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Home My WebLink About*Other - BOCC (002)-11ts AC EN SE'RVICES Insurance Quote Dear: Denise Lembcke, Martin Morris Agency, Inc - Ephrata Date: May 23, 2023 Attached please find Carrier quotation RPS has secured on your behalf for the below mentioned risk. Please review the attached and below carefully as coverage described herein may be different from the original application submitted, or prior policy if applicable. Insured: Morgan S Fife MD Insured ID: 11399704 Mailing Address: 1800 S Clover Dr Moses Lake, WA 98837 Physical Address: 35 CST NW, Ephrata, WA 98837 Carrier: General Star Indemnity Company / Non -Admitted Policy Period: 6/17/2023 to 6/17/2024 Coverage: Professional - Physician TIV: per Carrier terms attached Limit: per Carrier terms attached Rate: per Carrier terms attached Policy Premium: $57,955.00 Fees (fully earned): Broker Fee - RPS $3,000.00 Taxes: $11219.10 $60.96 Home State: WA TOTAL: $62,235.06 RPS Reference #: 5549947A AM Best Rating: A++ XV Surplus Lines Tax Stamping Office Fee 'HE PREMIUM ABOVE DOES NOT INCLUDE TERRORISM COVERAGE. IF THE INSURED ELECTS TO PURCHASI ERRORISM COVERAGE THE ADDITIONAL PREMIUM WILL BE PLUS TAX OF. Commission: 12% Conditions/ Subjectivities: per Carrier terms attached Subject to: See carrier binder for all subjectivities - highlighted Minimum Earned Premium: 25% GRANT COUNTY CONVIISSIONERS Please note: • You are responsible for reviewing and explaining the coverage to the client, including any options, available or not from our office. The terms hereon are not fully described and no assumption should be made as to the adequacy of the coverage of the risk to the client. • You are not an Agent of the insurer, and as such, cannot bind coverage nor make any commitments on behalf of the insurer, nor of us. This policy cannot be assigned to another without the written consent of the insurer or their Agent. • Insurance companies will not approve binding until all subjectivities (except inspections) have been received and accepted. • This document is a representation of the Carrier's quotation and is subject to all premiums, limits, terms, conditions and exclusions as set forth by the carrier. • If this policy is issued on a non -admitted basis, your office is responsible for completing, collecting and delivery to RPS any required surplus lines forms, taxes and fees from the insured at time of Binding. RPS will remit the applicable taxes and forms to the state. If this policy is subject to the surplus lines laws in your state, you should make every effort to comply with any special provisions and regulations of your state. • You are responsible for the issuance and review of Certificates of Insurance (COI). COls cannot amend or alter the terms provided herein. • All premiums and any fees are due to RPS within 20 days of binding unless otherwise stipulated. Accounts with payments that are overdue and are not received within this time frame are subject to cancellation. • By binding you commit to any provisions contained hereon, such as Minimum Earned Premiums. There are no flat cancellations allowed. Please advise in writing if you would like to bind coverage per the attached terms and conditions. Should you have any questions please give us a call. Thank you for the opportunity to work on your business! Sincerely, Jill A.Osborne Risk Placement Services, Inc. - Scottsdale GenStar�� General Star Indemnity Company 1 N. Wacker Drive, Suite 1760 Chicago, Illinois 60606 GENSTAR SPECIAL RISK PLUS PREMIUM INDICATION Date: 05/26/2023 *updated* Subject to the following terms & conditions, we are pleased to offer a premium and coverage indication for our Physicians & Surgeons, claims -made Professional Liability Program: INDICATION FOR: Morgan S Fife, MD APP ID: 2656363 MEDICAL SPECIALTY: Correctional Medicine Aim. Specialty Code: 85102 UNDERWRITING COMPANY: GENERAL STAR INDEMNITY COMPANY PROPOSED EFFECTIVE DATE: 06/17/2023 RETROACTIVE DATE: 05/18/2015 LIMITS OF LIABILITY: $1,000,000 EACH CLAIM/ $3,000,000 ANNUAL AGGREGATE DEDUCTIBLE: $10,000 ANNUAL PREMIUM: $57,955 *SEE RPS EMAIL FOR TOTAL DUE INCLUDING TAXES & FEES. THIS INDICATION WILL EXPIRE ON: 06/17/2023 Percentage of Full Annual Premium for 12 -Month Extended Reporting Period: 100% Percentage of Full Annual Premium for 36 -Month Extended Reporting Period: 150% Percentage of Full Annual Premium for 60 -Month Extended Reporting Period: 200% • page two • 05/22/2023 Morgan S Fife, MD Program Terms & Conditions: R1 A 25% minimum earned premium is charged upon binding. No flat cancel allowed. 0 No separate `corporation/entity' limit of liability is available. 0 All other terms and conditions as set forth in the policy. 0 Death, Disability and Retirement (DDR) coverage subject to terms and conditions of the policy. 0 Incident Sensitive, Defense Inside the Limits, Deductible applies to Indemnity and Defense, Consent applies with Hammer Clause. R1 IL P 001 01 04 U.S. TREASURY DEPARTMENT'S OFFICE OF FOREIGN ASSETS CONTROL (11OFAC11) (� IL 11 0001 07 22 Additional Policy Conditions - Trade Sanctions & Specially Designated Nationals (OFAC) C�1 PS 21 0008 07 22 Exclusion - Cyber Privacy Event, Cyber Security Event, Data Related Liability and Interruption or Failure of Services L� PS 21 0010 06 22 Physicians & Surgeons Private Citizen Statutory Abortion Liability Exclusion R1 PS 21 0011 05 23 Exclusion - Recording And Distribution Of Material In Violation Of Law 0 PS 21 0006 06 20 - Communicable Disease Exclusion 0 PS 06 0001 05 13 - Professional Services Redefined — Correctional healthcare services provided at Grant County Jail 35 C Street NW, Ephrata, WA 98823 by licensed medical professionals scheduled on this policy. 10 06 PS 396 — Exclusion — Performance for Specified Entity — Any/All Entities other than Correctional Medical Associates and Remedy Inmate Medical Services 0 PS 20 0003- Additional Insured — Vicarious Liability — Grant County Retro 6/17/2020 0 06 PS 458 — Schedule of Named Insureds • Tyson Andelin PA -C — Retro 6/6/2022 • Andrew Nielsen, PA -C — Retro TBA • Kathleen Tillie Holloway, PA -C — Retro: 5/18/15 Departed Providers: • Corbin Lynn Moberg, PA -C, MSPAS — Retro: 5/18/15 - 6/17/23 • Darci Sander, ARNP — Retro: 7/31/18 - 6/17/23 R1 • Eric Aronsohn PA -C, MSPAS — Retro: 5/18/15-6/27/16 - 6/17/23 PS 24 0007 10 22 Physician & Surgeon's Named Insured's Duties in the Event of a Potential Claim amendment. REQUIRED IN ORDER TO PROVIDE FIRM QUOTE OR BIND 1. None ;AGENT/BROKER RESPONSIBILITIES AND ACKNOWLEDGEMENTS: If bound, coverage will be ..................................�.�........ �. �....� .�...��........................................................................................................................................................................................................................................................... W.._- ... W _....-.. �._. provided on a surplus lines basis, through the company identified herein. The agent/broker will be solely responsible for any and all calculations, collections, and remittance of S/L taxes; stamping fees; any notices; full compliance with any state affidavit requirements; any/all state Patient Compensation/CAT Funds or similar organizations reporting requirements, fee collections and remittances. The premium shown hereon does not include any of the above fees/charges. We require a written order to bind coverage, no verbal bind orders will be accepted. As the Agent of Record with the Company on this specific account, you understand that once bound, you are responsible to the Company for payment of premium, subject to the minimum earned premium as stated above. Please sign and date the following as acceptance of these terms and a specific Order to Bind Coverage: Rob Jones Chair