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HomeMy WebLinkAbout374454 ARTHUR J GALLAGHER RISK MGT SERVICES - CONTRACT - RFP - P1158 INSURANCEStates Self -Insurers Amended and Restated Trust Agreement Adopted November 1, 2000 Page 9 of 9 SIGNATURE PAGE Attaching To And Forming Part Of The STATES SELF -INSURERS TRUST AGREEMENT IN WITNESS of its acceptance of membership in the States Self -Insurers Trust (the "Trust") and commitment to the terms of the Amended and Restated States Self -Insurers Trust Agreement (the "Agreement") dated November 1, 2000 and any duly authorized amendments thereto, if any, each party to the Agreement (the "Member") has caused this Signature Page to be executed by the Member's duly authorized officers or representatives. SIGNED IN t. i2 f L O C 4Tiil 3 CoY/C0=,STATE This L Day Of / t4L/ .200 MEMBERENTITY'SNAME: (' NOFI-ottx- C©(LUnSy vD( �Oce4vt*�OQi�1 Ij�ypQ,zp t -ta�a� MEMBER ENTITY'S ADDRESS: AUTHORIZED SIGNATURE: I M� (Attach Sea], if applicable) TYPED NAME OF SIGNA 0�JActite V N 6i c L SIGNATURE OF WITNESS: � // TYPED NAME OF WITNESS: Z v ej? NAME OF MEMBER ENTITY'S AUTHORIZED REPRESENTATIVE TO THE TRUST: G-A(N <-E ,S ACCEPTEDBY: SIGNATURE ON BEHALF OF STATES SELF -INSURERS TRUST BY: Robert W. Esenberg, ARM ITS: President & CEO DATE: C®f POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE You are hereby notified that under the'rerrorism Risk Insurance Act, as amended, (the "Act"), that you have a right to purchase insurance coverage for losses arising out of acts of terrorism,os defined in Section 101(l) ojthe.icl: The tern "act of terrorism" means any act that is certified by the Secretary of Treasury - in concurrence with the Secretary of State and the Attorney General ofthe 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 an air carrier or vessel or the premises of a United States mission; and to have been committed by an individual or individuals as pan 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 coercian. Coverage under your X New or —RENEWAL policy maybe affected as follows: YOU SHOULD KNOW THATWHERE COVERAGE IS PROVIDED BY THIS POLICY FOR LOSSES RESULTING FROM CERTIFIED ACTS OF TERRORISM, SUCH LOSSES MAY BE PARTIALLY REIMBURSED BY THE UNITED SI'A'I'ES 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 EVF,N'1'S. UNDER THE FORMULA, TIIE UNI"1"ED STATES GOVERNMENT GENERALLY REIMBURSES 85%OF COVERED TERRORISM LOSSES EXCEEDING'IHE S1'A'1'U'I'ORILY ESTABLISHED DEDUCTIBLE PAID BY Tl IE INSURANCE COMPANY PROVIDING THE COVERAGE, THE PREMIUM CHARGED FORTHIS COVERAGE IS PROVIDED BELOW AND DOES NO'r INCLUDE ANY CHARGES FOR THE PORTION OF LOSS THAT MAY BE COVERED BY THE FEDERAL GOVERNMENT UNDERTHE ACT. YOU SHOULD ALSO KNOW THAT THE ACT, CONTAINS A $100 BILLION CAP THAT LIMITS U.S. GOVERNMENT REIMBURSEMENT AS WELL AS INSURER'S LIABILITY FOR LOSSES RESUTA ING FROM CERTIFIED ACTS OF TERRORISM WHEN THE AMOUNT 017 SUCH LOSSES IN ANYONE CALENDAR YEAR EXCEEDS $100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS 17XCEED SI00 BILLION, YOUR COVERAGE MAY BE REDUCED. Acceptance or Rejection ofTerrorism Insurance Coverage I hereby elect to purchase coverage, subject to the limitations of the Act, for acts of terrorism, as defined in the Act , fora premium of 54,961 I hereby decline coverage for terrorism. I understand that I will have no coverage for losses resulting from acts of terrorism. City of Ft. Collins AoulicanUNamed Insured By. An oriz Representative's Summure � 2Daut 8 c��( States RRG Insurance Company Authorized Representatives Title SEL3017500 Policy Number Please indicate your choice above, sign where indicated, and return the original form to us at the address below no later than We recommend that you keep a copy of this notice for your records. States RRG c/o Berkley Risk Administrators Company 222 S Ninth St Ste 1300 Minneapolis, MN 55402-3332