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HomeMy WebLinkAboutC22-025 Gallagher Core360 Eagle County, Colorado 58 Client Authorization to Bind Coverage After careful consideration of Gallagher's proposal dated 1/1/2022, we accept the following coverage(s). Please check the desired coverage(s) and note any coverage amendments below: COVERAGE/CARRIER ☐ Accept ☐ Reject Public Entity Liability Program Travelers Indemnity Company ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Automobile Charter Oak Fire Insurance Company ☐ Accept ☐ Reject Excess Liability Travelers Property Casualty Co of America ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Property Zurich American Insurance Company ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Network Security and Privacy Liability ☐ Accept ☐ Reject ☐ Accept ☐ Reject ☐ Accept ☐ Reject ☐ Accept ☐ Reject Chubb – Limit: $1M, Retention: $50K, Premium: $50,730 Cowbell – Limit: $2M, Deductible: $100K, Premium: Cowbell – Limit: $3M, Deductible: $100K, Premium: Cowbell – Limit: $5M, Deductible: $100K, Premium: ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Crime ☐ Option # 1 Travelers Casualty and Surety Co of America - Limit: $1M, Retention: $25K, Premium: $6,380 ☐ Option # 2 Travelers Casualty and Surety Co of America - Limit: $2M, Retention: $25K, Premium: $8,710 ☐ Option # 3 Travelers Casualty and Surety Co of America - Limit: $3M, Retention: $25K, Premium: $11,740 ☐ Option # 4 Travelers Casualty and Surety Co of America - Limit: $5M, Retention: $50K, Premium: $14,360.00 ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Accidental Death and Dismemberment Arch Insurance Company ☐ Accept ☐ Reject TRIA x x x x x x x x x x x x x x x DocuSign Envelope ID: E05974E0-6214-4AC4-8346-45A8506D1251 Eagle County, Colorado 59 COVERAGE/CARRIER ☐ Accept ☐ Reject Workers Compensation ☐ Option # 1 ☐ Option # 2 ☐ Option # 3 ☐ Option # 4 ☐ Option # 5 Pinnacol Assurance Company - $0 Deductible Pinnacol Assurance Company - $5K Deductible Pinnacol Assurance Company - $10K Deductible Pinnacol Assurance Company - $15.5K Deductible Pinnacol Assurance Company - $18.5K Deductible TRIA Cannot Be Rejected ☐ Accept ☐ Reject Workers' Compensation - CT, OK Pinnacol Assurance Company TRIA Cannot Be Rejected The above coverage may not necessarily represent the entirety of available insurance products. If you are interested in pursuing additional coverages other than those addressed in the coverage considerations included in this proposal, please list below: _____________________________________________________________________________________________ Producer/ Insured Coverage Amendments and Notes: Exposures and Values We confirm the payroll, values, schedules, and other data contained in the proposal, and submitted to the underwriters, are compiled from information provided by you and we acknowledge it is our responsibility to see that such information is updated and maintained accurately. For renewal policies, if no updates were provided to Gallagher, the values, exposures and operations used were based on the expiring policies. Gallagher has established security controls to protect Client confidential information from unauthorized use or disclosure. For additional information, please review Gallagher’s Privacy Policy located at https://www.ajg.com/privacy-policy/. x x x DocuSign Envelope ID: E05974E0-6214-4AC4-8346-45A8506D1251 Eagle County, Colorado 60 I have read, understand and agree that the above information is correct and has been disclosed to us prior to authorizing Gallagher to bind coverage and/or provide services to us. By: _______________________________________________________________________ Print Name (Specify Title) _______________________________________________________________________ Company _______________________________________________________________________ Signature Date: _______________________________________________________________________ DocuSign Envelope ID: E05974E0-6214-4AC4-8346-45A8506D1251 12/21/2021 Chair, Board of County Commissione Eagle County Government Matt Scherr