HomeMy WebLinkAboutLiability for Riverstage (BPW Approved 7/24/24) 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: 7/24/2024
Department: Safety
Vendor Name: Burns and Wilcox
Sign Date: 7/24/2024
Ending Date: 8/12/2024
Amount of Original Contract: $8.097.50
Is this an amendment or change order
to original contract? No
Amended Contract Amount:
Purpose: Limited Liability for Riverstage
For Clerk's Office to fill out
Date uploaded to Gateway:
Igr"a
07/16/2024 08:31 AM Quote Number: QT-04793757 Page 1 of 4
Commercial Insurance Quote Proposal
To:
Contact Name:
r n Contact Email:
Contact Phone:
W
i
From: Burns&Wilcox Ltd- Indianapolis, IN
Address: 8888 Keystone Xing Ste 710 Indianapolis
IN 46240-4615
Contact Name: Greg Darling
Contact Email: GTDarling@Burns-Wilcox.com
Contact Phone:
License#:
Underwritten By: SCOTTSDALE INSURANCE COMPANY A.M. Best rated A (Excellent), FSC XV
Commission: % Minimum Earned: 25% Minimum and Advance
Premium: 100%
These terms are valid for 60 days from JULY 16,2024. 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: 08/12/2024 To 08/12/2025
Quote Number: QT-04793757
Agent Reference Number:
Renewal of#: CPS7844621
Premium Summary
LIABILITY $ 7.500.00
Sub Total Premium: $ 7,500.00
Policy Fee I $ 400.00
Surplus Lines Tax $ 197.50
Grand Total: ' $ 8,097.50
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.
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 underst. • that the federal Terrorism Risk Insurance Program Reauthorization Act of 2019 may
�-� termin. o December 31, 2027. Should that occur my coverage for terrorism, as defined by the
Act,/ I als• terminate
:f!by re ect the put ase of certified terrorism coverage.
Roy
Policy�hholld:r/Applicant's Sig atureA Named Insured!Business Name
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Print Name Policy Number, if available
Date
•
Nationwide'
NOTX0423CW(12-20) Page 2 of 2