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HomeMy WebLinkAboutAgreements/Contracts - BOCC (002)CRU M & FORSTER' A FAIRFAX. C`JMI'A%y DATE OF PROPOSAL: 06/09/2020 Item 1. NAMED INSURED & ADDRESS: Grant County PO Box 37 Ephrata, WA 98823 PRODUCER NAME & ADDRESS: Environmental Risk Managers PO Box 21017 Moline, M149335 FORM OF BUSINESS: Corporation PRODUCER CODE: 89294 Item 2. PROPOSED POLICY PERIOD: 1 YEAR TERM 12:01 a.m. Standard Time at the Named Insured's address stated above. Item 3. LIMITS OF INSURANCE: Policy Aggregate Limit: $1,000,000 Each Confirmed Release Limit: $1,000,000 Defense Expense Aggregate Limit: $1,000,000 Item 4. DEDUCTIBLE Storage Tank Pollution Deductible - Each Confirmed Release $5,000 Item 5. RETROACTIVE DATES: Storage Tank Pollution See CFSTP 00 525 05 16 Item 6, PREMIUM: Policy Premium: $4,210 TRIPRA Premium: $211 Total Policy Premium: $4,421 Minimum Earned Premium: 25% Minimum Policy Premium: 100% Item 7. AUDIT PERIOD: Not Subject to Audit Basis: 10 Tanks Rate: Flat PLEASE REMEMBER TO INCLUDE TO INCLUDE THE SURPLUS LINES TAX TO PREMIUM & TRIA AGENCY IS RESPONSIBLE FOR SURPLUS LINES TAX FILINGS All rates are based on the revenue basis shown above and no deductions of 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. CRUM&FORSTEW A FAM -AX COMPANY The following Coverage Forms and endorsements apply to this proposal 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 07 001 10 17 C&F SPECIALTY SIGNATURE PAGE EN0004-0816 CLAIMS REPORTING EN0011-1014 PRIVACY NOTICE EN0050-0816 EMERGENCY RESPONSE HOTLINE EN0052-0816 NOTICE OF LOSS CFSTP 00 000 01 15 STORAGE TANK POLLUTION POLICY CFSTP 00 002 10 15 DEDUCTIBLE ENDORSEMENT EN0005-1017 SERVICE OF PROCESS CLAUSE CFSTP 00 525 05 16 COVERED STORAGE TANK AND LOCATION ENDORSEMENT CFSTP 00 546 10 13 LOADING OR UNLOADING COVERAGE ENDORSMENT 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: Subjectivities Notes Time Frame Insured's name and contact phone number Prior to Binding Signed Notice of Terrorism Rejection / Selection Form Prior to Binding Completed & signed Storage Tank Application acceptable to the Prior to Binding underwriter EST. 1122 STORAGE TANK RENEWAL APPLICATION DRAFT COVERED STORAGE TANK AND LOCATION ENDORSEMENT This Endorsement shall not serve to increase our limits of insurance, as described in SECTION V - LIMITS OF INSURANCE. In consideration of the payment of premiums, it is hereby agreed that the following are added to the policy as "scheduled storage tank system(s)": Coverage Storage Tank System Tank Insured Site Retro Date Deductible Type Contents (Gallons) Install Lined # UST/AST Capacity Date Date 1 Ephrata Central Shop 7/07/2006 $5,000 UST Gasoline 10,000 1999 N/A 124 Enterprise St. SE Ephrata, WA 98823 2 Ephrata Central Shop 7/07/2006 $5,000 UST Diesel 10,000 1999 N/A 124 Enterprise St. SE Ephrata, WA 98823 1 Ephrata Landfill 7/07/2016 $5,000 AST Split Tank 4,000 2012 N/A 3803 Neva Lake Road Ephrata, WA 98823 2 Ephrata Landfill 7/07/2016 $5,000 AST Diesel 4,000 2012 N/A 3803 Neva Lake Road Ephrata, WA 98823 1 7/07/2016 $5,000 AST Split Tank 12,000 1999 N/A �Hartline 232 Chelan St. Hartline, WA 99135 1 Mattawa 7/07/2016 $5,000 AST Split Tank 6,000 1999 N/A 24378 Broadway St. Mattawa, WA 99344 1 Moses Lake 7/07/2016 $5,000 AST Gasoline 10,000 2009 N/A 12171 Wheeler Rd. Moses Lake, WA 98837 2 Moses Lake 7/07/2016 $5,000 AST Diesel 10,000 2009 N/A 12171 Wheeler Rd. Moses Lake, WA 98837 1 Quincy 7/07/2016 $5,000 AST Split Tank 12,000 2005 N/A 4718 Rd P -NW Quincy,WA 98848 1 New Royal City 7/07/2016 $5,000 AST Split Tank 12,000 2003 N/A 13766 Road E SW (Royal Clty, WA 99357 All other terms, conditions and exclusions under the policy are applicable to this Endorsement and remain unchanged CFSTP 00 525 05 16 Page 1 of 2 DRAFT CRU M & FORSTER° A FAIRFAX CoMOAt#Y STORAGE TANK RENEWAL APPLICATION -1 - AreAll tanks in compliance with current EPA and State regulations? Z.Yes []No if No, please provide details. (Attach separately) r-2 - Do .you own the tanks? VYes [] No If No, please provide the name & address of the tank owner. (Attach separately) 3 - Is the Applicant aware of any incident, fact, circumstance, or situation including any act, error or omission that may result in a claim being mp against it or any other person or entity for which coverage is sought? n Yes No - Have any Yes ever been made against the applicant or have any claims ever been reported under any Storage Tank policy? No If Yes, please provide details. (Attach separately) 5 - Has the Applicant ever had any reportable releases or spills of regulated substances, hazardous waste or any other pollutants, as defined by the applicable environmental statutes and regulations? Yes L(No if Yes, please provide details. (Attach separately) Has thereeve been any contamination at any owned facility prior to or during your tenancy, operation and/or ownership? — —� Yes o If Yes, please provide details. (Attach separately) , F7 - Are there any plans to close, remove or upgrade any tanks at any facility in the next 18 months? E] Yes eNo if Yes, please indicate anticipated ctosure/removaltupgrade date and plans (Attach separately) Are there arty dditionai insureds? Yes No If Yes, please provide the name(s) and address(es). (Attach separately) REPRESENTATIONS AND WARRANTIES NOTICE TO APPLICANT - PLEASE READ CAREFULLY The undersigned authorized officer of the applicant declares that the statements set forth herein are true to the best of my know- ledge and that no material fact has been omitted or misstated. The undersigned authorized officer agrees that if the Informadon supplied on the application changes between the date of the application and the effective date of the Insurance, hetshe (undersignei will Immediately notify the insurer of such change, and the insurer may withdraw or modify any outstanding quotations andtor auth- orization or agreement to bind the Insurance. Signing of this application does not bind the applicant to purchase or the insurer to provide the Insurance. Acceptance of the applicant by the company Is required prior to quotation or binding of coverage or the Issuance of a policy. tt is agreed that this application and the reliance upon its contents shall bathe basis of the issuance of a policy and shall be attached and made part of said policy. FRAUD WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD OR DECEIVE ANY INSURANCE COMPANY, SUBMITS AN APPLICATION OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE, INCOMPLETE, OR MISLEADING INFORMATION MAY BE SUBJECT TO CIVIL OR CRIMINAL PENALTIES. I HAVE READ AND FULLY UNDERSTAND THE QUESTIONS AND MY ANSWERS ON THIS APPLICATION. I UNDERSTAND THAT ANY OMISSION OR MISSTATEMENT OF ANYA THE RESPONS THAT ARE MATERIAL TO THE RISK ASSUMED (AS WELL AS ATTACHEI TO THIS APPLICATION), MAY CAUSEPO Tp'B€ QME NUL 'AND VOID AND/OR MAY GIVE RISE T A R CISSION OF THE POLICY. \ - J V Applicant/insured Signature Date Print Name and Title Ci 1 D6/- Producer Signature Print Name and Title Date Page 2 of 2 C_RUM &FORSTEW A FAIRFAX COMPAW POLICYHOLDER DISCLOSURE NOTICE OF CONDITIONAL TERRORISM INSURANCE COVERAGE 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 IO2(l) 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 M 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 TI -IE 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: I hereby elect to purchase terrorism coverage for a premium of $211 hereby decline to purchase terrorism coverage for certified acts of terrorism. I understand that I % coverage for losses resulting from certified acts of terrorism. P rn!Name Dore EN0006 - 0120 Named Insured/Firm Xfalling Address Quote'Policy Number CRU M & FORSTER" SURPLUS LINES TAX FILING ACKNOWLEDGMENT The producing broker is responsible for complying with surplus lines regulations in the applicable state and arranging for payment of the required state tax and /or stamping fee on this Policy. Please complete and return this form. Thank you. INSURED INFORMATION: Insured: Policy#: Effective Date:#: Policy Premium#: Producer#: Producer Mailing Address#: Independently Procured Coverage(IPC)? ❑ Yes E No SURPLUS LINES BROKER INFORMATION (The following licensed surplus line broker is handling all of the required filings and will pay the required taxes and fees, as indicated below.) Surplus Lines Broker's Name(Person or Entity): Surplus Lines Broker's Mailing Address: Surplus Lines State: Surplus Lines License #: Surplus Lines Association #(SLA #): (NJ domiciled risks only): Surplus Lines Tax: Surplus Lines Stamping Fee(if applicable): Other Taxes or Fees: SL TAX 10 12 CR_ U M & FORSTER' I IWWAX COMPANY Crum & Forster's Environmental Division has developed a value-added Spill Response Program available to all insureds at no additional charge. The program provides direct access 24/7, 365 days a year to a dedicated nationwide team of emergency environmental response and support providers. Crum & Forster's Spill Response Program leverages the resources of a national environmental claims management and emergency response leader with more than 25 years of experience in assessing, managing and assisting with pollution events. A dedicated team of legal, technical and environmental professionals will provide assistance with incident reporting to regulatory agencies, finding incident responders and cleanup contractors, and providing expert advice to help Crum & Forster clients contain their costs and limit potential liability arising from environmental incidents. The Spill Response Program is linked to a database of over 3,000 vetted and pre -qualified contractors across North America. Listings of nearly 30,000 federal, state, provincial, local and tribal jurisdictions requiring environmental incident reports are constantly updated to provide the best response effort and reporting. Our objective is to help our clients avoid fines and penalties associated with non- compliance with incident reporting regulations and response requirements. Crum & Forster's Environmental Division is dedicated to help our insureds deal with environmental incidents and spills in a timely, safe and comprehensive manner to ensure their businesses are not adversely affected and their liabilities are contained. The Spill Response Program is a great addition to any existing environmental incident or spill response protocols, plans or programs you might have. The Crum & Forster Spill Response Program is available only to our insureds. Upon becoming an insured with Crum & Forster Environmental you will gain access to this program, along with other loss control and loss prevention tools. A Spill Response Information Packet will be available for your immediate use to protect your business, your employees and the environment. PLEASE NOTE: Reporting a spill to Spill Center does not constitute reporting a claim, nor does it guarantee that a spill is covered under your policy. The Crum & Forster Spill Response Program is not intended to be a substitute for reporting claims as required by the terms and conditions of on insurance policy. The C&F logo, C&F and Crum & Forster are registered trademarks of United States Fire Insurance Company. The Crum & Forster Enterprise, which is part of Fairfax Financial Holdings Limited, is comprised of leading and well-established property and casualty business units. The insurance companies within the Enterprise, rate A (Excellent) by A. M. Best Company are; United States Fire Insurance Company, The North River Insurance Company, Crum & Forster Insurance Company, Crum & Forster Indemnity Company, Crum & Forster Specialty Insurance Company, Inc., Seneca Specialty Insurance Company, First Mercury Insurance Company, and American Underwriters Insurance Company.