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Home My WebLink AboutInsurance - BOCCC U &FORSTEW AfAAFAXCOMPANY CRUM & FORSTER SPECIALTY INSURANCE COMPANY ENVIRONMENTAL QUOTE DATE OF PROPOSAL: 06/21/2022 Item 1. NAMED INSURED & ADDRESS: GRANT COUNTY PO Box 37 Ephrata, WA 98823 PRODUCER NAME & ADDRESS: ENVIRONMENTAL RISK MANAGERS, INC. Po Box 210f Moline, Michigan 49335-0000 FORM OF BUSINESS: Corporation PRODUCER CODE: 9473 Item 2. PROPOSED POLICY PERIOD: 07/07/2022 to 07/07/2023 12:01 a.m. Standard Time at the Named Insured's address stated above. Item 3. LIMITS OF INSURANCE: Each Confirmed Release Limit: $190009000 Policy Aggreate Limit : $190009000 Defense Expense Aggregate Limit: $1,0009000 Item 4. DEDUCTIBLE/SELF-INSURED RETENTION: See Tank Schedule Item 5. RETROACTIVE DATES: T See Tank Schedule Item 6. PREMIUM: Policy Premium: $49685 Additional Insured Premium: $0 TRIPRA Premium: $234 Total Policy Premium: $49919 Minimum Earned Premium: 25% Minimum Policy Premium: 100% Item 7. AUDIT PERIOD: Not Subject to Audit Basis : Units: 2 U S T s , 8 A S T s Rate: Flat All rates are basea on the revenue basis shown above and no deductions ot- any kind are allowed. All premiums applicable to additional coverage(s) as required during the policy period will be invoiced separately and will not apply toward the minimum earned or estimated policy premium. The broker is responsible for filing all affidavits and paying all fees, if applicable. The insured shall be responsible for applying any and all applicable taxes and surcharges. PLEASE REMEMBER TO INCLUDESURPLUS LINES TAX TO PREMIUM & TRIA AGENCY IS RESPONSIBLE FOR FILING CRUM&FORSTEW I FORMS AND ENDORSEMENTS I CFSTP 00 001 10 16 COMMERCIAL STORAGE TANK LIABILITY POLICY DECLARATIONS EN002-0211 SCHEDULE OF FORMS AND ENDORSEMENTS IL P 001 01 04 U.S. TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL ("OFAC") ADVISORY NOTICE TO POLICY HOLDERS CS 07001 01 21 C&F SPECIALTY SIGNATURE PAGE EN0004-0521 CLAIMS REPORTING EN0005-1017 SERVICE OF PROCESS CLAUSE EN0006 0120 Policyholder Disclosure Notice of Terrorism Insurance Coverage EN0011-1014 PRIVACY NOTICE EN0050-0222 EMERGENCY RESPONSE HOTLINE EN0052-0222 NOTICE OF LOSS ALL CFSTP 00 000 01 15 STORAGE TANK POLLUTION POLICY CFSTP 00 002 0121 DEDUCTIBLE ENDORSEMENT CFSTP 00 501 10 15 MANDATORY NOTICE OF VOLUNTARY REMOVAL OR REPLACEMENT OF UNDERGROUND STORAGE TANKS SYSTEM CFSTP 00 525 05 16 COVERED STORAGE TANK COVERAGE ENDORSEMENT CFSTP 00 546 10 13 LOADING OR UNLOADING COVERAGE ENDORSMENT CFSTP FR CERT -FED FINANCIAL RESPONSIBILITY CERTIFICATE OF INSURANCE - FED This proposal is based on the insurance carrier's most recent policy forms and endorsements and is subject to all terms and conditions of such forms and endorsements. If you would like to review a copy, please let me know and I would be pleased to send you a specimen form. WARRANTIES/REQUIREMENTS Please be advised that coverage has been proposed conditional upon receipt, review, verification and approval of the following items: Subjectivity Time Frame Signed Terrorism Rejection / Selection Form Prior to Binding Completed Surplus Lines Tax Form Prior to Binding Sumps and Spill. Bucket(s) inspection within last 12 months Prior to Binding Last 2 months of Automatic Tank Gauge [ATG] Leak Tests Printout Prior to Binding Testing and inspection needed on USTs only. Prior to Binding Confirmation there have been no changes to application since signing. Prior to Binding This proposal is valid until the policy effective date or 30 days from the date of this letter, whichever is sooner. After expiration, all terms and conditions of this proposal must be re-evaluated by Crum & Forster Specialty Insurance Company. Please note that this proposal is based upon terms and conditions that Crum & Forster Specialty Insurance Company is willing to offer and not the terms and conditions which were requested. It is your responsibility to review these terms and conditions prior to presenting this proposal. Crum & Forster Specialty Insurance Company reserves the right to modify, change or cancel any or all terms of this proposal at anytime without notice. C Um &FORSTEW 9AARPAX COMPANY COVERED STORAGE TANK AND LOCATION ENDORSEMENT Loc Address Lily- State Zip, Tank AST Year Cgpacity Capacity Contents Deductible Retroactive # Code # /UST Installed Date 1 124 Enterprise St. SE Ephrata WA 98823 1 UST 1996 9,730 Gasoline $1500 7/7/2006 1 124 Enterprise St. SE Ephrata WA 98823 2 UST 1996 9,730 Diesel $1500 7/7/2006 2 3803 Neva Lake Road Ephrata WA 98823 1 AST 2012 4,000 Diesel $500 7/7/2016 2 3803 Neva Lake Road Ephrata WA 98823 2a AST 2012 2000 Gasoline $5,000 7/7/2016 2 3803 Neva Lake Road Ephrata WA 98823 2b AST 2012 2000 Waste Oil $5,000 7/7/2016 3 232 Chelan St. Hartline WA 99135 1a AST 1999 8000 Diesel $500 7/7/2016 3 232 Chelan St. Hartline WA 99135 lb AST 1999 4000 Gasoline $55000 7/7/2016 4 24378 Broadway St. Mattawa WA 99344 la AST 1999 2000 Gasoline $5,000 7/7/2016 4 24378 Broadway St. Mattawa WA 99344 lb AST 1999 2000 Diesel $55000 7/7/2016 5 12171 Wheeler Rd. Moses Lake WA 98837 1 AST 2009 105000 Gasoline $55000 7/7/2016 5 12171 Wheeler Rd. Moses Lake WA 98837 2 AST 2009 10,000 Diesel $55000 7/7/2016 6 4718 Rd P NW Quincy WA 98848 1a AST 2005 8000 Diesel $5,000 7/7/2016 6 4718 Rd P NW Quincy WA 98848 lb AST 2005 4000 Gasoline $500 7/7/2016 7 13766 Road E SW Royal CIty WA 99357 1a AST 2003 8000 Diesel $5,000 7/7/2016 7 13766 Road E SW Royal CIty WA 99357 lb AST 2003 4000 Gasoline $5,000 7/7/2016 K - MITA 4: 61 *W010 TERRORISM RISK INSURANCE ACT YOU ARE HEREBY NOTIFIED THAT UNDER THE TERRORISM RISK INSURANCE ACT, AS AMENDED, YOU HAVE A RIGHT TO PURCHASE INSURANCE COVERAGE FOR LOSSES RESULTING FROM ACTS OF TERRORISM, AS DEFINED IN SECTION 102(1) OF THE ACT: THE TERM "ACT OF TERRORISM" MEANS ANY ACT THAT IS CERTIFIED BY THE SECRETARY OF THE TREASURY -IN CONSULTATION WITH THE SECRETARY 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 CERTAIN AIR CARRIERS OR VESSELS OR THE PREMISES OF A UNITED STATES MISSION; AND 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 EVENTS. UNDER THE FORMULA, THE UNITED STATES GOVERNMENT GENERALLY REIMBURSES 80% BEGINNING ON JANUARY 1, 2020 OF COVERED TERRORISM LOSSES EXCEEDING 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 THE LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT 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. IN ACCORDANCE WITH THE ACT, YOU MUST CHOOSE TO ELECT OR REJECT COVERAGE FOR „CERTIFIED ACTS OF TERRORISM" BELOW: Pofwholder/Applicant Signature Danny E Stone, BOCC Chair Print Name Date EN0006 - 0120 GRANT COUNTY Named Insured/Firm PO Box 37, Ephrata, WA, 98823 Mailing Address Quote/Policy Number I hereby, elect to purchase certified acts of terrorism coverage for a premium of $234 I hereby decline to purchase terrorism coverage for certified acts of terrorism. I understand that I will have no coverage for losses resulting from certified acts of terrorism. Pofwholder/Applicant Signature Danny E Stone, BOCC Chair Print Name Date EN0006 - 0120 GRANT COUNTY Named Insured/Firm PO Box 37, Ephrata, WA, 98823 Mailing Address Quote/Policy Number CRU FORSTER7 A F";�IKF%A:X C 0N1f'As'w Y June 21, 2022 SURPLUS LINES COMPLIANCE AND TAX ACKNOWLEDGEMENT FORM Policy Number: Named Insured: GRANT COUNTY Home State: WA Insurance Company Name: Crum & Forster Speciality Insurance Company Policy Effective Date: 07/07/2022 Premium: $4,685 The insurance company shown above is eligible to write business in the insured's home state on an excess & surplus lines basis. As a condition to our binding and issuing of the policy, we require that you (i) satisfy any applicable diligent search requirements, (ii) properly declare the policy and premium shown above as a surplus lines transaction and (iii) pay any applicable surplus lines taxes resulting from this transaction, in each case, as required by the applicable regulatory authority in the insured's home state. Each state has its own requirements for both due diligence for the placement of business in the surplus lines market, as well as timely filing requirements for the payment of surplus lines taxes. Please confirm your office's compliance with both the due diligence requirements along with the filing requirements, including the date when taxes will be, or were paid, and any other necessary regulatory reporting for this account by completing the information requested below, and then signing and returning this form to us promptly. Resident or Non -Resident Surplus Lines Licensee Information: Surplus Lines Broker Entity: Surplus Lines Broker's Mailing Address: Name of Licensee: Surplus Lines License #: (For Named Insured's State): NJ Surplus Lines Association #: (NJ Risks only): Tax Filing Date: (Date Filed or To Be Filed): Signature of Licensee: Signed by (Print Name): SL Form Ed. 03/2021 Date: UST WALKTHROUGH INSPECTIONS CHECKLIST RTMENT OF �1 �i-%i Site Name Site Address Tag # Initial each box to indicate the equipment was inspected, as described. Use NA if the equipment inspection does not apply to the site. Take action for any alarms, damaged equipment and non -normal operating conditions; note actions taken on page 2 ➢ NOTE: Petroleum found in a sump or interstice must be reported to Ecology within 24 hours. D MONTHLY RE DIRE MON H Y Spill bucket(s) checked for damage and cracks*. Liquid and/or debris removed. Fill pipe(s) checked for obstructions. Removed, if found. Fill cap(s) securely fitted on fill pipe(s). Tank monitor equipment checked for alarms and normal operating condition. Inspected loose fitting, deterioration, obvious signs of leaks and improper function of dispenser hoses, nozzles and breakaways. *If a tank receives deliveries at intervals greater than 30 days, the spill bucket check may instead be conducted prior to each delivery. To be eligible for this option, include a copy of each delivery receipt with this form. Note: This checklist doesn't include the requirement to inspect hydrant pits and piping vaults at airport hydrant systems at least every 30 days. 18-09-043 1 Jan 2018 use anis tawe to explain actions taKen oy empioyees ano/or service proviaer to rix issues. use aaaivonai sneers, as necessary. IOND,.. 1111111111110111 Keep this record for three years after the last inspection date on the form. To request materials in a format for the visually impaired, visit httys:Hecology.wa.gov/accesslbility, call Ecology at 360-407-7668, Relay Service 711, or TTY 877-833-6341. 18-09-043 2 Jan 2018