The URL can be used to link to this page

Home My WebLink AboutInsurance - BOCC0 CRU: &FORSTER CRUM & FORSTER SPECIALTY INSURANCE COMPANY ENVIRONMENTAL QUOTE DATE OF PROPOSAL: 06/01/2021 Item 1. NAMED INSURED & ADDRESS: GRANT COUNTY PO Box 37 Ephrata, WA 98823 PRODUCER NAME & ADDRESS: ENVIRONMENTAL RISK MANAGERS, INC. Po Box 2]Of Moline, Michigan 49335-0000 FORM OF BUSINESS: Corporation PRODUCER CODE: 9473 Item 2. PROPOSED POLICY PERIOD: 07/07/2021 to 07/07/2022 12:01 a.m. Standard Time at the Named Insured's address stated above. Item 3. LIMITS OF INSURANCE: Each Confirmed Release Limit: $1,0.00,000 Policy Aggreaate Limit: $13000,000 Defense Expense Aggregate Limit: $13000,000 Item 4. DEDUCTIBLE/SELF-INSURED RETENTION: See Tank Schedule Item 5. IRETROACTIVE DATES: See Tank Schedule Item 6. PREMIUM: f Policy,Premium: $4,210 Additional Insured Premium: $0 TRIPRA Premium: $211 Total Policy Premium: $41421 Minimum Earned Premium: 25% Minimum Policy Premium: 100% Item 7. AUDIT PERIOD: Not Sub' ect to Audit [Basis: Units: 2 U S T s , 8 A S T s Rate: Flat 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. .............................................. ------------------------- T'- CR. FORS ERR .. .. ... ....: FORMS AND ENDORSEMENTS 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 EN0050-0816 EMERGENCY RESPONSE HOTLINE EN0052-0816 NOTICE OF LOSS ALL CFSTP 00 000 01 15 STORAGE TANK POLLUTION POLICY CFSTP 00 002 0121 DEDUCTIBLE ENDORSEMENT 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: ......... ruin Forsior Tan{ A �icat�an cam [eto: and .s ned : th P P 9. :y e First Named Lnurod'roro3in: dn �On+ed. Terrarisr [ ejeat�no l Selection arrn ............................... ........................................... pomp#tiled u.rpJu ire Talc Fe rn friar B ndng fror dg oca'iQrl#� opy..o currortfne Test........ 1S.�.1.:.,.- nrthn the fast 2 rnenth Prr finding .acat�on::2 ; #3:44:46::anci#'..Ne+tl :dota�ls :ofi..the :s: Iit tanks ccr P . :.. partrenfi;si�es and Priort Brd ng the contents inach 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. Itis 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. ................. ............................................... ............................................... 1R E . �-.-ST R: M F0 .. ......... ............ COVERED STORAGE TANK AND LOCATION ENDORSEMENT Loc Address city State Zip Tank AST Year ## Diesel 4,000 Diesel Code # /UST Installed 1 124 Enterprise St. SE Ephrata WA 98823 1 UST 1999 1 124 Enterprise St. SE Ephrata WA 98823 2 UST 1999 2 3803 Neva Lake Road Ephrata WA 98823 1 AST 2012 2 3 803 Neva Lake Road Ephrata WA 98823 2 AST 2012 3 232 Chelan St. Hartline WA 99135 1 AST 1999 4 24378 Broadway St. Mattawa WA 99344 1 AST 1999 5 12171 Wheeler Rd. Moses Lake WA 98837 1 AST 2009 5 12171 Wheeler Rd. Moses Lake WA 98837 2 AST 2009 6 4718 Rd P -NW Quincy WA 98848 1 AST 2005 7 13766 Road E SW Royal CIty WA 99357 1 AST 2003 Capacity Contents 10,000 Gasoline 10,000 Diesel 4,000 Gasoline/ $5,000 Diesel 4,000 Diesel 12,000 Gasoline/ $5,000 Diesel 6,000 Gasoline/ $5,000 Diesel 10,000 Gasoline 10,000 Diesel 12,000 Gasoline/ Diesel 12,000 Gasoline/ Diesel Deductible Retroactive Date $10,000 7/7/2006 $10,000 7/7/2006 $5,000 7/7/2016 $5,000 7/7/2016 $5,000 7/7/2016 $5,000 7/7/2016 $5,000 7/7/2016 $5,000 7/7/2016 $5,000 7/7/2016 $5,000 7/7/2016 POLICYHOLDER DISCLOSURE NOTICE OF 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 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: Policyh der pelican VSignafure Cindy Carter, B O C C Chair Print Name �% ' ° ✓'of Date E N 0006 - 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 $211 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. Policyh der pelican VSignafure Cindy Carter, B O C C Chair Print Name �% ' ° ✓'of Date E N 0006 - 0120 GRANT COUNTY Named Insured/Firm PO Box 37, Ephrata, WA, 98823 Mailing Address Quote/Policy Number CRUM&FORSTElt Pmducer SIgnature: Datc. Pdnt Name and Title: tm;.R U M & FO RSTE W June 01, 2021 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: 07/07/2021 Premium: $4,210 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. Fidet .or..Na�.rRo dent.Sur` ius:Lines.. Licene .ln-forrnajn 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: Date: Signed by (Print Name): NOTE: FAILURE TO RETURN THIS COMPLETED & SIGNED FORM WITHIN 15 DAYS WILL RESULT IN THE CANCELLATION OF THE ABOVE LISTED POLICY. SL Form Ed. 03/2021