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Signed Contract_Gallagher Risk Management Services for Worker's Compenstation Insurance Copyrighted September 3, 2019 City of Dubuque Consent Items # 28. ITEM TITLE: Signed Contract(s) SUMMARY: Gallagher Risk Management Services Agreementfor Worker's Compensation Insurance ProgramAnalysis; lowa Department of Transportation forARC /J FK Road Midtown Transfer Phase I I; Palebluedot, LLC Climate Action Plan Update Agreement; Walter Development, LLC (Hodge) Site Access Agreement for McFadden Farm Site SUGGESTED DISPOSITION: Suggested Disposition: Receive and File ATTACHMENTS: Description Type Gallagher Risk Managment Services Agreement Supporting Documentation IDOTMidtown Transfer Phase II Agreement Supporting Documentation Palebluedot, LLC Agreement Supporting Documentation � P'w".3�# � : � � �,;��y .� :.r � #rs }r�._ ,-t��- _, 4 J-p ', i ; � §'�� i �� II .-�. . �� a �:'� � � �D_. ��• �S }�� 5'1 _�f " y � gh I p � , { � j t � - J � ..�t * � - 4 �II �i41 � I � 3` 7 . 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'�i�.3. .. . : - s � � J ,. ��.a�.'' 4'a � �x ,g': � _.- �. �� R -.K. .� �'u� �,��.s .n-, �`,�'_. . .. �� i � � �". t, �, - . .,;�,=� .�' .T a� - ,��f�;r-.`,,�k�.� . .. � a `�F � Ar� `a +�,�.A� � � -r. : �. . �� Scop:e of�lNg�or�ka�llVorke�rs��orn ensatio� � �� ,�a�� .�� 4�� : �'4 -a �� - g �,��.k_! t€�'��``�F�'�'�4 i��S ��„ �a5��za�'a>�" # fPE 'ss t� � 4� S' � � �,2�s...�� I;nsurance�Markefiing Services�� ''�� "�� .: �?�';� �*�.� €��"�#�`e^�. �``�a��" v:�`' �*�r'� � � �,�� ,,,„�,.1 :} `�J a ��., � �e �Es.� � � �y.� 3�u�r -[�t ��' 't- �_ �. �� ,,'�*x.a�'..,• ,� � x. � . ,�, � ' y � a�}a�-�,��,r�` ��' � �".,. ,..�{ - E 3. � � �� a , uGJ Gall herR�s�Mana ementYServices�lnc�� ,� � sh• �7 g � t� �, �. p„-yy � at.„ �` z� ,c;�. y{Yr. ,.,� . �� """-�t`t��.��€��'�` �'��r�t ��' -�"' .,�' �k. ��.a . �� +.aren G;a am �,'xecutiye Vice P.res� � ��`��-.� � " �= �� ' ��. t,� � a e �gr ham@a�g"com[3Q3 889�538 � �: �� x � � �X� z..� �3 � "'.:tt^�e ., `a �. 9 �'�-�' �+ }�_ �� P es�e�ted�.�u�e�1`9��1U19��,� � "'�� ..'} �; � �-��' �� { �� ,�� ; s ' _ ��£ � - �,, �.,;�� _: �� -� ��„� �-�', �j� �� $ ��.,� ,� �allag�l�er t �. ' � -t� � r ,a ��' �`��i.'�4s��'; ',4,��s��.��Y L��,' �t 4. y,��r � � � � �� i� }ki��5�,�"��'`�-�� - �'' rr _ ��p�� # �� ' -.-rtr�,� p � �j 7�� C � , � Z�� .r � ��',� � j� Insurance Risk Mana�ement Consultin ;� '*��s '' �� '� .�� '=� _ �`��,�' I , . f� _ � d .�C'�� ,_�y g1 '`'�� .�„3.�# .�p .�,s { -. ��, 4��. ' 3 ��,r� `r.= ,�f��y � � a�° q ��,��_+�'� . "�s� �"�.�'��-�k xk��. `"4, ��,' � i i f� �� ..� f7� s�y"� t . ,� ` . ,�. �� a�f3 �t.� �'��s s` � �Y5;- ''`��,�',�t`•. �t e.<�- �� - � s4 �� '�'S��_�'` . , , �� , T�b�� r��r�t� _ SECTION - : PAGE I Workers' Compensation lnsurance Marketing Services........................................................4 � Purpose:.........,...............:...................................................................:........................ ....4 I ....... Scopeofi Work:::......:...........................:.........,...........................,............................................4 �I Proposed Cost & Gallagher Compensafiion............................................................................4 ' Underwriting Information Required ........:...............................................................................:5 ProjectTime Line....................::................................................................................:.......,........6 Acceptance of Scope of Work/Proposal..................................................................................6 GallagherAfi A Glance...:.................................................................................,.........................7 Appendix.... . .................... ................................................ .............. ... .. ......... ........8 I City of Dubuque, IA -�2019 Arth�r J.Gailarjher:Co.all riy�r r�sar�ad. 13GC,817'•2961:N!—Strat R3•i � 5 ��x�� ' �� , ..:�`k .. - ....,.,�.,,.� ' . . � _ �: - ; .- -... ' _ . �� !��+�,1�ti..,/,�.� Thank you for the opportunity to present this Proposal for Insurance Marketing Services. it's ail about Our Clienfi Experience and our approach is what sets us apart ✓ CORE360T"' is our unique comprehensive approach of evaluating your risk management program ✓ Gallagher leverages our analytical tools and diverse resources for customized, maximum impact on six cost drivers of your total cost of risk. ✓ We continuously challenge your existing program and look for opportunifiies for future improvements � ✓ We mutually agree on a strategy to build the most optimal risk management program for you _ # ' - How the individual pieces nF ycturp�ogram vro�k together;as vtell as°how ycu balaixe youl risk; appQtite agamst.yrou�loss exp@rience Cost lor all your existing lnsurance r policies It alsq inCludes our compensatlon ' . �, . �� I as your broker , � - L�._.�:;. . , . �y� ,:�Potenlial costs from any gaps in - '� exfsting polfcies,such as sutilimlts, � Y • , - removable exclusions and,eztens(ons ,, . ' �o(co.Vcrage. ' � � �� 1 ' • � , �� _..__..�, _._. .,._..�... _ �,. �� " �* Costs resulting from the unsur.cessful �. � �� trensfer of rlsk to,nr assmnplion oF ,�� , ' unmsured IlaUillry frcm a thlyd party .�� i�� _�, � . �x � �� - �-� . . __,_.,�.,w__._.._____�._,___._._._._ .,___� s�� potentlal or actual costs of any �� ,.�.��,�jr�r ' _ {isks yau knawmgly or unknowing(y � :' leave;uninsured or'are uriinsuiable. Your'pa�hcipahon in�(oss �nd how you ''Y� ' miofm(ze costs th)ough appfapnate Ioss ; �� prevention programs aqd'slairps management � , , City of Dubuque, (A Page �3 �'�� ai�� Y�i�.I� �.J ita ��r�� ,�� °�� City of Dubuque, IA (City) has requested Arthur J. Gallagher Risk Management Services(Gailagher) provide a consulting and program analysis of the City's currenfi Workers' Compensation Insurance Program. Following is scope of work (including cost) for consideration by the City. Purpose Analyze the City's current Workers' Compensation Insurance Program and provide recomm�ndations to improve the Cifiy's current program and provide quotes for comparison to the expiring program. To analyze the City's current program it is necessary to market the coverage in order to validate current market condifiions and premiums. We would focus efforts on a guaranteed cost program that would include claims adminisiration and risk control services provided by the insurance carrier. Scope of Work • Analysis of the current self-insured program to determine the total cost of risk (premium, fixed costs, and losses) that the City funds compared to a guaranteed cost program • Loss stratification to assist in analyzing losses and deductible attachment point • Collect underwriting information and applications; list of required underwriting information can be found on page 5 of this proposal • Review submitted underwriting information; prepare coverage specifications & submissions to present to insurance marketplace • Review and analyze quote(s)from marketplace • Present written marketing results and insurance proposal � • Consult with City and make a recommendation based on marketing resulfis Proposed Cost & Gallagher Compensation Gallagher is proposing a $7,500 Flat Fee for the Scope of Work outlined in this proposal. If the City binds insurance coverage as proposed by Gallagher, Gallagher will be compensated with commissions paid by the insurance carrier. The initial marketing fee paid to Gallagher will be reduced by the amount of the commissions received, subject to a minimum of$7,500. City of Dubuque, IA Page�4of7 ,. �� w/ W TM' �'��.. �� °�� The City will assist in providing current insurance program information, complete and sign applications, and provide additional underwriting information for quoting purposes. ❑ Current narrative of City's risk management department including organization chart and resumes of key risk management personnel ❑ City's FEW � ❑ Current premiums for excess coverage and any applicable bonds, letter of credit, or collateral ❑ Copy of current workers' compensation policy � ❑ Previous year's (2018) applications, including employee concentration ❑ Completed and signed Acord Applications— including answers to questions 1-24 on pages 3 and 4 (applications located in Appendix) ❑ Estimated 2019 Payroll by classification code ❑ Ten (10) years of payroll history by classification code ❑ 10 years (year 2008 to current) of City or TPA loss runs showing claims paid, reserves, total incurred in EXCEL format o Show amounts paid for medical, indemnity, expense; include date of loss and status (open/closed) o Include all claims reported on a first-dollar basis and losses in excess of self insured retention; do not include recoveries ❑ Provide details of any claims with total incurred values greater than $50,000; include narratives of the claims and current status City of Dubuque, IA Page� 5 of 7 ,. � i ' �'FY� ��l/A� `.yA �IIA ! i ��j��,� `"�� . This timeline is a sample only. In ord�r to allow ample time we would start analysis and marl<eting six manths prior to the insurance p'olicy progr�m effective d�te. We have used July 1, 2Q19 �s the effective date in this �xample. . � ;,. A • r r Request for Underwriting (nformation to Cifiy ` January 2019 Underwriting/Completed Applications Infarmation back February 2019 from City Program �nalysis February�Aprii 2019 'I Submissions to Marketplace F'ebruary 2019 Quotes from Marketpl�ce March -April 2019 Results and f'roposal presented to Cifiy May- June 2Q19 Bind Coverage Prior fio July 1, 2019 � � � ��: �F �c�� "��r:��l��.��1� The City hereby accepts the Scope of Work as autlined in this propos�i. CITY OF DU�3UQU�, fA By, Name; Michael C. Van Milligen Titlo, Cftv Mana er Date; �\..� City of Dubuque,IA Pac�e �6 of 7 „ City of Dubuque Insurance Requirements for Professional Services INSURANCE SCHEDULE J Arthur J.Gallagher Risk Management Services, Inc. 1. shall furnish a signed certificate of insurance to the City of Dubuque, lowa for the coverage required in Exhibit I prior to commencing work and at the end of the project if the term of work is longer than 60 days. Contractors presenting annual certificates shall present a certificate at the end of each project with the final billing. Each certificate shall be prepared on the most current ACORD form approved by the lowa Department of Insurance or an equivalent approved by the Director of Finance and Budget. Each certificate shall include a statement under ' Description of Operations as to why the certificate was issued. Eg: Project# or Project '� Location at or construction of ; I 2. All policies of insurance required hereunder shall be with an insurer authorized to do business in I lowa and all insurers shall have a rating of A or better in the current A.M. Best's Rating Guide. ! 3. Each certificate shall be furnished to the Finance Department of the City of Dubuque. ' 4. Failure to provide coverage required by this Insurance Schedule shall not be deemed a waiver of � these requirements by the City of Dubuque. Failure to obtain or maintain the required insurance � shall be considered a material breach of this agreement. ; 5. Contractors shall require all subconsultants and sub-subconsultants to obtain and maintain during the performance of work insurance for the coverages described in this Insurance Schedule and shall obtain certificates of insurances from all such subconsultants and sub-subconsultants. Contractors agree that they shall be liable for the failure of a subconsultant and sub- subconsultant to obtain and maintain such coverages. The City may request a copy of such certificates from the Contractor. 6. All required endorsements shall be attached to certificate of insurance. 7. Whenever a specific ISO form is listed, required the current edition of the form must be used, or an equivalent form may be substituted if approved by the Director of Finance and Budget and subject to the contractor identifying and listing in writing all deviations and exclusions from the ISO form. 8. Contractors shall be required to carry the minimum coverage/limits, or greater if required by law or other legal agreement, in Exhibit I. If the contractor's limits of liability are higher than the required minimum limits then the provider's limits shall be this agreement's required limits. 9. Contractor shall be responsible for deductibles and self-insured retention. Page 1 of 4 Schedule J Professional Services May 2019 i [ i l City of Dubuque Insurance Requirements for Professional Services „ f � INSURANCE SCHEDULE J (continued) �Xn�b�t i � A) COMMERCIAL GENERAL LIABILITY t General Aggregate Limit $2,000,000 ( Products-Completed Operations Aggregate Limit $1,000,000 Personal and Advertising Injury Limit $1,000,000 ! Each Occurrence $1,000,000 � Fire Damage Limit(any one occurrence) $50,000 j Medical Payments $5,000 j 1) Coverage shall be written on an occurrence, not claims made, form. The general I � liability coverage shall be written in accord with ISO form CG 00 01 or business owners form BP 00 02. All deviations from the standard ISO commercial general liability form CG 00 01, or business owners form BP 00 02, shall be clearly identified. 2) Include ISO endorsement form CG 25 04"Designated Location(s)General I, Aggregate Limit" or CG 25 03"Designated Construction Project(s)General � Aggregate Limit" as appropriate. � 3) Include endorsement indicating that coverage is primary and non-contributory. 4) Include Preservation of Governmental Immunities Endorsement. (Sample ', attached). 5) Include additional insured endorsement for: The City of Dubuque, including all its elected and appointed officials, all its , employees and volunteers, all its boards, commissions and/or authorities and their board members, employees and volunteers. Use ISO form CG 20 26. 6) Policy shall include Waiver of Right to Recover from Others endorsement. , B) AUTOMOBILE LIABILITY Combined Single Limit $1,000,000 ' C) WORKERS' COMPENSATION &EMPLOYERS LIA�ILITY Statutory Benefits covering all employees injured on the job by accident or disease as prescribed by lowa Code Chapter 85. Coverage A Statutory—State of lowa Coverage B Employers Liability Each Accident $100,000 Each Employee-Disease $100,000 Policy Limit-Disease $500,000 Policy shall include Waiver of Right to Recover from Others endorsement. Coverage B limits shall be greater if required by the umbrella/excess insurer. OR Nonelection of Workers' Compensation or Employers' Liability Coverage under lowa Code sec. 87.22. Completed form must be attached, Page 2 of 4 Schedule J Professional Services May 2019 , City of Dubuque Insurance Requirements for Professional Services INSURANCE SCHEDULE J (continued) D) UMBRELLA/EXCESS LIABILITY $1,000,000 Umbrella/excess liability coverage must be at least following form with the underlying policies included herein (General Liability, Automobile, Workers Compensation). E) PROFESSIONAL LIABILITY $1,000,000 Provide evidence of coverage for 5 years after completion of project. F) CYBER LIABILITY $1,000,000 X yes _no Coverage for First and Third Party liability including but not limited to lost data and restoration, loss of income and cyber breach of information. ( Page 3 of 4 Schedule J Professional Services May 2019 Cifiy of Dubuque Insurance Requirements for Professional Services , PRESERVATION OF GOVERNMENTAL IMMUNITIES ENDORSEMENT 1. Nonwaiver of Governmental Immunitv. The insurer expressly agrees and states that the purchase ' of this policy and the including of the City of Dubuque, lowa as an Additional Insured does not waive any of the defenses of governmental immunity available to the City of Dubuque, lowa under Code of lowa Section 670.4 as it is now exists and as it may be amended from time to time. 2. Claims Coveraqe. The insurer further agrees that this policy of insurance shall cover only those claims not subject to the defense of governmental immunity under the Code of lowa Section 670.4 as it now exists and as it may be amended from time to time. Those claims not subject to Code of lowa Section 670.4 shall be covered by the terms and conditions of this insurance policy. 3. Assertion of Government Immunitv. The City of Dubuque, lowa shall be responsible for asserting any defense of governmental immunity, and may do so at any time and shall do so upon the timely written request of the insurer, 4. Non-Denial of Coveraae. The insurer shall not deny coverage under this policy and the insurer shall not deny any of the rights and benefits accruing to the City of Dubuque, lowa under this policy for reasons of governmental immunity unless and until a court of competent jurisdiction has ruled in favor of the defense(s)of governmental immunity asserted by the City of Dubuque, lowa. No Other Chanqe in Policv. The above preservation of governmental immunities shall not otherwise ' change or alter the coverage available under the policy. 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COMMERCIAL GENERAL LIABILITY $ INSTALLATION/BUILDERS RISK $ $ CRIME/MISCELLANEOUS CRIME $ OPEN CARGO g $ DEALERS $ PROPERTY $ $ ATTACHMENTS ADDITIONAL INTEREST PREMIUM PAYMENT SUPPLEMENT ADDITIONAL PREMISES PROFESSIONAL LIABILITY SUPPLEMENT APARTMENT BUILDING SUPPLEMENT RESTAURANT I TAVERN SUPPLEMENT . CONDO ASSN BYLAWS(for D80 Coverage only) STATEMENT/SCHEDULE OF VALUES CONTRACTORS SUPPLEMENT STATE SUPPLEMENT(If applicable) COVERAGES SCHEDULE VACANT BUILDING SUPPLEMENT DRIVER INFORMATION SCHEDULE VEHICLE SCHEDULE INTERNATIONAL.'LIABILITY EXPOSURE SUPPLEMENT INTERNATIONAL:PROPERTY EXPOSURE SUPPLEMENT LOSS SUMMARY POLICY INFORMATION PROPOSED EFF DATE PROPOSED EXP DATE 81LLING PLAN PAYMENT PLAN METHOD OF PAYMENT AUDIT DEPOSIT MINIMUM pOLICY PREMIUM PREMIUM DIRECT AGENCY $ $ $ APPLICANT INFORMATION NAME(First Named Insured)AND MAILING ADDRESS(Including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC N BUSINESS PHONE#; WEBSITE ADDRESS CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION INDIVIDUAL LLC NO OF MEMBERS PARTNERSHIP TRUST AND MANAGERS: NAME(Other Named Insured)AND MAILING ADDRESS(including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC# BUSINESS PHONE N: WEeSITE ADDRESS CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION INDIVIDUAL LLC NO OF MEMBERS PARTNERSHIP TRUST AND MANAGERS: NAME(Other Named Insured)AND MAILING ADDRESS(Including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC# BUSINESS PHONE#: WEBSITE ADDRESS CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER"S"CORPORATION INDIVIDUAL LLC NO OF MEMBERS PARTNERSHIP TRUST AND MANAGERS: ACORD 125(2009/O8) Page 1 of 4 O 1993-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CONTACT INFORMATION AGENCY CUSTOMER ID: r , CONTACT TYPE: CONTACT TYPE: ' CONTACT NAME: CONTACT NAME; PHONER# ❑HOME❑ BUS ❑ CELL pHONEDARY �HOME�BUS ❑CELL PHONER# ❑ HOME� BUS ❑CELL pNONE# RY �HOME 0 BUS ❑CELL PRIMARY E-MAIL ADDRESS: PRIMARY E-MAIL ADDRESS; SECONDARY E-MAIL ADDRE55: SECONDARY E-MAIL ADORESS: PREMISES INFORMATION Attach ACORD 823 for Additional Premises LOC t� STREET CITY LIMITS INTEREST N FULL TIME EMPL ANNUAL REVENUES: $ INSIDE OWNER OCCUPIED AREA: SQ Ff BLD k CITY: STATE: OUTSIDE TENANT N PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT COUNTY: ZIPs TOTAL BUILDING AREA: SQ Fi , DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y I N �I LOC t� STREET CITY LIMITS INTEREST N FULL TIME EMPL ANNUAL REVENUES:$ I INSI�E OWNER OCCUPIED AREA: SQ FT BLD i{ CITY: STATE: OUTSIDE TENANT N PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT COUNTY: ZIP: TO7AL BUILDING AREA: SQ FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y 1 N LOC!f STREET CITY LIMITS INTEREST !f FULL TIME EMPL ANNUAL REVENUES: $ INSIDE OWNER OCCUPIED AREA: SQ Ff BLD N CITY: STATE: OUTSIDE TENANT R PART TIME EMPL OPEN TO PUBGC AREA: SQ Ff � COUNTY: ZIP: TOTAL BUILDING AREA: SQ FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y/N LOC iF STREET CITY LIMITS INTEREST #FULL TIME EMPL ANNUAL REVENUES: $ INSIDE OWNER OCCUPIED AREA: SQ Ff BLD# CITY: STATE: OUTSIDE TENANT k PART TIME EMPL OPEN TO PUBLIC AREA: SQ Ff COUNTY: ZIP: TOTAL BUILDING AREA: SQ FT DESCRIPTION OF OPERATIONS: ANY AREA LEASED TO OTHERS?Y/N NATURE OF BUSINESS DATE BUSINESS APARTMENTS CONTRACTOR MANUFACTURING RESTAURANT SERVICE STARTE�(MMIDDIYYYY) CONDOMINIUMS INSTITUTIUNAL OFFICE RETAIL WHOLESALE DESCRIPTION OF PRIMARY OPERATIONS INSTALLATION,SERVICE OR REPAIR WORK OFF PREMISES INSTALLATION,SERVICE OR REPAIR WORK RETAIL STORES OR SERVICE OPERATIONS%OF TOTAL SALES: % % DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS ADDITIONAL INTEREST Not all fields a I to all scenarios- rovide onl the necessa data Attach ACORD 45 for more Additional Interests INTER�ST NAME AND ADDRESS RANK: EVIDENCE; CERTIFICATE POLICY SEND BILL INTEREST IN ITEM NUMBER ADDITIONAL LOSS PAYEE LOCATION: BUIL�ING: INSURED ._ BREACH OF MORTGAGEE VEHICLE: BOAT: WARRANTY CO.OWNER OWNER AIRPORT: AIRCRAFT: EMPLOYEE REGISTRANT ITEM ITEM: AS LESSOR CLASS: LEASEBACK TRUSTEE ITEM�ESCRIPTION OWNER LIENHOLDER REFERENCE I LOAN Y�: INTEREST END DATE: LIEN AMOUNT: PHONE(AIC,No,Ext): FAX(AIC,No): REASON FOR INTEREST: E•MAIL ADDRESS: ACORD 125(2009/08) Page 2 of 4 GENERAL INFORMATION AGENCY CUSTOMER ID: ' EXPLAIN ALL"YES"RESPONSES YIN 1a. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY? PARENT COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 1b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? SUBSIDIARY COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED ' 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? I�� SAFETY MANUAL MONTHLY MEETINGS ❑ SAFETY POSITION OSHA 3. ANY EXPOSURE TO FLAMMABLES,EXPLOSIVES,CHEMICALS? 4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER 5. ANY POLICY OR COVERAGE DECLINED,CANCELLED OR NON-RENEWED DURING THE PRIOR THREE(3)YEARS FOR ANY PREMISES OR OPERATIONS? (Missouri Appticants-Do not answer this question) NON•PAYMENT AGENT NO LONGER REPRESENTS CARRIER ❑ NON-RENEWAL UNDERWRITING CONDITION CORRECTED(Describe): 6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS,DISCRIMINATION OR NEGLIGENT HIRING7 7. DURING THE LAST FIVE YEARS(TEN IN RI),HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY,ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI,this questlon must be answered by any appllcant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). 8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? OCCURRENCE, DATE EXPLANATION RESOLUTION RESOLUTION DATE 9. HAS APPLICANT HAD A FORECLOSURE,REPOSSESSION,BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE�5)YEARS7 OCCURRENCE DATE EXPLANATION RESOLUTION RESOLUTION DATE 10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE(5)YEARS7 OCCURRENCE DATE EXPLANATION RESOLUTION RESOLUTION DATE 11. HAS BUSINESS BEEN PLACED IN A TRUST? NAME OF TRUST 12. ANY FOREIGN OPERATIONS,FOREIGN PRODUCTS DISTRIBUTED IN USA,OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES? (If"YES",attach ACORD 815 for L1ability Exposure andlor ACORD 816 for Property Exposure) 13. DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? REMARKS!PROCESSING INSTRUCTIONS Attach ACORD 101,Additional Remarks Schedule,if more s ace is re uired ACORD 125(2009/08) Page 3 of 4 ' AGENCY CUSTOMER ID: PRIOR CARRIER INFORMATION YEAR CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER; r ' CARRIER I POLICY NUMBER I PREMIUM $ $ $ $ I EFFECTIVE DATE EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE CARRIER � POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE � EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM $ � $ $ , EFFECTIVE DATE ' I EXPIRATION DATE LOSS HISTORY Check if none (Attach Loss Summary for Additional Loss Information) ENTER ALL CLAIMS OR LOSSES(REGARDLESS OF FAULT AND WHETHER OR NOT INSURED)OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST _YEARS 70TAL LOSSES: $ SU8R0- CLAIM DATE OF LINE TYPE I DESCRIPTION OF OCCURRENCE OR CLAIM DATE OF CLAIM AMOUNT PAID AMOUNT RESERVED GATION OPEN OCCURRENCE YIN Y/N SIGNATURE COPY OF THE NOTICE OF INFORMATION PRACTICES(PRIVACY)HAS BEEN GIVEN TO THE APPLICANT.(Not applicable In all states,consult your agent or broker for your state's requirements.) NOTICE OF INSURANCE INFORMATION PRACTICES - PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE. SUCH INFORMATION AS WELL AS OTHERPERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US. ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION,OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO,COMMITS A FRAUDULENT INSURANCE ACT,WHICH IS A CRIME AND SUBJECTS THE PERSON TO CRIMINAL AND[NY:SUBSTANTIAL]CIVIL PENALTIES.(Not appl(cable in CO,DC,FL,HI,MA,NE,OH,OK,OR,VT or WA;in LA,ME,TN and VA,insurance benefits may also be denied) IN THE DISTRICT OF COLUMBIA,WARNING: IT IS A CRIME TO PROVIDE FALSE OR MISLEADING INFORMATION TO AN INSURER FOR THE PURPOSE OF DEFRAUDING THE INSURER OR ANY OTHER PERSON. PENALTIES INCLUDE IMPRISONMENT AND/OR FINES. IN FLORIDA, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE,INCOMPLETE,OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE. IN MASSACHUSETTS, NEBRASKA, OREGON AND VERMONT, ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CON7AINING ANY MATERIALLY FALSE INFORMATION,OR CONCEALS FOR THE PURPOSE OF MISLEADING INFORMATION CONCERNING ANY FACT MATERIAL THERETO,MAY BE COMMITTING A FRAUDULENT INSURANCE ACT,WHICH MAY BE A CRIME AND MAY SUBJECT THE PERSON TO CRIMINAL AND CIVIL PENALTIES. IN WASHINGTON,IT IS A CRIME TO KNOWINGLY PROVIDE FALSE,INCOMPLETE,OR MISLEADING INFORMATION TO AN INSURANCE COMPANY FOR THE PURPOSE OF DEFRAUDING THE COMPANY, PENALTIES INCLUDE IMPRISONMENT,FINES,AND DENIAL OF INSURANCE BENEFITS. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPL.ICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION, HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE,CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOVJLEDGE. PRODUCER'S SIGNATURE PRODUCER'S NAME(Please Print) STATE PRODUCER LICENSE NO (Requlred In Florida) APPLICANT'S SIGNATURE DATE NATIONAL PRODUCER NUMBER ACORD 125(2009108) Page 4 of 4 AICOR�� WORKERS COMPENSATIOIV APPLICATION DATE(MM/DDIYYYY) rrs� AGENCY NAME AND ADDRESS COMPANY: - UNDERWRITER: APPLICANT NAME: OFFICE PHONE: MOBILE PHONE: MAILING ADDRESS(Including ZIP +q or Canadlan Postal Code) YRS IN eUS: SIC: PRODUCER NAME; NAICS: CS REPRESENTATIVE WEBSITE ADDRESS: OFFICE PHONE E-MAIL ADDRESS; MOBILE SOLE PROPRIETOR CORPORATION LLC TRUST UNINCORPORATED NE• ASSOCIATION A� PARTNERSHIP S�BCORP TER JOINT VENTURE OTHER: E•MAIL CREDIT ' ADDRESS: BU AME• ID NUMBER: FEDERAL EMPLOYER ID NUMBER NCCI RISK ID NUMBER OTHER RATING BUREAU ID OR STATE CODE; SUB CODE: EMPLOYER REGISTRATION NUMBER ' AGENCY CUSTOMER ID: i STATUS OF SUBMISSION BIL.LING/AUDIT INFORMATION ' QUOTE ISSUE POLICY BILLING PLAN PAYMENT PLAN AUDIT BOUND(Give date and/or attach copy) AGENCY Blll ANNUAL � AT EXPIRATION e MONTHLY ASSIGNED RISK(Altach ACORD 133) DIRECT BILL SEMI-ANNUAL SEMI-ANNUAL QUARTERLY %DOWN: QUARTERLY � LOCATIONS LOC H HFLOOR STREET,C�TY,COUNTY,STATE,ZIP CODE ' POLICY INFORMATION PROPOSED EPF DATE PROPOSED EXP DATE NORMAL ANNIVERSARY RATING DATE pARTICIPATING RETRO PLAN NON•PARTICIPATING PART1-WORKHRS pqRT2•EMPLOYER'SLIABILITY PART3•OTHER DEDUCTIBLES qMOUNT/% OTHERCOVERAGES COMPENSATION(States) STATES INS N 1 A In WI) (N I A I�WI) $ EACH ACCIDENT MEDICAL U.S.L.&H. MANAGED — CARE OPTION $ DISEASE•POLICY LIMIT INDEMNITY VOLUNTARY • COMP $ DISEASE•EACH EMPLOYE FOREIGN COV DIVIDEND PLANISAFETY GROUP AD�ITIONAL COMPANY INFORMATION SPECIFY ADDITIONAL COVERAGES I ENDORSEMENTS(Attach ACORD 101,Addltlonal Remarks Schedule,if more space is required) TO7AL ESTIMATED ANNUAL PREMIUM-ALL STATES TOTAL ESTIMATED ANNUAL PREMIUM ALL STATES TOTAL MINIMUM PREMIUM ALL STATES TOTAL DEPOSIT PREMIUM ALL STATES � $ $ CONTACT INFORMATION TYPE NAME OFFICE PHONE MOBILE PHONE E•MAIL INSPECTION ACCTNG CLAIMS INDIVIDUALS INCLUDED/EXCLUDED PARTNERS,OFFICERS,RELATIVES(Must bn employed by business operatlons)TO BE INCLUDED OR EXCLUDED(Remuneratlan/Payroll to be Included must ba part of rating Informallon section.) Excluslons in Mlssouri must meot the requlrements of Sectlon 267,090 RSMo. siATe LOC S NAME DATE OF BIRTH E�TITL�EI OW PER- DUTIES INC/EXC CLASS CODE REMUNERATIONIPAYROLL ACORD 130(2013/01) Page 1 of 4 O 1980-2013 ACORD CORPORATION, All rights reserved, The ACORD name and logo are registered marks of ACORD STATE RATING SHEET# OF SHEETS AGENCY CUSTOMER ID: � STATE RATING WORKSHEET ' FOR MULTIPLE STATES,ATTACH AN ADDITIONAL PAGE 2 OF THIS FORM RATING INFORMATION-STATE: DESCR #EMPLOYEES ESTIMATEDANNUAL ESTIMATED LOC It CLASS CODE CODE CATEGORIES,DUTIES,CLASSIFICA710NS FULL PART SIC NAICS REMUNERATIONI RATE ANNUAL MANUAI. TIME TIME PAYROLL PREMIUM I � � � PREMIUM STATE: FACTOR FACTORED PREMIUM FACTOR FACTORED PREMIUM TOTAL N/A $ $ INCREASED LIMITS $ SCHEDULE RATING` $ DEDUCTIBLE" $ CCPAP $ $ STANDARD PREMIUM $ EXPERIENCE OR MERIT MODIFICATION $ PREMIUM DISCOUNT $ $ EXPENSE CONSTANT N/A $ ASSIGNEDRISKSURCHARGE' $ TAXES/ASSESSMENTS` N/A $ ARAP' $ $ ' N/A in Wisconsln TOTAL ESTIMATED ANNUAL PREMIUM MINIMUM PREMIUM DEPOSIT PREMIUM $ $ $ REMARKS ACORD 101,Additional Remarks Schedule,may be attached if more space is required) ACORD 130(2013/01) Page 2 of 4 s °' AGENCY CUSTOMER ID: �RIOR CARRIER INFORMATION/LOSS HISTORY PROVIDE INFORMATION FOR THE PAST 5 YEARS AND USE THE REMARKS SECTION FOR LOSS DETAILS LOSS RUN ATTACHED YEAR CARRIER&POLICY NUMBER ANNUAL PREM�UM MOD #CLAIMS AMOUNT PAItl RESERVE C0: POL#: C0: POL#: C0: POL#: CO: POL#: C0: POL#: NATURE OF BUSINESS/DESCRIPTION OF OPERATIONS , GIVE COMMENTS AND DESCRIPTIONS OF BUSINESS,OPERATIONS AND PRODUCTS:MANUFACTURING•RAW MATERIALS,PROCESSES,PRODUCT,EQUIPMENT;CONTRACTOR-TYPE ' OF WORK,SUB•CONTRACTS;MERCANTILE•MERCHANDISE,CUSTOMERS,DELIVERIES;SERVICE-TYPE,LOCATION;FARM-ACREAGE,ANIMALS,MACHINERY,SUB-CONTRACTS. !, GENERAL INFORMATION EXPLAIN ALI."YES"RESPONSES Y I N 1. DOES APPLICANT OWN,OPERATE OR LEASE AIRCRAFT/WATERCRAFT? 2. DO/HAVE PAST,PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D)STORING,TREATING,DISCHARGING,APPLYING,DISPOSING,OR TRANSPORTING OF HAZARDOUS MATERIAL?(e.g.landfllls,wastes,fuel tanks,etc) 3. ANY WORK PERFORMED UNDERGROUND OR ABOVE 15 FEET? 4. ANY WORK PERFORMED ON BARGES,VESSELS,DOCKS,BRIDGE OVER WATFR? 5. IS APPLICANT ENGAGED IN ANY OTHER TYPE OF BUSINESS7 6. ARE SUB-CONTRACTORS USED7(If"YES",give%of work subcontracted) 7. ANY WORK SUBLET WITHOUT CERTIFICATES OF INSURANCE7 (If"YES",payroll for this work must be included In the State Rating Worksheet on Page 2) 8. IS A WRITTEN SAFETY PROGR,4M IN OPERATION7 9. ANY GROUP TRANSPORTATION PROVIDED? 10. ANY EMPLOYEES UNDER 16 OR OVER 60 YEARS OF AGE? 11. ANY SEASONAL EMPLOYEES? 12. IS THERE ANY VOLUNTEER OR DONATED LABOR7 (If"YES",please specify) 13. ANY EMPLOYEES WITH PHYSICAL HANDICAPS? 14. DO EMPLOYEES TRAVEL OUT OF STATE? (If"YES",indicate state(s)of travel and frequency) 15. ARE ATHLETIC TEAMS SPONSORED? ACORD 130(2013/01) Page 3 of 4 � AGENCY CUSTOMER ID: � � � GENERAL INFORMATION continued EXPLAIN ALL"YES"RESPONSES Y I N � 16. ARE PHYSICALS REQUIRED AFTER OFFERS OF EMPLOYMENT ARE MADE? 17. ANY OTHER INSURANCE WITH THIS INSURER? 18, ANY PRIOR COVERAGE DECLINED/CANCELLED/NON-RENEWED IN THE LAST THREE(3)YEARS?(Missouri Applicants-Do not answer this question) 19. ARE EMPLOYEE HEALTH PLANS PROVIDED7 20. DO ANY EMPLOYEES PERFORM WORK FOR OTHER BUSINESSES OR SUBSIDIARIES? 21. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? 22. DO ANY EMPLOYEES PREDOMINANTLY WORK AT HOME? If"YES",#of Employees: 23. ANY TAX LIENS OR BANKRUPTCY WITHIN THE LAST FIVE(5)YEARS7 (If"YES",please specify) 24. ANY UNDISPUTED AND UNPAID WORKERS COMPENSATION PREMIUM DUE FROM YOU OR ANY COMMONLY MANAGED OR OWNED ENTERPRISES? IF YES,EXPLAIN INCLUDING ENTITY NAME(S)AND POLICY NUMBER(S). SIGNATURE Copy of the Notice of information Practices(Privacy)has been given to the applicant.(Not required In all states;contact your agent or broker for your state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDNIENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRO PARTIES WITHOUT YOUR AUTHORIZATION. CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE. YOU MAY HAVE THE RIGHT TO � REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES.YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE.THESE RIGHTS MAY BE LIMITED IN SOME STATES,PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable In AZ,CA,DE,KS,MA,MN,ND,NY,OR,VA,or WV. Speciflc ACORD 38s are avaliable for applicants In these states.) �AppUcant's Initlals): Any person who knowingiy and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals,for the purpose of misleading,information concerning any fact material thereto commits a fraudulent insurance act,which is a crime and subJects that person to criminal and civil penalties (In Oregon, the aforementioned actions may constitute a fraudulent insurance act which may be a crime and may subJect the person to penalties). (In New York, the civil penalty is not to exceed five thousand dollars($5,000)and the stated value of the claim for each such violation). (Not applicable in AL,AR,AZ,CO,DC,FL,KS,LA,ME,MD,MN,NM,OK,PR,RI,TN,VA,VT,WA and WV). Applicabie in AL,AR,AZ,DC,LA,MD,NM,RI and WV: Any person who knowingly(or willfully in MD)presents a false or fraudulent claim for payment of a loss or beneFlt or who knowingly(or willfully in MD)presents false information in an application for insurance is guilty of a crime and may be subject to fines or confinement in prison. Applicable in Colorado: It is unlawful to knowingly provide false,incomplete,or misieading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company, Penallies may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete,or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the department of regulatory agencies. Applicabie in Florida and Oklahoma: Any person who knowingly and with intent to injure,defraud, or deceive any insurer files a statement of claim or an application containing any false,incomplete,or misleading information is guilty of a felony(In FL,a person is guilty of a felony of the third degree). Applicable in Kansas: Any person who, knowingly and with intent to defraud;presents,causes to be presented or prepares with knowiedge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of,or in support of,an application for the issuance of,or the rating of an insurance policy for personal or commerciai insurance,or a claim for payment or other benefit pursuant to an insurance polfcy for commercfal or personai insurance which such person knows to contain materially false information concerning any,fact material thereto; or conceals,for the purpose of misleading,information concerning any fact material thereto commits a fraudulent insurance act, Applicable in Maine,Tennessee,Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment,fines or a denial of insurance beneflts. Applicable in Puerto Rico: Any person who knowingly and with the intention of defrauding presents false information in an insurance application, or presents,helps,or causes the presentation of a fraudulent claim for the payment of a loss or any other benefit,or presents more than one claim for the same damage or loss,shall incur a felony and, upon conviction,shall be sanctioned for each violation by a fine of not less than five thousand dollars($5,000)and not more than ten thousand dollars($10,000), or a fixed term of imprisonment for three(3)years, or both penalties. Shouid aggravating circumstances be present, the penalty thus established may be increased to a maximum of five (5) years, if extenuating circumstances are present, it may be reduced to a mfnimum of two(2)years. Applicable in Utah: Any person who knowingly presents false or fraudulent underwriting information,files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and ma be sub'ect to fines and confinement in state rison. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE,CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. APPLICANT'S SIGNATURE(Must be Officer,Owner or Partner) DATE PRODUCER'S SIGNATURE NATIONAL PRODUCER NUMBER ACORD 130(2013/01) Page 4 of 4