EIB a limited power of attorney to complete and execute a premium financing
agreement on its behalf.
‘The undersigned shall have the right to, without charge, rescind by paying to EIB the net amount financed on the financing agreement
executed on its behalf by EIB within 10 days after EIB or the actual premium finance company (PFC) mails to the undersigned a true copy of
the actual premium financing agreement being executed by EIB as attorney-in fact for the undersigned. Failure to rescind shall be deemed a
ratification and affirmation of the actions of the attorney-in-fact in the execution of a premium financing.
Security Interest: Borrower hereby gives the PFC a security interest in and assigns any amount payable to Borrower under the policy to
first satisfy any amounts owed by borrower to PFC, including interest, late fees or cancellation charges. Borrower agrees that PFC shall be
listed as a loss payee on the policy and that PFC's interest shall have priority over any other loss payees or lienholders. This security
interest shall include, without limitation, any and all uneamed premiums and dividends which may be payable under the insurance policies
listed in the Schedule of Policies, loss payments which reduce the unearned premiums, and any interest arising under a state guarantee
fund relating to these items.
[] No, Ido not want to finance. _! am paying 100% of the total premium listed on my quote. (See payment methods below)
Authorization to Set Up Financing
I,the insured, have read and authorize (EIB) to set up financing according to my selection on the previous page.
Docusigned by:
3/23/2021
Wh duraklamon, Malyanor
Si |AEAB31ABD40D. Date
Abdurakhnon Mavlyanov PRESIDENT
Print name and title
PAYMENT METHOD: PAY BY WIRE, PHONE, FAX, OR MAIL
BANK WIRE | CHECK VIA OVERNIGHT ~~ CHECK
BY FAX
a = OR EXPRESS MAIL CREDIT CARD BY PHONE
Account name: Evolution Insurance
FAX: 1-877-452-6910
Brokers, LC EIB = .
= E-MAIL:
Bank
we nami Altabank 8722 South Harrison St, at@primeis.cor
Telephon: 1-800-815-2265 Sandy, UT 84070
Routing no.: 124301025
eo PHONE: 1-877-257-5590
Account no: 07110224
CHECK DISCLOSURE:
Checks received may be processed electronically. The Company, through its bank, has the ability to provide electronic check processing
rather than submitting a paper copy of the check to the bank. Funds transfer in the same manner if transacted electronically or by submitting
@ paper copy of the check to the bank, except funds transfer the day the information is received with electronic processing rather than within a
few business days as with a paper check. Electronically processed checks transactions appear on your bank statement in the same manner
as paper checks. Charge will appear as ‘Evolution Insurance Brokers, LC Premium Trust.’
‘CHECK BY FAX METHOD:
4. Make out physical check, payable to Evolution Insurance Brokers. Date and sign the check, but do not mail it.
2. Complete and sign the authorization, giving us permission to convert check to an EFT (Electronic Funds Transfer). Transaction will
appear as a debit from Evolution Ins BK
3. Tape the check to this form, where indicated at the bottom. Fax this form and check to 1-877-452-6910
4. Keep this form and original check. DO NOT MAIL IT
pace
Attach Check here or Enter Check Information;
Bank name and address: —
071000013 613793279
Bank routing no.(usually 9 digits): Account no.:
Amount of check: $—pocusioned by: ‘Check no.:
3/23/2021
Authorized by:
Ts
3/23/2021
‘Signature of authorization: Date
IF FINANCING: Attach an addiTonaV GREEK TPYR2 would like to use a different account for your auto draft monthly payments.
SERVICE FEE: EIB reserves the right to collect directly from your account a processing fee of $25 for any incomplete transaction due to
insufficient funds in your account (i.¢. a "bounced check").
This is not a loan document and is not binding on any premium finance company to accept any loan for the undersigned.
‘The first payment is due in 30 days after the coverage effective date,
EIBLF-033 29JAN2020
EIBI-F-033 16MAY2019 Page 6 of 13 ‘Quote Number: PA2103419-4
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72
Ohio Department Surplus Lines Statement
of Insurance
Mike DeWine, Gover —_ilian Brewtant, Ditector OPRAS-PAKC Division, 50 W Tow Stet, Jed Floor - Suite 265, ColumbusOH 43215
Son Histted, Lf Geveener 614-644-2635 | Fax 614-729-1280 | isuranceohiogoy
PART 1, STATEMENT OF SURPLUS LINE BROKER
OR GRIGINATING AGENT
Gene Brodsky
acknowledges that he/she is a duly licensed full multiple line agent currently
licensed with insurance nies, other than life, authorized to do business in Ohio or he/she is a duly licensed surplus
line broker pursuant to section 3905.30 of the Ohio Revised Code and that after due diligence, he/she is unable to procure
the insurance
policy described below from insurers authorized to do business in Ohio to which he/she is a licensed agent.
Circle O Inc
Property
or risk to be insured: =
He/she acknowledges that he/she has complied with the applicable requirements of due diligence as set forth in section
3905.33 of the Ohio Revised Code, and has explained to the insured the meaning of the signed statements
prior to binding
coverage and received declinations for the reasons set forth below from the following authorized insurer(s) to which
he/she is so licensed and which are known to him/her to customarily write the kind of insurance described above.
INSURERS REASONS
Progressive Fleet size
ATG RRG does not offer cargo
Northland Drivers and CDL Experience
Signature of Surplus Line Broker or Originating Agent
PART 2, SIGNED STATEMENT OF INSURED AS REQUIRED BY SECTION 3905.33 OF THE ORIO
REVISED CODE
‘The named insured CIRCLE O INC » acknowledges that the insurance policy (other
than life insurance) as described above is to be placed with an insurance company not authorized to do business in Ohio.
‘The insured understands that the insurance companyis not a member of the Ohio Insurance Guaranty Association and that
Chapter 3955 of the Chio Revised Code is not applicable to claimants or insureds of said insurance company. The surplus
Tine broker shall collect the Ohio tax of five-percent of the amount of the premium for the insurance policy at the time the
insurance policy is delivered to the insured.
DocuSigned by:
Signature
of Insured: hbdur nMawlyanoe
==
the broker or agent, not ta Ohio Department of Insurance.
INS4024 (Rev. 06/2020) Page
1 of 1
—
EIBI-F-033 16MAY2019 Page
7 of 13 “Quote Number: PA2103419-4
E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO
DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72
int
INSURED CONTACT FORM
Prime's Risk Management Department fosters a mutually beneficial relationship with every insured by
taking a partnership approach to the management of each insured's account.
We begin this partnership with a call to the insured where we:
™® Welcome the insured to the company,
® Review policy terms, limits, and conditions,
® Establish a direct point of contact for risk management related concerns.
In addition to the conditions of the policy, below are three requirements that the applicant needs to
complete during the policy period:
1 Return a signed copy of the Policy Receipt Form and Coverage Conditions Summary to
the Risk Management Department within 10 calendar days of receipt of the policy.
2 Complete a risk management discussion call within 30 days of the policy being bound.
3. An onsite visit will be completed during the policy period at our discretion. We encourage
your agent to also be part of this onsite visit.
Please complete:
Abdurakhmon Mavlyanov
Owner/decision maker name(s):
5139912422
Contact phone number(s):
circleoinc@gmai1.com
Contact email address(s):
8044 MONTGOMERY RD STE 700-7306 CINCINNATI OH 45236
Physical location for business operations:
Gene Brodsky GIA Group, LLC
Agent contact & agency:
855-876-0717
Agent phone number:
If you do not receive a phone call within 10 days of the policy being bound, please contact one of our team
members at 1-877-585-2851. We are available Monday through Friday, 7:00 AM-6:00 PM Mountain Time.
By signing below, | understand that | will need to complete a discussion call with the Risk
Management Department within 30 days of policy being bound and return a signed copy of the
Policy Receipt Form and Coverage Conditions Summary within 10 days of receipt of the policy. | also
understand that there may be a required onsite visit completed at my physical location during the policy
period to keep coverage in effect.
DocuSigned by: Docusigned by:
Abduratlunon Malyanon. Gun Brodsky
Preview
i GE PF SOy 2 e Or cou PAVAN PARIKH HAMILTON COUNTY CLERK OF COURTS COMMON PLEAS DIVISION ELECTRONICALLY FILED July 31, 2023 10:52 AM PAVAN PARIKH Clerk of Courts Hamilton County, Ohio CONFIRMATION 1350987 GREENLIGHT PREMIUM A 2303226 FINANCE COMPANY vs. CIRCLE O INC FILING TYPE: INITIAL FILING (OUT OF COUNTY) WITH NO JURY DEMAND PAGES FILED: 21 EFR200 E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO IN THE HAMILTON COUNTY COMMON PLEAS COURT HAMILTON COUNTY, OHIO GREENLIGHT PREMIUM FINANCE) COMPANY ) CASE NO.: 955 Executive Parkway Dr Suite 216 ) St Louis MO 63166-6501 ) JUDGE: Plaintiff ) Vv. COMPLAINT CIRCLE O INC 8044 Montgomery Rd Ste 700-730 Cincinnati OH 45236 And ABDURAKHMON MAVLYANOV 8044 Montgomery Rd Ste 700-730 Cincinnati OH 45236 Defendant(s). Now comes Plaintiff, by and through undersigned counsel and for its Complaint against Defendant states as follows: INTRODUCTION 1 Plaintiff is a licensed business whose principal place of business is as set forth in the caption. 2. At all times pertinent herein, Defendant Circle O Inc is and was a licensed Ohio corporation and Defendant Abdurakhmon Mavlyanov is a principal of Circle O, Inc and also is a resident of the of Cincinnati, County of Hamilton, and State of Ohio. 3 Plaintiff is in the business of providing financing options to businesses in need of said financing of their insurance premiums. 4 Plaintiff and Circle O Inc entered into a business relationship whereby Plaintiff provided financing for the $202,603.99 insurance premium incurred by Circle O Inc for the Cargo and Physical Damage insurance policy issued by Evolution Insurance Brokers, LLC for the period of March 23, 2021 to March 23, 2022. Based upon the actions of Plaintiff, Circle O Inc received and accepted insurance coverage from EIB. E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO COUNTI (Failure to Pay) 5 Plaintiff incorporates by reference all the foregoing allegations of Paragraphs | through 4 as if fully rewritten herein. 6 Plaintiff provided said financing and Circle O Inc received said insurance coverage, however the Defendant has failed to tender payment for said coverage. A copy of the agreement is attached hereto as Exhibit “A”. 7 As a direct and proximate result of Defendant’s failure to pay, Plaintiff has been damaged in the amount of $76,097.08, together with accrued interest. COUNT IT (Breach of Guarantee) 8 Plaintiff incorporates by reference all the foregoing allegations of Paragraphs | through 7 as if fully rewritten and restated herein. 9 As a Condition of granting credit terms to Circle O Inc, Plaintiff requested and Defendant Abdurakhmon Mavlyanov entered into a personal guarantee contract, whereby Defendant Abdurakhmon Mavlyanov guaranteed payment. The Guarantee referenced is attached hereto as Exhibit “B”. 10. Defendant breached the guaranty by failing to make payment to Plaintiff for the amount due and owing. il. As a direct and proximate result of Abdurakhmon Mavlyanov breach of the Guarantee, Plaintiff has incurred damages of $76,097.08, plus interest at the statutory rate, together with costs incurred herein. COUNT Til (Unjust Enrichment) 12. Plaintiff incorporates by reference all the foregoing allegations of Paragraphs 1 through 11 as if fully rewritten herein. 13. Plaintiff conferred a benefit to both Defendants when it extended credit to Circle O Inc, and upon information and belief said credit benefited Abdurakhmon Mavlyanov financial position. 14. Defendants knowingly received a benefit when they received the good and services from Plaintiff. 15. Defendants unjustly retained the benefit of the loan proceeds by failing to pay the balance due. E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO 16. As a direct and proximate result of Defendants’ failure to pay the amount due, Plaintiff has been damaged in the amount of $76,097.08 plus accrued interest. WHEREFORE, Plaintiff demands judgment against the Defendant, Circle O Inc on the first, and third causes of action, in the amount of $76,097.08, plus interest at the statutory rate of five percent (5%) per annum from the date of judgment, and against Abdurakhmon Mavlyanov on the second and third causes of action, in the amount of $76,097.08, plus interest at the statutory rate of five percent (5%) per annum from the date of judgment, plus its costs incurred herein, and any further relief this Court deems just and equitable. Respectfu| mitted, Jeffrey L. Koberg (0047386) Law Offices of Timothy M. Sullivan 18013 Cleveland Parkway Suite 180 Cleveland, Ohio 44135 Phone: (216) 762-1700 Email: jkoberg@tmslaw.net Attorney for Plaintiff E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72 Evolution Insurance Brokers, LC Wy 8722 S. Harrison St. indy, UT 84070 P.O. Box 4439, Sandy, UT 84091 Phone: 800-257-5580 - Fax: 877-452-6910 Website: ~ bind@eibdirect.com 3/22/2021 GIA Group, LLC. 148 East Street Road Suite 171 Feasterville, PA 19053 Re: Circle O Inc Please find below an Indication Quote. In orderto accommodate the insurer's underwriting parameters and/or the insured's premium preference, the Quote may contain coverage options or be based upon factors such as lower limits of liability or a higher self-insured retention or deductible than what was stated as preferred on the Application. Accordingly, please read the Quote carefully. INDICATION QUOTE Quote number: PA2103419-4 ‘Customer number: E21-303419 Underwriter: Pete Andersen Direct phone no. (801) 304-5591 E-mail: petea@orimeis.com This is an Indication Quote only. The prices listed below are subject to review and change after receipt of any requested additional information. This Indication Quote is valid for thirty (30) days from today unless the Company withdraws this Indication in writing or issues a new or revised Indication Quote. rms of quotec Unless otherwise specifically indicated herein, or in the policy forms themselves, the following apply to the quoted policy: a) The quoted policy is a manuscript policy which differs substantially from standard insurance forms, please review this quote and the policy carefully to ensure that it meets your insurance needs; (2) This policy is quoted for claims-made-and-reported coverage which includes strict reporting requirements. However, you have the option of purchasing broader “occurrence coverage" for an additional premium as quoted below; @) If you are purchasing claims-made-and-reported coverage, you have the option of purchasing broader “retroactive coverage” as explained and quoted below; (4) The quoted policy requires any disputes arising out of the policy to be resolved in a Utah court applying Utah law, (5) The quoted policy may not include all the coverages you have requested in your application and the insurance company has no obligation to quote all coverage and terms you may have requested. Please review this quote to ensure it meets your insurance requirement, (6) The quoted policy may not provide all the insurance you are required to have under federal or focal laws. You, and your broker/agent if you have one, are solely responsible to ensure that the type and amountof coverage you have selected meets your needs and the requirements of your operation; and (7) In the event a court reforms or revises the quoted policy to comply with laws or regulations governing your operations,and ‘such reformation or revisions results in the insurance company providing more or broader coverage than you have selected, you are required to indemnify the Company for any increased exposure created by your failure to purchase mandated insurance. Description of risk(s): Long Haul Trucking Description of coverage: Commercial Auto Liability - Motor Truck Cargo - Trailer interchange Minimum eared: 40% EXHIBIT Premium: $383,545.00 Policy/inspection fee: $850.00 Agent commission amount: $38,354.50 State taxes: SLSC: $19,177.25 $0.00 Total due: $365,217.75 KL- Total: $403,572.25 ‘TO.BIND COVERAGE: Several other conditions must be met prior to binding coverage, including but not limited to, receipt of payment, compliance with all stated conditions below, and receipt of all completed forms and requested information. Sevetese ie not bour wil bouns in prior rite ome In the event of any material change in underwriting information before coverage is bound, terms may be modified ‘or withdrawn by the underwriter. EIBI-F-033 16MAY2019 Page 1 of 13 ‘Quote Number: PA2103419-4 E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72 INDICATION QUOTE (cont.} Commercial Auto: $1,000,000 Per Accident $5,000 SIR $10,000 Property Damage Clean Up Cost Sublimit $2,500 Trailer Interchange Deductible Number of Vehicles: 25 [y] Excludes Physical Damage $50,000 Trailer Interchange limit per unit (25 units) Coverages: Form Type: [¥] Claims Made (1 Occurrence Composite Rate - Revenue - based on 12,000,000. Rate of $3.2/100. PoticyType: ¥] Manuscript Oso Motor Truck Cargo Motor Truck Cargo Units: 25 Value: $250,000 with Refer Breakdown [_ Deductibie $2,500 _ EIBI-F.033 16MAY2019 Page 2 of 13 ‘Quote Number: PA2103419-4 - E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72 INDICATION QUOTE (cont.) —— Other coverages availablo: (additional underwriting required and an increase in premium, if accepted) Retroactive coverage: One year of retroactive coverage is available for an additional premium of. $153,418. Additional years are available, but require additional underwriting (See "Explanation of retroactive coverage" below). Occurrence coverage: Unless otherwise stated herein, the policy is quoted on a claims-made-and-reported basis. However, you may purchase broader occurrence coverage for an additional: 40% of the quoted premium. ——— Explanation of retroactive coverage: Ifthe quoted policy is a claims-made-and-reported policy, you should consider purchasing broader “retroactive coverage". A “claims made and reported” policy provides coverage only for incidents that occur during the policy period where the claim is also made and reported during that same coverage period. If an accident occurs during a different policy period than the policy period during which the claim is first made against you, or reported to the insurance company, there would be no coverage. "Retroactive coverage” broadens coverage so that an accident occurring before the policy will be covered if the claim is made and reported during the next policy period year. As such, retroactive coverage provides continuous uninterrupted coverage for claims made against you during the new coverage period but which result from an accident that happened before the new coverage period. If you have questions regarding retroactive coverage, please contact us or your broker/agent. m Optional coverages available for additional premium — additional underwriting information required: 1. Pandemic Liability; 2. Active Shooter/Workplace Violence Liability. Insured is required to submit a written copy of policies/procedures: all must be above the standard of care set by governing authorities (local, state, federal government) and proactively evolve as needed based on the direction of authorities. Any fraudulent activities on any policy, will be reported to the Department of Transportation, Departmentof Insurance and any Certificate/Al holders. Any unreported vehicles discovered will result in additional premium and the policy wil! be put under Notice of Cancellation. Quote based on 25 Tractor/Trailers units and 12,000,000 Annual Revenue for the next 12 months. Defense coverage is within the limits of liability. If Higher Liability Limits are required by the insured, please contact underwriting for a formal quote. If using outside finance companies, the underwriter must be notified priorto binding - sample policy forms will be sent. PICIPPCI Deregulation: Excludes coverage for pollution costs or expenses. Terms can be offered for additional premium, ‘Subject to the insured’s completion of a discussion call with aur Risk Management Department within 30 days of binding coverage. Toll Free 877-585-2851 Insured driver contract may not have wording that promotes a driver, owner/operator or any employee to break or be penalized for the FMSCA tules and regulations (ex: penalties for late deliveries causing HOS violations etc.). Signed UMIUIM/PIP selection / rejection form required. Towing & Labor Costs are excluded - terms can be offered for additional premium, physical damage coverage must be purchased. ‘Only scheduled drivers are covered and premiums for additional drivers must be paid before coverage is in force. Premium (including taxes/fees) for each additional driver is $50 (not including MVR surcharges) and is 100% fully earned. All Drivers are subjectto Driver Premium Charges: processing charge, 5 years MVR, and CDL experience. MVR charges are fully earned. Personal Guarantee and Indemnity Agreement with a Claims Fund Agreement required along with approved security prior to binding Claims Fund Agreement with prefunded retention of $5,000 required to bind. Agent/broker may not charge any kind of fee to the Insured that is different from or exceeds the premiums and fees set forth in the quote, unless specifically authorized by us in writing. ‘Subject to an unlimted radius Only carrier can issue vehicle identification cards. The Policy Receipt Form (PRF) must be signed and returned to us within 10 days of the receipt of the Policy. In the event the PRF is not timely retumed, we reserve the right to issue a Notice of Cancelation (NOC). Covered Pollution Cos/Expense/PD Cleanup:max payment for costs to clean up, remove or mitigate damage, debris, spilled cargo, or any other impediment or impairment to property not owned by an insured, caused by a covered Accident. PIC/PPCI Deregulation - Physical damage coverage excludes diminution in value and loss of use. May consider offering for additional premium. Provide a government issued document evidencing the exact name of the legal entity to be insured, including any DBA’s or alternative names All owner operators are required to carry bob-tail / non-trucking liability coverage and the insured is required to maintain proof of active coverage. Proofof active coverage must be available upon request. uote excludes Additional Insureds (Als) unless specifically outlined in the quote documents. Als can be added for additional premium Approved Driver Endorsement: Only drivers that meet the endorsement guidelines are automatically covered, drivers outside of the endorsement guidelines require a driver surcharge and must be specifically scheduled. Approved Driver Endorsement: Specifically scheduled drivers (fall outside of Approved Driver Endorsement guidelines) included in this quote: NONE ADE: If expiring policy is scheduled drivers, current scheduled drivers will NOT be renewed. Insured must submit a list of drivers that fall outside of the guidelines, driver is not covered until the additional driver premium is paid & scheduled. Any Accident or Claim brought forth may have multiple SIR’s owed for each loss (review the full policy language). Sample policy language is available upon request. MTC includes Refer Breakdown EIBI-F-033 18MAY2019 Page 3 of13 ‘Quote Number: PA2103419-4 E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72 ito Liability: Composite Rate used - vehicles are not required to be scheduled. Insured is required to maintain an up to date excel ‘spreadsheet of vehicles (make, model, year, VIN), drivers, and dates - must be available upon request Composite Rate includes 50,000 Physical Damage coverage non-owned trailers while attached to a Tractor Unit on dispatch from the insured. Composite Rate includes 250,000 Motor Truck cargo coverage while hauled by a Tractor Unit on dispatch from the insured. AUDITABLE exposure: Quarterly reports required: 1.Revenue 2. Number of power units, additional premium may be required at the time of audit Current composite rate for auto liability only: $3.2 per $100 in trucking revenue. ‘UW to review all audits and advise if additional premium is needed. - add condition as needed. All audit information is due the 5th of the month on a Quarterly basis. Audit dates will be as follows: Motor Truck Cargo Coverage excludes claims due to theft from an unattended or unsecured vehicle. EIBI-F-033 16MAY2019 Page 4 of 13 ‘Quote Number: PA2103419.4 E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO DocuSign Envelope ID: 034C9E95-0786-4ED3-95BC-AE40682CBC72 Greenlight Premium Financing Options Quote date: 3/22/2021 Company name: Circle O Inc Customer number: E21-303419 Total premium due (includes taxes and fees): _ $403,572.25 If you want to finance, INITIAL the option containing the finance terms of your choice. Choose ONLY ONE option otherwise 100% of the total premium is due. 25% Down Payment~ | 30% Down Payment | 40% Down Payment $100,893.06 $121,071.68 $161,428.90 “Auto draft monthly payments are required 3.Monthly Payments Initial Here initial Here __ Initial Here 3@ $102,591.31 : 3@ $95,752.78 3@ $82,075.71 Interest Rate 10.00% 10.00% 10.00% Finance Charge $5,094.74 $4,757.76 $4,083.70 Final APR™* 10.08% 10.08% 10.1% Amount Financed $302,679.19 $282,500.58 $242,143.35 Total of Payments $307,773.93 $287,258.33 $246,227.14 + 5 Monthly Payments Initial Here Initial Here Initial Here = s@ seam02 o : 5@ “$58,214.42 ae 5@ $49,899.22 | Interest Rate 12.00% 2.00% 12.00% Finance Charge $9,180.91 $8,571.52 $7,362.73 Final APR** 12.08% 12.06% 12.07% Amount Financed $302,679.19 $282,600.58 $242,143.35 Total of Payments $311,860.10 $201,072.09 $249,496.08 Monthly Payments Initial Here Initial Here Initial Here - woe 7@ $45,139.51 7 7 @ “$42,130.59 7@ $36,4 12.75 : i Interest Rate 13.00% 13.00% 13.00% Finance Charge $13,207.36 $12,413.53 $10,645.88 Final APR** 13.04% 13.05% 13.05% ‘Amount Financed $302,679.19 $282,500.58 $242,143.35 Tolal of Payments $315,976.54 $294,914.10 $252,789.23 DS. 9 Monthly Payments AM. initial Here Initial Here __ Initial Here - ~ 51.62 Interest Rate XROIGAX 14.00% 14.00% Finance Charge $17,958.61 $16,764.03 $14,374.89 Final APR™* 14.03% 14.03% 14.04% ‘Amount Financed $302,679.19 $262,500.58 $242,143.35 Total of Payments $320,637.80 $299,264.61 $256,518.24 Check this box if you would like to setup your monthly payments to be auto drafted (this option Is for 30 & 40% down, all 25% down payments will automatically be setup up for auto drafts). After initialing an option listed above, sign the agreement on the next page and attach a check for the down payment amount shown in your selected option above. *Note: All 25% down payment options require an automatié draft from your bank account monthly. “Note: Final APR is based on the annual percentage ‘rate plus fees for the duration of the numberof monthly payments selected, This is nol a foan document and is not binding on any premium finance company to accept any loan for the undersigned. ‘The first payment is due in 30 days after the coverage effective date. a EIBI-F-033 16MAY2019 Page 5 of 13 ‘Quote Number: PAZ103419-4 E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72 Greenlight Premium Financing Request (Continued) Yes, | want to finance according to the option selected on the previous page (please sign and see down payment methods below) (Note: All 25% down payment options require an automatic draft from your bank account monthly.) The undersigned insured/member requests that, EIB International, LLC. (EIB) a Utah company, arrange the financing for its premium in monthly installments and hereby imevocably appoints EIB a limited power of attorney to complete and execute a premium financing agreement on its behalf. ‘The undersigned shall have the right to, without charge, rescind by paying to EIB the net amount financed on the financing agreement executed on its behalf by EIB within 10 days after EIB or the actual premium finance company (PFC) mails to the undersigned a true copy of the actual premium financing agreement being executed by EIB as attorney-in fact for the undersigned. Failure to rescind shall be deemed a ratification and affirmation of the actions of the attorney-in-fact in the execution of a premium financing. Security Interest: Borrower hereby gives the PFC a security interest in and assigns any amount payable to Borrower under the policy to first satisfy any amounts owed by borrower to PFC, including interest, late fees or cancellation charges. Borrower agrees that PFC shall be listed as a loss payee on the policy and that PFC's interest shall have priority over any other loss payees or lienholders. This security interest shall include, without limitation, any and all uneamed premiums and dividends which may be payable under the insurance policies listed in the Schedule of Policies, loss payments which reduce the unearned premiums, and any interest arising under a state guarantee fund relating to these items. [] No, Ido not want to finance. _! am paying 100% of the total premium listed on my quote. (See payment methods below) Authorization to Set Up Financing I,the insured, have read and authorize (EIB) to set up financing according to my selection on the previous page. Docusigned by: 3/23/2021 Wh duraklamon, Malyanor Si |AEAB31ABD40D. Date Abdurakhnon Mavlyanov PRESIDENT Print name and title PAYMENT METHOD: PAY BY WIRE, PHONE, FAX, OR MAIL BANK WIRE | CHECK VIA OVERNIGHT ~~ CHECK BY FAX a = OR EXPRESS MAIL CREDIT CARD BY PHONE Account name: Evolution Insurance FAX: 1-877-452-6910 Brokers, LC EIB = . = E-MAIL: Bank we nami Altabank 8722 South Harrison St, at@primeis.cor Telephon: 1-800-815-2265 Sandy, UT 84070 Routing no.: 124301025 eo PHONE: 1-877-257-5590 Account no: 07110224 CHECK DISCLOSURE: Checks received may be processed electronically. The Company, through its bank, has the ability to provide electronic check processing rather than submitting a paper copy of the check to the bank. Funds transfer in the same manner if transacted electronically or by submitting @ paper copy of the check to the bank, except funds transfer the day the information is received with electronic processing rather than within a few business days as with a paper check. Electronically processed checks transactions appear on your bank statement in the same manner as paper checks. Charge will appear as ‘Evolution Insurance Brokers, LC Premium Trust.’ ‘CHECK BY FAX METHOD: 4. Make out physical check, payable to Evolution Insurance Brokers. Date and sign the check, but do not mail it. 2. Complete and sign the authorization, giving us permission to convert check to an EFT (Electronic Funds Transfer). Transaction will appear as a debit from Evolution Ins BK 3. Tape the check to this form, where indicated at the bottom. Fax this form and check to 1-877-452-6910 4. Keep this form and original check. DO NOT MAIL IT pace Attach Check here or Enter Check Information; Bank name and address: — 071000013 613793279 Bank routing no.(usually 9 digits): Account no.: Amount of check: $—pocusioned by: ‘Check no.: 3/23/2021 Authorized by: Ts 3/23/2021 ‘Signature of authorization: Date IF FINANCING: Attach an addiTonaV GREEK TPYR2 would like to use a different account for your auto draft monthly payments. SERVICE FEE: EIB reserves the right to collect directly from your account a processing fee of $25 for any incomplete transaction due to insufficient funds in your account (i.¢. a "bounced check"). This is not a loan document and is not binding on any premium finance company to accept any loan for the undersigned. ‘The first payment is due in 30 days after the coverage effective date, EIBLF-033 29JAN2020 EIBI-F-033 16MAY2019 Page 6 of 13 ‘Quote Number: PA2103419-4 E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72 Ohio Department Surplus Lines Statement of Insurance Mike DeWine, Gover —_ilian Brewtant, Ditector OPRAS-PAKC Division, 50 W Tow Stet, Jed Floor - Suite 265, ColumbusOH 43215 Son Histted, Lf Geveener 614-644-2635 | Fax 614-729-1280 | isuranceohiogoy PART 1, STATEMENT OF SURPLUS LINE BROKER OR GRIGINATING AGENT Gene Brodsky acknowledges that he/she is a duly licensed full multiple line agent currently licensed with insurance nies, other than life, authorized to do business in Ohio or he/she is a duly licensed surplus line broker pursuant to section 3905.30 of the Ohio Revised Code and that after due diligence, he/she is unable to procure the insurance policy described below from insurers authorized to do business in Ohio to which he/she is a licensed agent. Circle O Inc Property or risk to be insured: = He/she acknowledges that he/she has complied with the applicable requirements of due diligence as set forth in section 3905.33 of the Ohio Revised Code, and has explained to the insured the meaning of the signed statements prior to binding coverage and received declinations for the reasons set forth below from the following authorized insurer(s) to which he/she is so licensed and which are known to him/her to customarily write the kind of insurance described above. INSURERS REASONS Progressive Fleet size ATG RRG does not offer cargo Northland Drivers and CDL Experience Signature of Surplus Line Broker or Originating Agent PART 2, SIGNED STATEMENT OF INSURED AS REQUIRED BY SECTION 3905.33 OF THE ORIO REVISED CODE ‘The named insured CIRCLE O INC » acknowledges that the insurance policy (other than life insurance) as described above is to be placed with an insurance company not authorized to do business in Ohio. ‘The insured understands that the insurance companyis not a member of the Ohio Insurance Guaranty Association and that Chapter 3955 of the Chio Revised Code is not applicable to claimants or insureds of said insurance company. The surplus Tine broker shall collect the Ohio tax of five-percent of the amount of the premium for the insurance policy at the time the insurance policy is delivered to the insured. DocuSigned by: Signature of Insured: hbdur nMawlyanoe == the broker or agent, not ta Ohio Department of Insurance. INS4024 (Rev. 06/2020) Page 1 of 1 — EIBI-F-033 16MAY2019 Page 7 of 13 “Quote Number: PA2103419-4 E-FILED 07/31/2023 10:52 AM / CONFIRMATION 1350987 / A 2303226 / COMMON PLEAS DIVISION / IFO DocuSign Envelope ID: D34C9E95-0786-4ED3-95BC-AE40682CBC72 int INSURED CONTACT FORM Prime's Risk Management Department fosters a mutually beneficial relationship with every insured by taking a partnership approach to the management of each insured's account. We begin this partnership with a call to the insured where we: ™® Welcome the insured to the company, ® Review policy terms, limits, and conditions, ® Establish a direct point of contact for risk management related concerns. In addition to the conditions of the policy, below are three requirements that the applicant needs to complete during the policy period: 1 Return a signed copy of the Policy Receipt Form and Coverage Conditions Summary to the Risk Management Department within 10 calendar days of receipt of the policy. 2 Complete a risk management discussion call within 30 days of the policy being bound. 3. An onsite visit will be completed during the policy period at our discretion. We encourage your agent to also be part of this onsite visit. Please complete: Abdurakhmon Mavlyanov Owner/decision maker name(s): 5139912422 Contact phone number(s): circleoinc@gmai1.com Contact email address(s): 8044 MONTGOMERY RD STE 700-7306 CINCINNATI OH 45236 Physical location for business operations: Gene Brodsky GIA Group, LLC Agent contact & agency: 855-876-0717 Agent phone number: If you do not receive a phone call within 10 days of the policy being bound, please contact one of our team members at 1-877-585-2851. We are available Monday through Friday, 7:00 AM-6:00 PM Mountain Time. By signing below, | understand that | will need to complete a discussion call with the Risk Management Department within 30 days of policy being bound and return a signed copy of the Policy Receipt Form and Coverage Conditions Summary within 10 days of receipt of the policy. | also understand that there may be a required onsite visit completed at my physical location during the policy period to keep coverage in effect. DocuSigned by: Docusigned by: Abduratlunon Malyanon. Gun Brodsky