HomeMy WebLinkAbout2021 Richard MacCutcheon Oath, Cert & BondCrime Certificate Holder Declaration Master Coverage Document Number: CR 00 26 11 15 Insurer: Fidelity and Deposit Company of Maryland Certificate Number: POL-0004683 Coverage Period: 1/1/2021 to EOD 12/31/2021 Named Member:Broker of Record: Siena Lake Metropolitan District c/o Marchetti & Weaver LLC 28 Second Street, Suite 213 Edwards, CO 81632 Covered ERISA Plan: Covered Designated Agent(s): Coverage Limits: Public Employee Dishonesty Coverage:$5,000 Limit is Per Loss Faithful Performance of Duty Officers, Directors, and Trustees Welfare and Pension Plan ERISA Compliance if Covered Plan is shown Volunteer Workers as Employees Forgery or Alteration Coverage:$5,000 Theft, Disappearance, and Destruction Coverage:$5,000 Inside Premises Outside Premises Computer and Funds Transfer Fraud Coverage:$5,000 Debit, Credit or Charge Card Forgery Coverage:$5,000 Money Orders and Counterfeit Paper Currency Coverage:$5,000 Fraudulent Impersonation Coverage:$5,000 Crime Deductible:$100 Fraudulent Impersonation Deductible: 20% of Fraudulent Impersonation Limit Contribution: $135 Policy Forms: CR 00261115 Government Crime Policy (Discovery Form) CR 25081010 Include Specified Non-Compensated Officers as Employees CR 25091010 Include Volunteer Workers as Employees CR 25190813 Add Faithful Performance of Duty Coverage for Government Employees CR 25121010 Include Treasurers or Tax Collectors as Employees CR 02151010 Colorado Changes CR 25201010 Debit, Credit or Charge Card Forgery CR 25021010 Include Designated Agents as Employees, when scheduled CR 04171115 Fraudulent Impersonation This Certificate Holder Declaration is made and is mutually accepted by the CSD Pool and the Named Member subject to all terms which are made a part of the Master Crime Policy. This Certificate represents only a brief summary of coverages. Please refer to the Master Policy Document for actual coverage, terms, conditions, and exclusions. Countersigned by: Authorized Representative