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Home My WebLink AboutLiability Policy City of Jeffersonville Government Contract Coversheet Please note: All information MUST be completely filled out and submitted to Clerk's Office within 48 hrs of execution. Date Submitted to Clerk: 8/2/2023 Department: Safety et,mS W,/c+ex' Vendor Name: Sign Date: 8/2/2023 Ending Date: 8/12/2024 Amount of Original Contract: $8,046.25 Is this an amendment or change order to original contract? Yes or No Amended Contract Amount: $8,046.25 Purpose: Liability Policy For Clerk's Office to fill out Date uploaded to Gateway: �� J 07/13/2023 09:06 AM Quote Number: QT-03196089 Page 1 of 4 Commercial Insurance Quote Proposal To: Contact Name: r n $ Contact Email: Contact Phone: ■ From: Burns&Wilcox Ltd-Indianapolis, IN Address: 8888 Keystone Xing Ste 710 Indianapolis Wi ICOX IN4 15 Darling Name: Gary Contact Email: GTDarling@Burns-Wilcox.com Contact Phone: License#: Underwritten By: SCOTTSDALE INSURANCE COMPANY A.M. Best rated A+(Superior), FSC XV Commission:% Minimum Earned:25% Minimum and Advance Premium: 100% These terms are valid for 60 days from JULY 13,2023. Our quote may differ from the terms requested. Please review the quote carefully. If the policy is cancelled at the insured's request, including non-payment of premium, there will be a minimum earned premium retained by us. If a policy or inspection fee is applicable to this policy. the fees are fully earned. No flat cancellations. At the close of each audit period, we will compute the earned premium for that period. If the earned premium is greater than the advance premium paid, an audit premium will be due. There will be no returned premium upon Audit if the estimated exposure is less than shown, unless the Minimum and Advance Premium is less than 100%. Applicant Name: CITY OF JEFFERSONVILLE Proposed Policy Period: I 08/12/2023 To 08/12/2024 Quote Number: QT-03196089 Agent Reference Number: Renewal of#: CPS7635177 Premium Summary LIABILITY i$7,500 Sub Total Premium: $7,500 Policy Fee $350.00 Surplus Lines Tax 1$196.25 Grand Total: I$8,046.25 Terrorism:Terrorism coverage can be purchased for an additional premium of$375.00 plus applicable taxes and fees. Signed acceptance/rejection required at binding. Subject to following terms and conditions: • Signed TRIA form at time of binding,rejecting or accepting coverage. 07/13/2023 09:06 AM Page 2 of 4 Commercial Liability Coverage Limits General Aggregate $2,000,000 Products/Completed Operations Aggregate $2,000,000 Personal and Advertising Injury $1,000,000 Per Occurrence $1,000,000 Damage to Premises Rented to You $100,000 Medical Payments $5,000 Deductible $500 Bl/PD/PA PER CLAIMANT Liability Rating Classifications and Premium Loc#1 Program l Class Code Description Exposure Prem I Prem/Prod Bldg# ISO Prod Rate Premium SPRING ST JEFFERSONVILLE IN 47130 1 / 1 ISO 49185 THEATERS-NOT-FOR-PROFIT 30,000/PER $165.19 I$7,500 ONLY+ 1000/ADMIS INCL INCL SIONS +PRODUCTS/COMPLETED OPERATIONS ARE SUBJECT TO THE GENERAL AGGREGATE t LIMIT Final Liability Premium: $7,500 07/13/2023 09.06 AM Page 3 of 4 Forms and Endorsements Common Policy NOTX0178CW 03-16 CLAIM REPORTING INFORMATION NOTX0423CW 12-20 POLICYHOLDER DISCLOSURE-NOTICE OF TERRORISM INSURANCE COVERAGE UTS-COVPG 03-21 COVER PAGE OPS-D-1-0117 01-21 COMMON POLICY DECLARATIONS UTS-126L 10-93 SCHEDULE OF TAXES, SURCHARGES OR FEES UTS-SP-2 12-95 SCHEDULE OF FORMS AND ENDORSEMENTS UTS-SP-3 08-96 SCHEDULE OF LOCATIONS IL 00 17 11-98 COMMON POLICY CONDITIONS IL 02 72 11-21 INDIANA CHANGES-CANCELLATION AND NONRENEWAL UTS-496 06-19 MINIMUM EARNED CANCELLATION PREMIUM UTS-9g 06-22 SERVICE OF SUIT CLAUSE Commercial Liability CLS-SD-1L 08-01 COMMERCIAL GENERAL LIABILITY COVERAGE PART SUPPLEMENTAL DECLARATIONS CLS-SP-1L 10-93 COMMERCIAL GENERAL LIABILITY COVERAGE PART EXTENSION OF SUPPLEMENTAL DECLARATIONS CG 00 01 04-13 COMMERCIAL GENERAL LIABILITY COVERAGE FORM CG 01 23 03-97 INDIANA CHANGES-POLLUTION EXCLUSION CG 21 06 05-14 EXCLUSION-ACCESS OR DISCLOSURE OF CONFIDENTIAL OR PERSONAL INFORMATION AND DATA-RELATED LIABILITY-WITH LIMITED BODILY INJURY EXCEPTION CG 21 16 04-13 EXCLUSION-DESIGNATED PROFESSIONAL SERVICES Description Of Professional Services Any and all professional exposures CG 21 32 05-09 COMMUNICABLE DISEASE EXCLUSION CG 21 44 04-1 7 LIMITATION OF COVERAGE TO DESIGNATED PREMISES, PROJECT OR OPERATION Premises Spring St, Jeffersonville, IN 47130 CG 21 47 12-07 EMPLOYMENT-RELATED PRACTICES EXCLUSION CG 21 67 12-04 FUNGI OR BACTERIA EXCLUSION CG 21 73 01-15 EXCLUSION OF CERTIFIED ACTS OF TERRORISM CG 24 12 11-85 BOATS Description of Watercraft Jeffersonville Riverstage Barge CG 24 26 04-13 AMENDMENT OF INSURED CONTRACT DEFINITION CG 40 12 12-19 EXCLUSION-ALL HAZARDS IN CONNECTION WITH AN ELECTRONIC SMOKING DEVICE,ITS VAPOR,COMPONENT PARTS. EQUIPMENT AND ACCESSORIES CG 40 15 12-20 CANNABIS EXCLUSION WITH HEMP EXCEPTION GLS-106s 12-13 TOTAL LIQUOR LIABILITY EXCLUSION GLS-152s 08-16 AMENDMENT TO OTHER INSURANCE CONDITION 07/13/2023 09:06 AM Page 4 of 4 Forms and Endorsements GLS-278s 01-06 INJURY TO WORKER EXCLUSION GLS-289s 11-07 KNOWN INJURY OR DAMAGE EXCLUSION-PERSONAL AND ADVERTISING INJURY GLS-290s 11-07 CLASSIFICATION LIMITATION GLS-341s 08-12 HYDRAULIC FRACTURING EXCLUSION GLS-457s 10-14 AIRCRAFT EXCLUSION GLS-47s 10-07 MINIMUM AND ADVANCE PREMIUM ENDORSEMENT GLS-570 07-21 CONTRACTORS SPECIAL CONDITIONS GLS-5s 04-08 SPECIAL EVENT PARTICIPANT EXCLUSION GLS-666 06-22 PFC/PFAS EXCLUSION GLS-94s 06-15 BODILY INJURY, PROPERTY DAMAGE, PERSONAL AND ADVERTISING INJURY LIABILITY DEDUCTIBLE ENDORSEMENT(PER CLAIMANT) IL 00 21 09-08 NUCLEAR ENERGY LIABILITY EXCLUSION ENDORSEMENT UTS-267g 05-98 LEAD CONTAMINATION EXCLUSION UTS-365s 02-09 AMENDMENT OF NONPAYMENT CANCELLATION CONDITION UTS-428g 11-12 PREMIUM AUDIT UTS-610 06-22 ASBESTOS EXCLUSION UTS-611 07-22 EXCLUSION—BIOMETRIC INFORMATION UTS-74g 08-95 PUNITIVE OR EXEMPLARY DAMAGE EXCLUSION Freedom Specialty Insurance Company National Casualty Company Scottsdale Indemnity Company Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE TERRORISM RISK INSURANCE ACT Under the Terrorism Risk Insurance Act of 2002, as amended pursuant to the Terrorism Risk Insurance Program Reauthorization Act of 2019 (the "Act"), you have a right to purchase insurance coverage for losses arising out of acts of terrorism, as defined in Section 102(1) of the Act: The term "certified acts of terrorism" means any act that is certified by the Secretary of the Treasury—in consultation with the Secre- tary of Homeland Security, and the Attorney General of the United States—to be an act of terrorism; to be a violent act or an act that is dangerous to human life, property,or infrastructure;to have resulted in damage within the United States, or outside the United States in the case of certan air carriers or vessels or the premises of a United States mission; to have been committed by an individual or individuals as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. You should know that where coverage is provided by this policy for losses resulting from "certified acts of terrorism," such losses may be partially reimbursed by the United States Government under a formula established by federal law. However, your policy may contain other exclusions which might affect your coverage, such as an exclusion for nuclear, chemical, biological or radioactive events. Under the formula, the United States Government agrees to reimburse eighty percent (80%)of covered terrorism losses that exceed the statutorily established deductible paid by the insurance company providing the coverage. The premium charged for this coverage is provided below and does not include any charges for the portion of loss that may be covered by the Federal Government under the Act. You should also know that the Act, as amended, contains a $100 billion cap that limits United States Gov- ernment reimbursement as well as insurers' liability for losses resulting from "certified acts of terrorism" when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured losses for all insurers exceed $100 billion, your coverage may be reduced. CONDITIONAL TERRORISM COVERAGE The federal Terrorism Risk Insurance Program Reauthorization Act of 2019 is scheduled to terminate at the end of December 31, 2027, unless renewed, extended or otherwise continued by the federal govern- ment. Should you select Terrorism Coverage provided under the Act and the Act is terminated Decem- ber 31, 2027, any terrorism coverage as defined by the Act provided in the policy will also terminate. f Nationwide' NOTX0423CW(12-20) Page 1 of 2 IN ACCORDANCE WITH THE ACT, YOU MUST CHOOSE TO SELECT OR REJECT COVERAGE FOR "CERTIFIED ACTS OF TERRORISM" BELOW: The Note below applies for risks in these states: California, Georgia, Hawaii, Illinois, Iowa, Maine, Missouri, New Jersey, New York, North Carolina, Oregon, Rhode Island, Washington, West Virginia, Wisconsin. NOTE: In these states, a terrorism exclusion makes an exception for(and thereby provides coverage for) fire losses resulting from an act of terrorism. Therefore, if you reject the offer of terrorism coverage, that rejection does not apply to fire losses resulting from an act of terrorism coverage for such fire losses will be provided in your policy. If you do not respond to our offer and do not return this notice to the Company, you will have no Terrorism Coverage under this policy. Please select one of the checkboxes below. I hereby elect to purchase certified terrorism coverage for a premium of$ 375.00 I understand tha - federal Terrorism Risk Insurance Program Reauthorization Act of 2019 may terminate n D• - ber 31, 202T. Should that occur my coverage for terrorism,as defined by the Act, will o t• ate. PiI hereby eje. - purchase of Jertified terrorism coverage. • Policyholder/App4icant's Signature Named Insurebi Business Name ,, .,(M- QT-03196089 Print Name Policy Number, if available �- �3 Date Nationwide' NOTX0423CW(12-20) Page 2 of 2