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12.20.21
AGENDA Special City Council Meeting Monday, December 20, 2021 Lorraine H. Morton Civic Center 6:00 PM Those wishing to make public comments for this City Council meeting may submit written comments in advance or sign up to provide public comment by phone or video during the meeting by completing the City Clerk's Office's online form at www.cityofevanston.org/government/city-clerk/public-comment-sign-up or by calling/texting 847-448-4311. Community members may watch the City Council meeting online at www.cityofevanston.org/channel16 or on Cable Channel 16 Page (I) ROLL CALL - COUNCILMEMBER SUFFREDIN (II) MAYOR PUBLIC ANNOUNCEMENTS AND PROCLAMATIONS (III) CITY MANAGER PUBLIC ANNOUNCEMENTS C1. What Works Cities Silver Designation Award (IV) COMMUNICATIONS: CITY CLERK (V) PUBLIC COMMENT Page 1 of 152 Members of the public are welcome to speak at City Council meetings. As part of the Council agenda, a period for public comments shall be offered at the commencement of each regular Council meeting. Public comments will be noted in the City Council Minutes and become part of the official record. Those wishing to speak should sign their name and the agenda item or non -agenda topic to be addressed on a designated participation sheet. If there are five or fewer speakers, fifteen minutes shall be provided for Public Comment. If there are more than five speakers, a period of forty-five minutes shall be provided for all comment, and no individual shall speak longer than three minutes. The Mayor will allocate time among the speakers to ensure that Public Comment does not exceed forty-five minutes. The business of the City Council shall commence forty-five minutes after the beginning of Public Comment. Aldermen do not respond during Public Comment. Public Comment is intended to foster dialogue in a respectful and civil manner. Public comments are requested to be made with these guidelines in mind. (VI) SPECIAL ORDERS OF BUSINESS SP1. Purchase of Insurance/Renewals - Property, Excess Liability & Excess Worker's Compensation for Fiscal Year 2022 Staff Recommends Approval to Purchase Insurance Policies for Fiscal Year 2022 Insurance Fund: 605.99.7800.62615 Workers Comp: 605.99.7800.66044 For Action Purchase of Insurance/Renewals - Property, Excess Liability & Excess Worker's Compensation for Fiscal Year 2022 - Attachment - Pdf 4 - 147 SP2. Discussion Regarding Additional Funding to Support Youth Initiatives to Address Youth Violence City staff recommends City Council discuss the expansion of the “My City, Your City, Our City '' Initiative to address youth and families' violence prevention strategies and families impacted by violence. The estimated cost of the program expansion is $867,500. Suspension of City Council Rule 16.3 is required for discussion of the item For Discussion Discussion Regarding Additional Funding for Youth Programming to Address Youth Violence - Attachment - Pdf 148 - 152 (VII) CALL OF THE WARDS Page 2 of 152 (Aldermen shall be called upon by the Mayor to announce or provide information about any Ward or City matter which an Alderman desires to bring before the Council.) {Council Rule 2.1(10)} (VIII) UPCOMING ALDERMANIC COMMITTEE MEETINGS DATE TIME BOARD/COMMITTEE/COMMISSION 12/22/21 2:30 PM Design and Project Review Committee - CANCELED 12/29/21 2:30 PM Design and Project Review Committee - CANCELED (IX) ADJOURNMENT Page 3 of 152 Memorandum To: Honorable Mayor and Members of the City Council From: Hitesh Desai, Chief Financial Officer Subject: Purchase of Insurance/Renewals - Property, Excess Liability & Excess Worker's Compensation for Fiscal Year 2022 Date: December 20, 2021 Recommended Action: Staff Recommends Approval to Purchase Insurance Policies for Fiscal Year 2022 Funding Source: Insurance Fund: 605.99.7800.62615 Workers Comp: 605.99.7800.66044 Council Action: For Action Summary: City staff recommends approval to purchase the outlined insurance policies for Fiscal Year 2022 at a total cost of $1,290,146. This includes quote of $1,103,897 towards General Liability Insurance package (Program 2 Package from Safety National) as outlined in the Gallag her proposal pages 66-67. This also includes a quote of $186,249 from The Owens Group towards Crime and Excess worker’s Compensation insurance. The policies will renew all insurance coverage for the City of Evanston for Fiscal Year 2022. Attachments: 2022 insurance renewal memo revised City of Evanston 112022 - 12.3.21 Draft WC Owens group P&C Proposal 20-21 SP1.Page 4 of 152 To: Honorable Mayor and Members of the City Council Administration & Public Works Committee From: Nicholas Cummings, Corporation Counsel Hitesh Desai, Chief Financial Officer and Treasurer Subject: Purchase of Insurance/Renewals – Property, Excess Liability & Excess Worker’s Compensation for Fiscal Year 2022 Date: December 11, 2021 Recommended Action: City staff recommends approval to purchase the outlined insurance policies for Fiscal Year 2022 at a total cost of $1,290,146. This includes quote of $1,103,897 towards General Liability Insurance package (Program 2 Package from Safety National) as outlined in the Gallagher proposal pages 66-67. This also includes a quote of $186,249 from The Owens Group towards Crime and Excess worker’s Compensation insurance. The policies will renew all insurance coverage for the City of Evanston for Fiscal Year 2022. Livability Benefits: Innovation & Process: Support local government best practices and processes. Funding Source: Insurance Fund: 605.99.7800.62615 - $1,103,897 and Workers Comp 605.99.7800.66044 - $186,249 Summary: The City is exposed to various risks of loss related to torts, theft, asset damage, errors and omissions, and natural disasters. Current insurance policies expire on December 31, 2021. The City’s brokers of record, Arthur J. Gallagher and The Owens Group, took all insurance through underwriting and market. Below is a summary of the total premium costs for each policy. Arthur J. Gallagher is the City’s insurance brokerage service provider for property, casualty, and cyber and Owens Group is the broker for workers compensation. Overall Premiums are going up by 23% reflecting lack of capacity, carriers leaving public sector insurance arena, large jury awards in Cook County, increase in police liability claims, civil unrest in metro areas etc. Memorandum Page 2 of 144 SP1.Page 5 of 152 a. General liability insurance The City currently maintains a self-insured retention (SIR) of $1.25 million (except Cyber with $1M) with an additional layer of excess insurance totaling $15 million. For purposes of prudent risk management, it is advisable to maintain the current retention level and $15M excess layer of coverage. b. Property insurance The City of Evanston maintains commercial all-risk insurance to cover damage to City facilities and contents within the facilities, including business interruption and loss of rents. The coverage is subject to a deductible of $50,000 for each loss and each location. City of Evanston Premium Comparison Broker : Gallagher 2021 2022 % Diff *Pollution - Beazley 35,598$ 38,647$ 9% *Pollution is a 3 year Term Liability/APD Package & Excess - Safety National 210,017$ 314,013$ 49.5% 5M X 5M Excess Liability - Old Republic 206,775$ 256,866$ 24.2% 5M X 10M Excess Liability - Arch 121,442$ 145,005$ 19.4% Property - Affiliated FM 244,938$ 264,525$ 8.0% Cyber - Obsidian 21,494$ 52,341$ 143.5% Service Fee 32,500$ 32,500$ 0.0% Total 872,764$ 1,103,897$ 26.48% Broker : The Owens Group Government Crime 6,812$ 7,970$ 17.00% Excess Worker's Compensation 171,634$ 178,279$ 3.87% 178,446$ 186,249$ 4.37% GRAND TOTAL 1,051,210$ 1,290,146$ 23% Page 3 of 144 SP1.Page 6 of 152 c. Environmental In 2019, Staff recommended adding a policy for environmental coverage. The Service Center has 8 underground gas tanks that support fleet vehicles. From a risk management perspective, it is prudent to protect the City from this potential source of liability. Current insurance policy is for 3 years which runs out at the end of 2021. The new policy will cover three-year term of 2022-2024. d. Other Insurance Policies The City also maintains insurance for excess worker’s compensation and, crime liability. The premium went up by 4.37%. Staff recommends award of the policies as set forth in the table. Legislative History: N/A ------------------------------------------------------------------------------------- Attachments: Insurance Rates proposal Gallagher Insurance Rates proposal The Owens Group Page 4 of 144 SP1.Page 7 of 152 ajg.com ©2018 Arthur J. Gallagher & Co. All rights reserved. Proposal of Insurance City of Evanston 2100 Ridge Avenue Evanston, IL 60201 Presented: December 2, 2021 Effective: January 1, 2022 Rich Stokluska, ARM Area Senior Executive Vice President Arthur J. Gallagher Risk Management Services, Inc. 2850 Golf Road Rolling Meadows, IL 60008 (630) 773-3800 Rich_Stokluska@ajg.com Page 5 of 144 SP1.Page 8 of 152 City of Evanston 2 Table of Contents Service Team ............................................................................................................................................................... 3 Service Commitment .............................................................................................................................................. 3 Program Structure ....................................................................................................................................................... 5 Named Insured ....................................................................................................................................................... 6 Market Review ........................................................................................................................................................ 7 Location Schedule .................................................................................................................................................. 9 Structure Graph .................................................................................................................................................... 13 Program Details .................................................................................................................................................... 14 Package - General Liability - Liberty Mutual Fire Insurance Company, (More) ............................................. 14 Package - Automobile - Liberty Mutual Fire Insurance Company, (More) ..................................................... 19 Package - Law Enforcement Liability - Liberty Mutual Fire Insurance Company, (More) .............................. 23 Package - E&O - Public Officials Liability - Liberty Mutual Fire Insurance Company, (More) ........................ 25 Package - Employment Practices Liability - Liberty Mutual Fire Insurance Company, (More) ...................... 27 Umbrella - $4M - Liberty Insurance Corporation ........................................................................................... 30 Package - General Liability - Safety Specialty Insurance Company, (More) ................................................. 34 Package - Public Officials Liability/Employment Practices Liability Coverage - Safety Specialty Insurance Company, (More) .......................................................................................................................................... 38 Package - Law Enforcement Liability Coverage - Safety Specialty Insurance Company, (More) .................. 40 Package - Excess Liability - Safety Specialty Insurance Company, (More) .................................................. 42 Package - Automobile - Safety Specialty Insurance Company, (More) ......................................................... 44 Excess Liability ($5M x Primary) - Old Republic Union Insurance Company ................................................ 47 Excess Liability ($5M x $10M) – Arch Specialty Insurance Company ........................................................... 50 Property - Affiliated FM Insurance Company ................................................................................................. 52 Cyber Liability - Obsidian Specialty Insurance Company .............................................................................. 57 Underground Storage Tank - Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) ....................................... 62 Premium Summary ............................................................................................................................................... 66 Payment Plans ..................................................................................................................................................... 69 Carrier Ratings and Admitted Status ....................................................................................................................... 70 Proposal Disclosures ................................................................................................................................................ 71 Proposal Disclosures ............................................................................................................................................ 72 Client Signature Requirements ................................................................................................................................ 74 Coverages for Consideration ................................................................................................................................ 75 Client Authorization to Bind Coverage .................................................................................................................. 76 Appendix .................................................................................................................................................................... 79 Bindable Quotations & Compensation Disclosure Schedule ................................................................................ 80 Binding Requirements .......................................................................................................................................... 82 Carrier Forms ....................................................................................................................................................... 84 Claims Reporting By Policy ................................................................................................................................ 135 CORE360™ Loss Control Flyer ......................................................................................................................... 136 Cyber Liability eRiskHub Features ..................................................................................................................... 137 Page 6 of 144 SP1.Page 9 of 152 City of Evanston 3 Service Team Rich Stokluska has primary service responsibility for your company. We operate using a team approach. Your Service Team consists of: NAME / TITLE PHONE EMAIL Rich Stokluska, ARM Area Senior Executive Vice President (630) 285-4012 Rich_Stokluska@ajg.com Catreena Maglio, CISR Client Service Manager II (630) 285-3485 Catreena_Maglio@ajg.com Brianna Riske Client Service Associate (630) 647-3035 Brianna_Riske@ajg.com Arthur J. Gallagher Risk Management Services, Inc. Main Office Phone Number: (630) 773-3800 Service Commitment Account Service At Arthur J. Gallagher & Co., our goal is to provide you with an exceptional insurance and risk management program delivered by a world class service organization. Gallagher is committed to partnering with our clients to ensure we consistently deliver the highest quality service possible. Renewals We use a standard Renewal Timeline and start early to make sure your needs are met and we are able to offer you the most comprehensive and competitively priced insurance program. At each renewal, we will meet with you to establish a renewal game plan, determine how many markets should be approached, discuss pricing in the insurance marketplace, and identify what specific needs must be addressed. We will then approach markets that we feel will offer the best alternatives. These alternatives will be presented at renewal as an option, even if we feel the incumbent program is strongest. We will demonstrate how we hav e created competition within the marketplace to ensure that you receive the best renewal terms. We make ourselves accountable by working with you to develop a written service schedule that meets your needs. You can track our service by referring to our written service commitment. Service becomes especially important as your type of organization continues to change and prosper. As a top national broker, we have access to over 150 insurance companies and wholesalers. This maximizes your insurance options in any given policy year situation. In addition, our integrity and influence in the marketplace have resulted in excellent relationships with our markets. These factors are especially important to consider as the insurance needs of your organizatio n become more complex and require more sophisticated solutions. Automobile Identification Cards ID cards will be issued upon binding of coverage. Phone Calls Phone calls will be returned within one working day of receipt. Certificates of Insurance Certificates of Insurance will be issued within one working day of request. Page 7 of 144 SP1.Page 10 of 152 City of Evanston 4 Page 8 of 144 SP1.Page 11 of 152 City of Evanston 5 Program Structure Program Structure Page 9 of 144 SP1.Page 12 of 152 City of Evanston 6 Named Insured Named Insured Schedule: Named Insured Line of Coverage City of Evanston All Lines of Coverage included in this proposal Note: Any entity not named in this proposal, may not be an insured entity. This may include affiliates, subsidiaries, LLC's, partnerships and joint ventures. Page 10 of 144 SP1.Page 13 of 152 City of Evanston 7 Market Review We approached the following carriers in an effort to provide the most comprehensive and cost effective insurance program. INSURANCE COMPANY LINE OF COVERAGE RESPONSE PREMIUM Liberty Mutual Fire Insurance Company LM Insurance Corporation Package Quoted $425,295.00 Safety Specialty Insurance Company Safety National Casualty Corporation Package Quoted $308,627.00** Old Republic Insurance Group Package Declined to Quote N/A The Travelers Companies, Inc. Package Declined to Quote N/A Intact Insurance Group Package Declined to Quote N/A W. R. Berkley Group Package Declined to Quote N/A Paragon Insurance Holdings, LLC Package Declined to Quote N/A Munich (PESLIC) Package Declined to Quote N/A Ambridge Partners LLC Package Declined to Quote N/A Euclid Insurance Services, Inc. Package Declined to Quote N/A Cincinnati Insurance Companies Package Declined to Quote N/A Genesis Insurance Company Package Declined to Quote N/A Chubb Group of Insurance Companies Package Declined to Quote N/A Old Republic Union Insurance Company Excess Liability ($5M x Primary) Recommended Quote $248,000.00** Arch Specialty Insurance Company Excess Liability ($5M x $10M) Recommended Quote $140,000.00** Liberty Insurance Corporation Umbrella - $4M Quoted $119,785.00 Affiliated FM Insurance Company Property Recommended Quote $264,525.00 Travelers Casualty and Surety Co of America Cyber Liability Unable to Quote until MFA in Place; however offered 30 day extension (1/31/22) $1,767.00* Obsidian Specialty Insurance Company Cyber Liability Quoted $49,605.00** CFC Insurance Company Cyber Liability Declined to Quote N/A Coalition Insurance Company Cyber Liability Declined to Quote N/A XL Insurance Company Cyber Liability Declined to Quote N/A At Bay Insurance Company Cyber Liability Declined to Quote N/A Page 11 of 144 SP1.Page 14 of 152 City of Evanston 8 INSURANCE COMPANY LINE OF COVERAGE RESPONSE PREMIUM Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) Underground Storage Tank Recommended Quote $37,340.00** Ironshore Specialty Insurance Co Underground Storage Tank Quoted $42,856.00** Hartford Financial Services Group Underground Storage Tank Indication (Written)*** $50,000.00 - $55,000.00 Markel Corporation Group Underground Storage Tank Indication (Written)*** $55,000.00 - $65,000.00 Aspen American Insurance Company Underground Storage Tank Indication (Written)*** $72,000.00 - $78,000.00 Ascot Insurance Company Underground Storage Tank No Response N/A Allianz Underground Storage Tank No Response N/A Great American Underground Storage Tank Declined to Quote N/A Chubb Underground Storage Tank Declined to Quote N/A Allied Underground Storage Tank Declined to Quote N/A Tokio Marine Underground Storage Tank Declined to Quote N/A *Travelers is unable to Quote 22/23 Cyber Renewal until MFA is in place; however they offered 30 day extension (1/31/22) for an AP of $1,767.00 **SLT Tax/Fees are not Included in above Pricing ***The premium indicated is an estimate provided by the market. The actual premium and acceptance of the coverage requested will be determined by the market after a thorough review of the completed application. Page 12 of 144 SP1.Page 15 of 152 City of EvanstonStatement of Values with COPE InformationPolicy Term; 2021‐2022Currency of Values: Reported in US DollarsValues as: 14‐Oct‐16Loc IDValuesIns Index# Rec CBI ID Address City St/Prv County Post Occupancy/ Description Real Property Personal Total Insured 1 64226.1 1 10351371454 Elmwood Ave. and 909 Lake St.EvanstonIL Cook 60201Police Headquarters/Fire Headquarters $ 11,703,120 $ 7,109,000 $ 18,812,120.00 2 64226.1 1 1035138702 Madison StreetEvanstonIL Cook 60202 Fire Station $ 1,287,520 $ 1,750,000 $ 3,037,520.00 3 64226.2 1 10351391105 Central StreetEvanstonIL Cook 60201 Fire Station $ 3,182,400 $ 1,428,000 $ 4,610,400.00 4 10351401817 Washington StreetEvanstonIL Cook 60202 Fire Station $ 406,640 $ 1,023,000 $ 1,429,640.00 5 64226.2 1 10351412830 Central StreetEvanstonIL Cook 60201 Fire Station $ 1,272,960 $ 1,496,000 $ 2,768,960.00 6 64226 2 1035142551 Lincoln StreetEvanstonIL Cook 60201 Utilities ‐ Water $ 5,140,080 $ 20,606,000 $ 25,746,080.00 7 64226 2 1035143555 Lincoln StreetEvanstonIL Cook 60201Water and Sewage Treatment Plant $ 3,245,840 $ 3,091,000 $ 6,336,840.00 8 64226 2 1035144577 Lincoln StreetEvanstonIL Cook 60201Water and Sewage Treatment Plant (Filtration) $ 23,804,560 $ 31,424,000 $ 67,987,560.00 9 64226 2 1035145531 Lincoln StreetEvanstonIL Cook 60201 Water ‐ Pumping Station $ 3,790,800 $ 258,000 $ 4,048,800.00 10 64226.2 1 10351461655 Foster EvanstonIL Cook 60602Community Center ‐ Fleetwood Jourdain $ 6,094,520 $ 4,772,339 $ 11,300,859.00 11 64223 1 10351472222 Oakton StreetEvanstonIL Cook 60202Vacant Warehouse ‐ Store recreation vehicles and boats $ 1,287,520 $ 774,000 $ 3,361,520.00 12 64224 2 10351481703 Orrington AvenueEvanstonIL Cook 60201 Public Library $ 28,697,760 $ 16,131,000 $ 46,713,760.00 13 10351492026 Central StreetEvanstonIL Cook 60201 Library $ 865,280 $ 859,000 $ 1,724,280.00 15 64224.8 1 10351512603 Sheridan RoadEvanstonIL Cook 60201Community Center ‐ Harley Clark ‐ Vacant $ 4,187,040 $ 936,000 $ 5,123,040.00 16 64220.2 1 10351521801 Main StreetEvanstonIL Cook 60202Recreation Center ‐ Ice Rink, Gymnasium, Library, Preschool, Community Center $ 48,141,803 $ 5,153,718 $ 55,209,521.00 Page 13 of 144 SP1.Page 16 of 152 17 64228.1 2 10351532100 Ridge AvenueEvanstonIL Cook 60201Civic Center ‐ Public and Private Office Building $ 23,804,560 $ 6,183,718 $ 29,988,278.00 18 782.62 1 1035154525 Church StreetEvanstonIL Cook 60201Automotive Sales and Service incl. Public/Private Parking $ 15,600,000 $ 1,010,000 $ 17,270,000.00 19 64220.4 2 1035155927 Noyes StreetEvanstonIL Cook 60201Community Center (Noyes Cultural Arts Center) $ 6,763,120 $ 884,718 $ 7,971,838.00 20 64226.5 2 10351562020 Asbury AvenueEvanstonIL Cook 60201Municipal Service Center ‐Equipment Storage, Tradesmen Shops, $ 19,476,080 $ 5,152,000 $ 24,628,080.00 21 10351571028 Central StreetEvanstonIL Cook 60201Community Center (Chandler) $ 1,171,040 $ 309,859 $ 2,133,899.00 22 64224.8 1 10351582601 Sheridan RoadEvanstonIL Cook 60201Municipal ‐ (Gross Point Light House) $ 2,843,360 $ 2,095,000 $ 4,938,360.00 23 10351592024 McCormick BoulevardEvanstonIL Cook 60201 Ecology Center $ 1,521,520 $ 369,859 $ 2,324,379.00 24 64220.4 1 10351601332 Emerson StreetEvanstonIL Cook 60201 Fire Station $ 2,458,560 $ 306,000 $ 2,764,560.00 25 64228.2 1 10351611800 Maple AvenueEvanstonIL Cook 60201Automotive Sales and Service incl. Public/Private Garages $ 36,400,000 $ 4,040,000 $ 46,040,000.00 26 420.02 1 1035162300 Dodge AvenueEvansto IL Cook 60202 Misc. ‐ Non $ 9,482,720 $ 1,779,718 $ 11,262,438.00 27 874.59 1 1035163821 Davis Street/1617 BensenEvanstonIL Cook 60201 Parking Structure $ 51,500,000 $ 500,000 $ 52,000,000.00 Parking Garage w/ Two Entry Points 28727‐729 Howard StreetEvanstonIL Cook 60602 Tenant Spaces ‐ 727 Fitness Studio (Hip Cricle) 729 Vacant $ 620,000 $ ‐ $ 620,000.00 29721‐723 HowardEvanstonIL Cook 60202Tenant Space ‐ Non‐profit Theater $ 1,385,469 $ ‐ $ 1,385,469.00 301823 ChurchEvanstonIL Cook 60201Community Center (Gibbs Morrison) $ 350,000 $ 50,000 $ 400,000.00 31633 Howard EvanstonIL Cook 60201Tenant Space ‐ Vacant ‐ formerly Café Coralie (storefront) $ 250,000 $ ‐ $ 250,000.00 1223 SimpsonEvanstonIL CookBoiler Building/Apartment on 2nd Floor2603 Sheridan RoadEvanstonIL CookCoach House ‐ Apartments2310 OaktonEvanstonIL CookAnimal Shelter $ ‐ Page 14 of 144 SP1.Page 17 of 152 2020 Asbury AvenueEvanstonIL Cook Salt Dome 1236 Chicago AveEvanston IL CookLot 60 Garage (ground level only)2627 Sheridan EvanstonIL CookDeering Shelter 2200 Oakton EvanstonIL CookJames Park Field House 2621 Sheridan EvanstonIL CookLighthouse 2535 Sheridan EvanstonIL CookFog House North 2535 Sheridan EvanstonIL CookFog House South 1600 Church EvanstonIL CookMason Park Field House 526 Grove EvanstonIL CookRaymond Park Shelter 1811 Sheridan EvanstonIL CookClark St Beach Building $ 859 1251 Lake Shore Drive EvanstonIL CookDempster Beach Building $ 1,718 1401 Sheridan EvanstonIL CookGreenwood Beach Building1111 Lake Shore EvanstonIL CookLee Street Beach Building1631 Sheridan EvanstonIL CookLagoon Beach Building 2621 Sheridan EvanstonIL CookLighthouse Beach Building525 Sheridan EvanstonIL CookSouth Blvd Beach Building Central/Hartrey EvanstonIL CookAlice K. Berg Bus ShelterCentral/McDaniel EvanstonIL CookAckerman Park Field HousePage 15 of 144 SP1.Page 18 of 152 Keeney/ Forest EvanstonIL CookBaker Park Field House Harrison/ Hastings EvanstonIL CookBent Park Field House Custer/Madison EvanstonIL CookEiden Park ShelterLincoln/RidgeEvanstonIL CookLeahy Park Field HouseCrain/ Oak StreetEvanstonIL CookLarimer Park Field House Emerson/McCormick EvanstonIL CookBeck Park Building and Restrooms Emerson/McCormick EvanstonIL CookMcCormick Meter Vault TOTAL316,734,272$ 119,491,929$ 462,188,201.00$ Page 16 of 144 SP1.Page 19 of 152 City of Evanston R:\CLNTDOCS\03\NonProfit\30908.docx Arthur J. Gallagher Risk Management Services,Inc. Program Structure – 1/1/2022 – 1/1/2023 $1,250,000 Retention $1,250,000 Retention $1,250,000 Retention $1,250,000 Retention $1,250,000 Retention $50,000 AOP Deductible $25,000 Retention Philadelphia $1M Occ./ $3MAgg. Eff. Annually May 25th General and Employee Benefits Liability Automobile Liability Law Enforcement Liability Public Officials Liability Employment Practices Liability Property Building &Business Personal Property Cyber Liability Special Events Liability Safety National Safety National $5M Occ./$5M Occ. $5M Agg. Safety National $5M Occ./ $5MAgg. Safety National $5M Occ./ $5MAgg. Safety National $5M Occ./ $5MAgg. Old Republic $5M Occ./ $5M Agg. Old Republic $5M Occ. Old Republic $5M Occ./ $5M Agg. Old Republic $5M Occ./ $5M Agg. Old Republic $5M Occ./ $5M Agg. Arch Specialty Insurance Company $5M Excess Limit Shared Layer Affiliated Ins.Co. $464,000,000 Loss Limit Travelers $1M Agg.Page 17 of 144SP1.Page 20 of 152 City of Evanston 14 Program Details Package - General Liability - Liberty Mutual Fire Insurance Company, (More) Coverage: Package - General Liability Carrier: Liberty Mutual Fire Insurance Company LM Insurance Corporation Policy Period: 1/1/2022 to 1/1/2023 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE General Liability Occurrence Not Applicable Not Applicable Employee Benefits Liability Claims Made 1/1/2022 Not Applicable Sexual Misconduct Liability Claims Made Not Applicable Participation Schedule: CARRIER Liberty Mutual Fire Insurance Company LM Insurance Corporation Coverage: DESCRIPTION AMOUNT General Aggregate Limit $2,000,000 Products/ Completed Operations Limit $2,000,000 Personal and Advertising Injury Limit $1,000,000 Each Occurrence Limit $1,000,000 Employee Benefits Liability* $1,000,000 Employee Benefits Aggregate* $1,000,000 Sexual Misconduct Liability - Each Sexual Misconduct $1,000,000 Aggregate Sexual Misconduct $1,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Self-Insured Retention General Liability $1,250,000 Self-Insured Retention Employee Benefits Liability - Each Employee $1,250,000 Self-Insured Retention Sexual Misconduct Liability - Each Sexual Misconduct $1,250,000 Page 18 of 144 SP1.Page 21 of 152 City of Evanston 15 Claims Made Coverage: Should you elect to change carriers (if a new retroactive date is provided) or non-renew this policy, a supplemental extended reporting endorsement may be available subject to policy terms and conditions. You must request the extended reporting period in writing to the carrier within (60) days of the expiration date. The cost of this extended reporting period is 200% of the annual premium and is fully earned. The extended reporting period extends only to those claims made during the extended reporting period for wrongful acts that occurred prior to the expiration date and would have been covered by the policy. Claims must be reported to the carrier within (60) days of the end of the policy period. The extended reporting period does not increase the limits of liability and is subject to all policy terms, conditions and exclusions. Definition of Claim: DESCRIPTION Refer to attached policy form Incident or Claim Reporting Provision: DESCRIPTION Refer to attached policy form Run Off Provisions: DESCRIPTION PREMIUM AMOUNT PREMIUM DUE DATE LENGTH % OF EXPIRING PREMIUM Refer to attached policy form -- -- -- Endorsements include, but are not limited to: DESCRIPTION Additional Insured - Automatic Status When Required In Written Contract Or Agreement - CG 20 43 12 19 Common Policy Conditions - IL 00 17 11 98 Illinois Notice To Policyholders Regarding The Religious Freedom Protection And Civil Union Act - IL N 175 11 11 Advertisement Redefined - LC 29 08 10 11 Commercial General Liability Coverage Form - CG 00 01 04 13 Commercial General Liability Enhancement - LC 32 187 01 17 Employee Benefits Liability Coverage (CM/SIA) - LC 04 33 02 19 Governmental Subdivisions - CG 24 09 07 98 Non-Cumulation Of Liability (Same Occurrence) - LC 25 13 08 08 Personal And Advertising Injury - Occurrence Redefined - LC 29 06 08 08 Personal And Advertising Injury Redefined - Definition Of Publication - LC 29 04 08 08 Premium Responsibility - LC 99 36 02 13 Public Entity Immunity And Tort Cap Preservation Endorsement - LIL 90 09 05 17 Self-Insured Amount Allocated Loss Adjustment Expense Erodes the Self-Insured Amount - LC 24 49 11 18 Sexual Misconduct Liability Coverage (Claims-Made) Allocated Loss Adjustment Expense Erodes The Self-Insured Amount - LC 04 112 07 21 Waiver Of Transfer Of Rights Of Recovery Against Others To Us (Waiver Of Subrogation) – Automatic - CG 24 53 12 19 Commercial General Liability Declarations Occurrence Subject To Self-Insured Amount - LC 00 100 11 18 Declarations Extension Schedule - LCS 00 02 05 12 Page 19 of 144 SP1.Page 22 of 152 City of Evanston 16 Endorsements include, but are not limited to: DESCRIPTION Declarations Extension Schedule - Classification Descriptions - LCS 00 01 05 12 Declarations Extension Schedule - Miscellaneous Charges - LCS 00 03 05 12 Illinois Notice To Policyholders - SNI 12 01 07 18 Liberty Mutual Group California Privacy Notice - SNI 04 01 12 20 Policyholder Disclosure Terrorism Risk Insurance Act - SNI 90 02 01 20 Participating Provision - LIL 90 05 06 13 Illinois Changes - Cancellation And Nonrenewal - CG 02 00 01 18 Illinois Changes - Civil Union - IL 01 47 09 11 Illinois Changes-Defense Costs - IL 01 62 10 13 Inventory Coverage Forms/Parts, Endorsements, Enclosures - IC 00 42 07 09 Exclusions include, but are not limited to: COVERAGE TYPE DESCRIPTION General Liability Bodily Injury and Property Damage from pollutants - Absolute Exclusion General Liability Losses arising from the ownership maintenance or use of aircraft (including drones), autos, or watercraft, with some minor exceptions including certain contractual obligations General Liability Employment Related Practices Exclusion General Liability Liquor Liability Exclusion General Liability Aircraft Products Exclusion General Liability Professional Liability Exclusion General Liability Real Property in Your Care, Custody, and Control Exclusion General Liability Absolute Asbestos Exclusion General Liability Absolute Lead Exclusion General Liability War and Nuclear Hazard General Liability Mold / Fungus EBL Dishonest, fraudulent, criminal or malicious act or omission EBL Bodily Injury or Property Damage or Personal Injury EBL Failure of performance of contract EBL Failure of any investment to perform as represented by you EBL Failure to comply with mandatory provisions of any law concerning Workers' Compensation, unemployment insurance, social security or disability benefits EBL Wrongful termination of an employee EBL Coercion, demotion, reassignment, discipline or harassment of an employee EBL Discrimination against an employee General Liability Coverage C - Medical Payments Exclusion - LC 21 152 11 18 General Liability Abuse Exclusion - LC 21 173 07 21 Page 20 of 144 SP1.Page 23 of 152 City of Evanston 17 Exclusions include, but are not limited to: COVERAGE TYPE DESCRIPTION General Liability Access Or Disclosure Of Confidential Or Personal Information With Limited Bodily Injury Exception - CG 21 06 05 14 General Liability Asbestos Exclusion - LC 21 01 06 05 General Liability Communicable Disease Exclusion - CG 21 32 05 09 General Liability Discrimination Exclusion - LC 21 04 06 05 General Liability Exclusion - Law Enforcement Professional Liability - LC 21 110 08 18 General Liability Employment - Related Practices Exclusion - CG 21 47 12 07 General Liability Exclusion - Failure To Supply - CG 22 50 04 13 General Liability Exclusion - Law Enforcement Activities - CG 22 51 07 98 General Liability Exclusion - Riot, Civil Commotion Or Mob Action - Governmental Subdivisions - CG 22 31 07 98 General Liability Exclusion - Services Furnished By Health Care Providers - CG 22 44 04 13 General Liability Fungi or Bacteria Exclusion (Legionella Bacterium Excluded) - LC 21 91 09 12 General Liability Lead Exclusion - LC 21 06 06 07 General Liability MTBE Exclusion - LC 21 65 08 07 General Liability Nuclear Energy Liability Exclusion Endorsement (Broad) - IL 00 21 09 08 General Liability Polychlorinated Biphenyls (PCBs) Exclusion - LC 21 38 06 07 General Liability Silica Exclusion - LC 21 02 06 05 General Liability Total Pollution Exclusion With A Hostile Fire Exception - CG 21 55 09 99 General Liability Alaska Exclusion Of Punitive Damages Related To A Certified Act Of Terrorism - CG 26 93 01 15 General Liability Arkansas Exclusion Of Punitive Damages Related To A Certified Act Of Terrorism - CG 26 86 01 15 General Liability Cap On Losses From Certified Acts Of Terrorism - CG 21 70 01 15 General Liability Exclusion Of Punitive Damages Related To A Certified Act Of Terrorism - CG 21 76 01 15 Binding Requirements: DESCRIPTION Governmental Entity Supplemental Application/Confirming receipt of the corrected proposal and Government Supp with COVID Questionnaire. If the Named Insured’s signature is required for any of the policies or coverages included in this proposal, they must be signed by the proposed Named Insured and returned to us by the effective date of the policy, or within 30 days of receipt, whichever is later. Prior approval of TPA and Self-Administration. Please forward a contact name at the insured’s and the TPA so that an interview or visit may be arranged. (Sent to Carrier on 11.24.21) A Liberty Mutual Supplemental Application, with the General Information and all other applicable sections c ompleted, signed by the Insured. Signed TRIA forms (if rejecting). Insured Contact (Name, Email, Phone) for risk control, premium/loss billing, claims, as applicable. Favorable results or compliance with recommendations from any risk control survey which may be provided to the insured during the policy year. Page 21 of 144 SP1.Page 24 of 152 City of Evanston 18 Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: LM Insurance Corporation Total Premium includes the TRIA Premium of $6,165 Premium $121,276.00 ESTIMATED PROGRAM COST $121,276.00 Deposit Premium - $121,276.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) INCLUDED Page 22 of 144 SP1.Page 25 of 152 City of Evanston 19 Package - Automobile - Liberty Mutual Fire Insurance Company, (More) Coverage: Package - Automobile Carrier: Liberty Mutual Fire Insurance Company LM Insurance Corporation Policy Period: 1/1/2022 to 1/1/2023 Participation Schedule: CARRIER Liberty Mutual Fire Insurance Company LM Insurance Corporation Coverage: DESCRIPTION AMOUNT COVERED AUTOS Liability $1,000,000 1 Uninsured Motorist $1,000,000 2, 10 Underinsured Motorist $1,000,000 2, 10 Hired Liability $1,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Self-Insured Retention Liability $1,250,000 Self-Insured Retention Uninsured Motorist $1,250,000 Self-Insured Retention Underinsured Motorist $1,250,000 Self-Insured Retention Hired Liability $1,250,000 Covered Autos: SYMBOL SYMBOL NAME DESCRIPTION OF COVERED AUTO DESIGNATION SYMBOLS 1 Any Auto 2 Owned Autos Only Only those autos you own (and for Liability Coverage any trailers you don't own while attached to power units you own). This includes those autos you acquire ownership of after the policy begins. 3 Owned Private Passenger Autos Only Only the private passenger autos you own. This includes those private passenger autos you acquire ownership of after the policy begins. 4 Owned Autos Other Than Private Passenger Autos Only Only those autos you own that are not of the private passenger type (and for Liability Coverage any trailers you don't own while attached to power units you own). This includes those autos not of the private passenger type you acquire ownership of after the policy begins. 5 Owned Autos Subject To No-Fault Only those autos you own that are required to have No-Fault benefits in the state where they are licensed or principally garaged. This includes those autos you acquire ownership of after the policy begins provided they are required to have No- Fault benefits in the state where they are licensed or principally garaged. Page 23 of 144 SP1.Page 26 of 152 City of Evanston 20 Covered Autos: SYMBOL SYMBOL NAME DESCRIPTION OF COVERED AUTO DESIGNATION SYMBOLS 6 Owned Autos Subject To A Compulsory Uninsured Motorists Law Only those autos you own that because of the law in the state where they are licensed or principally garaged are required to have and cannot reject Uninsured Motorists Coverage. This includes those autos you acquire ownership of after the policy begins provided they are subject to the same state uninsured motorists’ requirement. 7 Specifically Described Autos Only those autos described in Item Three of the Declarations for which a premium charge is shown (and for Liability Coverage any trailers you don't own while attached to any power unit described in Item Three). 8 Hired Autos Only Only those autos you lease, hire, rent or borrow. This does not include any auto you lease, hire, rent, or borrow from any of your employees, partners (if you are a partnership), members (if you are a limited liability company) or members of their households. 9 Nonowned Autos Only Only those autos you do not own, lease, hire, rent or borrow that are used in connection with your business. This includes autos owned by your employees, partners (if you are a partnership), members (if you are a limited liability company), or members of their households but only while used in your business or your personal affairs. 10 19 Mobile Equipment Subject To Compulsory Or Financial Responsibility Or Other Motor Vehicle Insurance Law Only Only those autos that are land vehicles and that would qualify under the definition of mobile equipment under this policy if they were not subject to a compulsory or financial responsibility law or other motor vehicle insurance law where they are licensed or principally garaged. Endorsements include, but are not limited to: DESCRIPTION 2016 Commercial Auto Miscellaneous Form Revisions Advisory Notice to Policyholders - Cna 90 15 11 16 Annual Meeting Notice - Lil 90 04 06 13 Business Auto Coverage Form - CA 00 01 10 13 Business Auto Declarations - AC 00 03 02 13 Business Auto Declarations Extension Schedule - Hired or Borrowed Autos and Nonowned Autos - Acs 00 03 11 11 Changes in Your Policy - AC 00 30 10 13 Common Policy Conditions - IL 00 17 11 98 Forms Inventory - Acs 00 26 04 13 Illinois Changes - CA 01 20 01 15 Illinois Changes - Cancellation and Nonrenewal - CA 02 70 01 18 Illinois Changes - Civil Union - IL 01 47 09 11 Illinois Changes-Defense Costs - IL 01 62 10 13 Illinois Notice to Policyholders - Sni 12 01 07 18 Illinois Notice to Policyholders Regarding the Religious Freedom Protection and Civil Uni on Act - IL N 175 11 11 Illinois Underinsured Motorists Coverage - CA 21 38 10 13 Illinois Uninsured Motorists Coverage - CA 21 30 01 15 Insured Mailer Page - Cni 90 04 01 12 Item 3 - Schedule of Covered Autos You Own - Acs 00 24 04 13 Page 24 of 144 SP1.Page 27 of 152 City of Evanston 21 Endorsements include, but are not limited to: DESCRIPTION Liberty Mutual Group California Privacy Notice - Sni 04 01 12 20 Named Insured Endorsement - AC 84 13 01 11 Producer Mailer Page - Cni 90 05 01 12 Professional Services not Covered - CA 20 18 10 13 Public Entity Immunity and Tort Cap Preservation Endorsement - Lil 90 09 05 17 Self-Insured Amount Endorsement – Auto Liability Coverage Allocated Loss Adjustment Expenses (Alae) Included in Self Insured Amount - AC 85 88 11 19 Self-Insured Amount Endorsement – Uninsured and/or Underinsured Motorist Coverage - AC 21 23 11 19 Uninsured/Underinsured Motorists Insurance (UM/Uim) Schedule - Acs 21 02 04 13 Exclusions include, but are not limited to: DESCRIPTION Excluded Drivers Expected or Intended Injury Contractual Workers’ Compensation Employers' Liability Property Damage to Property Owned or Transported by you Pollution Other standard policy exclusions apply Terrorism Alaska Exclusion of Terrorism Minimum Statutory Limits - CA 23 88 10 13 Alaska Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism Above Minimum Statutory Limits - CA 23 89 10 13 Assault, Battery, Abuse or Molestation Exclusion - AC 20 01 11 16 Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism - CA 23 85 01 06 Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism - CA 23 85 10 13 Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism Above Minimum Statutory Limits - CA 23 87 10 13 Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism Above Minimum Statutory Limits - CA 23 87 01 06 Nuclear Energy Liability Exclusion Endorsement (Broad) - IL 00 21 09 08 Public or Livery Passenger Conveyance and on-Demand Delivery Services Exclusion - CA 23 45 11 16 State Application of Terrorism Exclusion Endorsements - AC 84 27 08 15 State Application of Terrorism Exclusion Endorsements Involving Nuclear, Biological or Chemical Terrorism - AC 84 26 08 15 Washington Exclusion of Terrorism - CA 23 92 10 13 Washington Exclusion of Terrorism Involving Nuclear, Biological or Chemical Terrorism - CA 23 93 10 13 Page 25 of 144 SP1.Page 28 of 152 City of Evanston 22 Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: Liberty Mutual Fire Insurance Company Premium $110,769.00 ESTIMATED PROGRAM COST $110,769.00 Deposit Premium - $110,769.00 Page 26 of 144 SP1.Page 29 of 152 City of Evanston 23 Package - Law Enforcement Liability - Liberty Mutual Fire Insurance Company, (More) Coverage: Package - Law Enforcement Liability Carrier: Liberty Mutual Fire Insurance Company LM Insurance Corporation Policy Period: 1/1/2022 to 1/1/2023 Form Number: LC 00 67 10 15 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE Law Enforcement Liability Coverage Occurrence Not Applicable Not Applicable Participation Schedule: CARRIER Liberty Mutual Fire Insurance Company LM Insurance Corporation Coverage: DESCRIPTION AMOUNT Each Wrongful Act Limit $2,000,000 Aggregate Limit $2,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Self-Insured Retention Law Enforcement Professional Liability - Each Wrongful Act $1,250,000 Endorsements include, but are not limited to: DESCRIPTION Common Policy Conditions - IL 00 17 11 98 Law Enforcement Liability Coverage Form - LC 00 67 10 15 Law Enforcement Liability Declarations - LC 00 102 11 19 Self-Insured Amount-Allocated Loss Adjustment Expense-Erodes SIA - LC 24 65 11 19 Declarations Extension Schedule - Classification Descriptions - LCS 00 01 05 12 Declarations Extension Schedule - LCS 00 02 05 12 Declarations Extension Schedule Miscellaneous Charges - LCS 00 03 05 12 Annual Meeting Notice - LIL 90 04 06 13 Illinois Changes - Cancellation and Nonrenewal - LC 32 371 01 18 Illinois Changes - Civil Union - LC 32 372 02 17 Illinois Notice to Policyholders - SNI 12 01 06 18 Policyholder Disclosure Terrorism Risk Insurance Act - SNI 90 02 01 15 Page 27 of 144 SP1.Page 30 of 152 City of Evanston 24 Endorsements include, but are not limited to: DESCRIPTION Participating Provision - LIL 90 05 06 13 Public Entity Immunity and Tort Cap Preservation Endorsement - LIL 90 09 05 17 Cap on Losses from Certified Acts of Terrorism - LC 21 138 02 17 Exclusions include, but are not limited to: DESCRIPTION Exclusion of Punitive Damages Related to a Certified Act of Terrorism - LC 21 137 02 17 Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: Liberty Mutual Fire Insurance Company Total Premium includes the TRIA Premium of $1,000.00 Premium $101,000.00 ESTIMATED PROGRAM COST $101,000.00 Deposit Premium - $101,000.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) INCLUDED Page 28 of 144 SP1.Page 31 of 152 City of Evanston 25 Package - E&O - Public Officials Liability - Liberty Mutual Fire Insurance Company, (More) Coverage: Package - E&O - Public Officials Liability Carrier: Liberty Mutual Fire Insurance Company LM Insurance Corporation Policy Period: 1/1/2022 to 1/1/2023 Form Number: LC 00 72 10 15 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE Public Officals Liability Claims Made 1/1/2022 Not Applicable Participation Schedule: CARRIER Liberty Mutual Fire Insurance Company LM Insurance Corporation Coverage: DESCRIPTION AMOUNT Each Wrongful Act Limit $1,000,000 Aggregate Limit $1,000,000 Deductibles / Self-Insured Retention TYPE COVERAGE AMOUNT Self-Insured Retention Public Officials Professional Liability - Each Wrongful Act $1,250,000 Claims Made Coverage: Should you elect to change carriers (if a new retroactive date is provided) or non -renew this policy, a supplemental extended reporting endorsement may be available subject to policy terms and conditions. You must request the extended reporting period in writing to the carrier within (60) days of the expiration date. The cost of this extended reporting period is 200% of the annual premium and is fully earned. The extended reporting period extends only to those claims made during the extended reporting period for wrongful acts that occurred prior to the expiration date and would have been covered by the policy. Claims must be reported to the carrier within (60) days of the end of the policy period. The extended reporting period does not increase the limit s of liability and is subject to all policy terms, conditions and exclusions. Definition of Claim: DESCRIPTION Refer to attached policy form Incident or Claim Reporting Provision: DESCRIPTION Refer to attached policy form Page 29 of 144 SP1.Page 32 of 152 City of Evanston 26 Run Off Provisions: DESCRIPTION PREMIUM AMOUNT PREMIUM DUE DATE LENGTH % OF EXPIRING PREMIUM Refer to attached policy form -- -- -- Endorsements include, but are not limited to: DESCRIPTION Common Policy Conditions - IL 00 17 11 98 Public Officials Liability Coverage Form (Claims-Made) - LC 00 72 10 15 Public Officials Liability Declarations (Claims-Made) Declarations Extension - LC 00 104 11 19 Schedule - Classification Descriptions - LCS 00 01 05 12 Declarations Extension Schedule - LCS 00 02 05 12 Declarations Extension Schedule Miscellaneous Charges - LCS 00 03 05 12 Self-Insured Amount-Allocated Loss Adjustment Expense-Erodes the SIA - LC 24 67 11 19 Annual Meeting Notice - LIL 90 04 06 13 Illinois Changes - Cancellation and Nonrenewal - LC 32 371 01 18 Illinois Changes - Civil Union - LC 32 372 02 17 Illinois Notice to Policyholders - SNI 12 01 06 18 Illinois Changes - Your Right To Claim Information (Claims-Made) - LC 32 373 02 17 Policyholder Disclosure Terrorism Risk Insurance Act - SNI 90 02 01 15 Participating Provision - LIL 90 05 06 13 Public Entity Immunity and Tort Cap Preservation - LIL 90 09 05 17 Endorsement Boards, Commissions or Governmental Depts. Amendment - LC 99 55 10 15 Cap on Losses from Certified Acts of Terrorism (If TRIA is accepted) - LC 21 138 02 17 Exclusions include, but are not limited to: DESCRIPTION Exclusion of Punitive Damages Related to a Certified Act of Terrorism (If TRIA is accepted) - LC 21 137 02 17 Exclusion of Certified Acts of Terrorism (IF TRIA is Rejected) - LC 21 139 02 17 Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: Liberty Mutual Fire Insurance Company Total Premium includes the TRIA Premium of $248.00 Premium $25,085.00 ESTIMATED PROGRAM COST $25,085.00 Deposit Premium - $25,085.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) INCLUDED Page 30 of 144 SP1.Page 33 of 152 City of Evanston 27 Package - Employment Practices Liability - Liberty Mutual Fire Insurance Company, (More) Coverage: Package - Employment Practices Liability Carrier: Liberty Mutual Fire Insurance Company LM Insurance Corporation Policy Period: 1/1/2022 to 1/1/2023 Form Number: LC 00 79 09 16 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE Employment Practices Liability Claims Made 1/1/2022 Not Applicable Defense Limitations: COVERAGE TYPE DEFENSE COST DOLLAR LIMIT DEFENSE LIMIT Employment Practices Liability Applies Other / Defense Within Limits Basis Participation Schedule: CARRIER Liberty Mutual Fire Insurance Company LM Insurance Corporation Coverage: DESCRIPTION AMOUNT Each Wrongful Employment Practices Act Limit $5,000,000 Aggregate Limit $5,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Self-Insured Retention Employment Practices Liability - Each Wrongful Act $1,250,000 Claims Made Coverage: Should you elect to change carriers (if a new retroactive date is provided) or non -renew this policy, a supplemental extended reporting endorsement may be available subject to policy terms and conditions. You must request the extended reporting period in writing to the carrier within (60) days of the expiration date. The cost of this extended reporting period is 200% of the annual premium and is fully earned. The extended reporting period extends only to those claims made during the extended reporting period for wrongful acts that occurred prior to the expiration date and would have been covered by the policy. Claims must be reported to the carrier within (60) days of the end of the policy period. The extended reporting period does not increase the limits of liability and is subject to all policy terms, conditions and exclusions. Definition of Claim: DESCRIPTION Refer to attached policy form Page 31 of 144 SP1.Page 34 of 152 City of Evanston 28 Incident or Claim Reporting Provision: DESCRIPTION Refer to attached policy form Run Off Provisions: DESCRIPTION PREMIUM AMOUNT PREMIUM DUE DATE LENGTH % OF EXPIRING PREMIUM Refer to attached policy form -- -- -- Endorsements include, but are not limited to: DESCRIPTION Common Policy Conditions - IL 00 17 11 98 Employment Practices Liability Coverage Form (Claims-Made) DWL - LC 00 79 09 16 Employment Practices Liability Declarations (Claims-Made) DWL - LC 00 106 11 19 Declarations Extension Schedule Miscellaneous Charges - LCS 00 03 05 12 Annual Meeting Notice - LIL 90 04 06 13 Policyholder Notice - Company Contact Information - SNI 90 01 05 12 Illinois Changes - Cancellation and Nonrenewal - LC 32 371 01 18 Illinois Changes - Your Right To Claim Information (Claims-Made) - LC 32 373 02 17 Illinois Notice to Policyholders - SNI 12 01 06 18 Policyholder Disclosure Terrorism Risk Insurance Act - SNI 90 02 01 15 Participating Provision - LIL 90 05 06 13 Boards, Commissions or Governmental Departments Amendment - LC 99 57 09 16 Public Entity Immunity and Tort Cap Preservation Endorsement - LIL 90 09 05 17 Cap on Losses from Certified Acts of Terrorism - LC 21 138 02 17 Self-Insured Amount-Allocated Adjustment Expense-Erodes the SIA - LC 24 69 11 19 Exclusions include, but are not limited to: DESCRIPTION Exclusion of Punitive Damages Related to a Certified Act of Terrorism - LC 21 137 02 17 Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: Liberty Mutual Fire Insurance Company Total Premium includes the TRIA Premium of $665.00 Page 32 of 144 SP1.Page 35 of 152 City of Evanston 29 Premium $67,165.00 ESTIMATED PROGRAM COST $67,165.00 Deposit Premium - $67,165.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) INCLUDED Page 33 of 144 SP1.Page 36 of 152 City of Evanston 30 Umbrella - $4M - Liberty Insurance Corporation Coverage: Umbrella - $4M Carrier: Liberty Insurance Corporation Policy Period: 1/1/2022 to 1/1/2023 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE Umbrella Occurrence Not Applicable Not Applicable Coverage: DESCRIPTION AMOUNT Each Occurrence Limit $4,000,000 General Aggregate Limit $4,000,000 Products - Completed Operations Aggregate Limit $4,000,000 Crisis Management Coverage Crisis Management Expense Aggregate Limit $250,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Self-Insured Retention Umbrella - Each Occurrence $1,250,000 Underlying Policies: COVERAGE DESCRIPTION LIMIT CARRIER NAME EFFECTIVE DATE EXPIRATION DATE Employers Liability Each Accident $1,000,000 To Follow (Must be Best Rated A-/V) 1/1/2022 1/1/2023 Employers Liability Policy Limit $1,000,000 To Follow (Must be Best Rated A-/V) 1/1/2022 1/1/2023 Employers Liability Each Employee $1,000,000 To Follow (Must be Best Rated A-/V) 1/1/2022 1/1/2023 Business Auto Combined Single Limit $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 General Liability Each Occurrence $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 General Liability General Aggregate $2,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 General Liability Products/Completed Operations Aggregate $2,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 General Liability Personal & Advertising Injury Limit $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Employee Benefits Liability Each Employee $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Page 34 of 144 SP1.Page 37 of 152 City of Evanston 31 Underlying Policies: COVERAGE DESCRIPTION LIMIT CARRIER NAME EFFECTIVE DATE EXPIRATION DATE Employee Benefits Liability Aggregate $2,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Law Enforcement Liability Each Wrongful Act $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Law Enforcement Liability Aggregate $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Public Officials Liability Each Wrongful Act $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Public Officials Liability Aggregate $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Sexual Misconduct Liability Each Sexual Misconduct $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Sexual Misconduct Liability Aggregate Sexual Misconduct $1,000,000 Liberty Mutual Fire Insurance Company 1/1/2022 1/1/2023 Endorsements include, but are not limited to: DESCRIPTION Commercial Liability – Umbrella Coverage Form - LCU 00 01 01 18 Crisis Management Coverage - LCU 32 143 01 18 Declarations Extension – Named Insured - LCU 99 05 01 18 Foreign Liability Limitation - LCU 24 09 09 19 Illinois Changes – Cancellation And Nonrenewal - LCU 02 26 01 18 Illinois Changes - Defense Costs - LCU 32 97 05 19 Illinois Notice To Policyholders - SNI 12 01 07 18 Illinois Notice To Policyholders Regarding The Religious Freedom Protection And Civil Union Act - IL N 175 11 11 Liberty Mutual Group California Privacy Notice - SNI 04 01 12 20 Non-Cumulation Of Liability (Same Occurrence) - LCU 25 09 01 18 Participating Provision - LIL 90 05 06 13 Policyholder Disclosure Terrorism Risk Insurance Act - SNI 90 02 01 20 Public Entity Immunity And Tort Cap Preservation - LCU 22 04 01 18 Underlying Coverage Requirement for Certified Acts of Terrorism – LCU 60 01 (If TRIA is Accepted) Cap on Losses from Certified Acts of Terrorism – LCU 60 04 (If TRIA is Accepted) Exclusions include, but are not limited to: DESCRIPTION Workers' Compensation, Auto No Fault, Uninsured/ Underinsured Motorists, Disability, and Unemployment Compensation Laws Pollution (Hostile Fire Exception) Page 35 of 144 SP1.Page 38 of 152 City of Evanston 32 Exclusions include, but are not limited to: DESCRIPTION Asbestos Physical Damage to Property in Insured’s Care, Custody, or Control Auto First-party Coverage Pollution (Auto) Products Recall Employment Related Practices Exclusion Total Pollution Exclusion Professional Liability Exclusion Retained Limit Abuse Exclusion - LCU 21 191 07 21 Access or Disclosure of Confidential or Personal Information and Data – Related Liability Exclusion– With Limited Bodily Injury Exception - LCU 21 85 01 18 Communicable Disease Exclusion (Specified Diseases) - LCU 32 144 01 18 Damage First Occurring Prior To Policy Period Exclusion - LCU 21 47 01 18 Failure To Supply Exclusion - LCU 21 02 01 18 Health Care Professional Services Exclusion - LCU 21 177 01 20 Lead Exclusion - LCU 21 122 01 18 MTBE Exclusion - LCU 21 127 01 18 Polychlorinated Biphenyls (PCBs) Exclusion - LCU 21 139 01 18 Silica or Silica-Related Dust Exclusion - LCU 21 19 01 18 Total Pollution Exclusion With A Hostile Fire Exception - LCU 26 12 01 18 Punitive Damages Related to a Certified Act of Terrorism Exclusion – LCU 60 06 (If TRIA is Accepted) Punitive Damages Related to a Certified Act of Terrorism Exclusion – LCU 60 10 (If TRIA is Accepted) Certified Acts of Terrorism Exclusion – LCU 60 05 (If TRIA is Rejected) Other Significant Terms and Conditions/Restrictions: DESCRIPTION Deposit Premium: $119,785.00 Total Premium includes the TRIA Premium of $2,922 Payment Terms: Premium is due 20 days from invoice date Premium $119,785.00 ESTIMATED PROGRAM COST $119,785.00 Minimum Earned Premium - $0.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) INCLUDED Page 36 of 144 SP1.Page 39 of 152 City of Evanston 33 Auditable Exposures: DESCRIPTION EXPOSURE Expenditures $154,616,035 Power Units 263 PPT 123 LT 47 MT 37 HT 41 EHT 0 Tractor 15 Number of Employees 0 Page 37 of 144 SP1.Page 40 of 152 City of Evanston 34 Package - General Liability - Safety Specialty Insurance Company, (More) Coverage: Package - General Liability Carrier: Safety Specialty Insurance Company Safety National Casualty Corporation Policy Period: 1/1/2022 to 1/1/2023 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE General Liability Occurrence N/A Not Applicable Employee Benefits Liability Claims Made TBD Not Applicable Participation Schedule: CARRIER Safety Specialty Insurance Company Safety National Casualty Corporation Coverage: DESCRIPTION AMOUNT General Aggregate Limit: Other than Product/Complete Operation $4,000,000 Products/Completed Operations Aggregate Limit $4,000,000 Each Occurrence Limit: Combined BI & PD $2,000,000 Personal and Advertising Injury Limit: Any One Person or Origination $2,000,000 Damages to Premises Rented to You Limit: including Fire Damage Legal $500,000 Employee Benefits Liability: - Aggregate Limit $4,000,000 - Each Employee Limit $2,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Retention ALAE Treatment: ALAE Within Retention Paid By Insured Retention CGL - Each Occurrence $1,250,000 Retention Personal and Advertising Injury $1,250,000 Retention Damages to Premises Rented to You $1,250,000 Retention Employee Benefits Liability $1,250,000 Claims Made Coverage: Should you elect to change carriers (if a new retroactive date is provided) or non-renew this policy, a supplemental extended reporting endorsement may be available subject to policy terms and conditions. You must request the extended reporting period in writing to the carrier within ([Days To Extend]) days of the expiration date. The cost of this extended reporting period is [Percent Cost]% of the annual premium and is fully earned. The extended reporting period extends only to those claims made during the extended reporting period for wrongful acts that occurred prior to the expiration date and would have been covered by Page 38 of 144 SP1.Page 41 of 152 City of Evanston 35 the policy. Claims must be reported to the carrier within ([Days To Report]) days of the end of the policy period. The extend ed reporting period does not increase the limits of liability and is subject to all policy terms, conditions and exclusions. Definition of Claim: DESCRIPTION "Claim" Means any Demand, Or "Suit", Made by an "Employee" or an "Employee's" Dependents and Beneficiaries, For Damages as the Result of an Act, Error or Omission. Incident or Claim Reporting Provision: DESCRIPTION Refer to attached policy form Run Off Provisions: DESCRIPTION PREMIUM AMOUNT PREMIUM DUE DATE LENGTH % OF EXPIRING PREMIUM Refer to attached policy form -- -- -- Endorsements include, but are not limited to: DESCRIPTION Amended Definition of Bodily Injury - Sngl 004 Unintentional Failure to Disclose Hazards or Occurrences - Sngl 021 Deletion of Premium Audit Condition - Sngl 053 Designated Additional Insured (Broad Form) - Sngl 022 Governmental Subdivisions Endorsement - CG 24 09 Employee Benefits Liability Coverage with Self-Insured Retention - SNGL 054 0514 Self-Insured Retention Endorsement - Sngl 024 Sexual Abuse or Molestation Coverage - Glm 007-2 CO-Employee Exclusion Deleted - Sngl 012 CGL Coverage Form - CG 00 01 Exclusions include, but are not limited to: COVERAGE TYPE DESCRIPTION General Liability Bodily Injury and Property Damage from pollutants - Absolute Exclusion General Liability Losses arising from the ownership maintenance or use of aircraft (including drones), autos, or watercraft, with some minor exceptions including certain contractual obligations General Liability Employment Related Practices Exclusion General Liability Liquor Liability Exclusion General Liability Aircraft Products Exclusion General Liability Professional Liability Exclusion General Liability Real Property in Your Care, Custody, and Control Exclusion General Liability Absolute Asbestos Exclusion Page 39 of 144 SP1.Page 42 of 152 City of Evanston 36 Exclusions include, but are not limited to: COVERAGE TYPE DESCRIPTION General Liability Absolute Lead Exclusion General Liability War and Nuclear Hazard General Liability Mold / Fungus EBL Dishonest, fraudulent, criminal or malicious act or omission EBL Bodily Injury or Property Damage or Personal Injury EBL Failure of performance of contract EBL Failure of any investment to perform as represented by you EBL Failure to comply with mandatory provisions of any law concerning Workers' Compensation, unemployment insurance, social security or disability benefits EBL Wrongful termination of an employee EBL Coercion, demotion, reassignment, discipline or harassment of an employee EBL Discrimination against an employee General Liability Total Pollution Exclusion W/ Hostile Fire Exception - CG 21 55 General Liability Nuclear Energy Liability Exclusion - IL 00 21 General Liability Fungi or Bacteria Exclusion - CG 21 67 General Liability Silica Exclusion - CG 21 96 General Liability Asbestos Exclusion - Sngl 044 General Liability Lead Exclusion - Sngl 043 General Liability Employment Related Practices Exclusion - CG 21 47 General Liability Law Enforcement Exclusion - CG 22 51 General Liability Erisa Exclusion - Sngl 002 General Liability Failure to Supply Exclusion - CG 22 50 General Liability Injury to Volunteer Firefighters Exclusion - CG 22 56 General Liability Access or Disclosure of Confidential or Personal Information and Data-Related Liability Exclusion - CG 21 07 General Liability Coverage C- Medical Payments Exclusion - CG 21 35 Binding Requirements: DESCRIPTION Subject to: - Need retroactive dates for EBL and POL/EPL coverages; - Self-Administration of Claims Application and Supporting Documention Must be Submitted and Subsequent Approval for the Self-Administration of Claims Must be Provided as a Condition to Binding - TRIA Per attached disclosure- Signed copy must be received prior to binding of coverage Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: Safety National Casualty Corporation Page 40 of 144 SP1.Page 43 of 152 City of Evanston 37 Other Significant Terms and Conditions/Restrictions: DESCRIPTION Self-Insured Retention Program Employee Benefits Liability: Retroactive Date: TBD – per current program Premium $45,787.00 ESTIMATED PROGRAM COST $45,787.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) $1,829.00 Page 41 of 144 SP1.Page 44 of 152 City of Evanston 38 Package - Public Officials Liability/Employment Practices Liability Coverage - Safety Specialty Insurance Company, (More) Coverage: Package - Public Officials Liability/Employment Practices Liability Coverage Carrier: Safety Specialty Insurance Company Safety National Casualty Corporation Policy Period: 1/1/2022 to 1/1/2023 Form Number: POEPCM- 0416 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE Public Officials and Employment Practices Liability Claims Made and Reported TBD Not Applicable Participation Schedule: CARRIER Safety Specialty Insurance Company Safety National Casualty Corporation Coverage: DESCRIPTION AMOUNT POL/EPL Coverage: - Annual Aggregate Limit $2,000,000 - Each Wrongful Act $2,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Retention ALAE Treatment ALAE Within Retention Paid By Insured: Each Wrongful Act $1,250,000 Claims Made Coverage: Should you elect to change carriers (if a new retroactive date is provided) or non -renew this policy, a supplemental extended reporting endorsement may be available subject to policy terms and conditions. You must request the extended reporting period in writing to the carrier within ([Days To Extend]) days of the expiration date. The cost of this extended reporting period i s [Percent Cost]% of the annual premium and is fully earned. The extended reporting period extends only to those claims made during the extended reporting period for wrongful acts that occurred prior to the expiration date and would have been covered by the policy. Claims must be reported to the carrier within ([Days To Report]) days of the end of the policy period. The extended reporting period does not increase the limits of liability and is subject to all policy terms, conditions and exclusions. Definition of Claim: DESCRIPTION 3. Claim Means any of the Following Received by an Insured and Alleging a Wrongful Act During the Policy Period or Subsequent to the Retroactive Date, If Applicable: A. A written demand for Damages or a notice advising an Insured of an intent to sue for Damages or a right to sue for Damages; B. Notice of an arbitration or alternative dispute proceeding seeking Damages to which the Insured must submit or does submit Page 42 of 144 SP1.Page 45 of 152 City of Evanston 39 Definition of Claim: DESCRIPTION with the Company’s consent; or C. A civil proceeding alleging Damages commenced by the service of a summons, complaint or similar pleading Incident or Claim Reporting Provision: DESCRIPTION Refer to attached policy form Run Off Provisions: DESCRIPTION PREMIUM AMOUNT PREMIUM DUE DATE LENGTH % OF EXPIRING PREMIUM Refer to attached policy form -- -- -- Endorsements include, but are not limited to: DESCRIPTION Public Officials and Employment Practices Liability Coverage Form - POEPCM- 0416 Coverage Retention Form - ILSIR 0716 Mandatory State Forms Non-Stacking of Limits Endorsement – Form - ILNONSTACK 0416 Binding Requirements: DESCRIPTION Subject to: - Need retroactive dates for EBL and POL/EPL coverages; - Self-Administration of Claims application and supporting documention must be submitted and subsequent approval for the self - administration of claims must be provided as a condition to binding Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: Safety Specialty Insurance Company Self-Insured Retention Program Retroactive Date: Tbd – Per Current Program Premium $67,676.00** ESTIMATED PROGRAM COST $67,676.00** **SLT applies; however is not included in the above premium. Page 43 of 144 SP1.Page 46 of 152 City of Evanston 40 Package - Law Enforcement Liability Coverage - Safety Specialty Insurance Company, (More) Coverage: Package - Law Enforcement Liability Coverage Carrier: Safety Specialty Insurance Company Safety National Casualty Corporation Policy Period: 1/1/2022 to 1/1/2023 Form Number: LELPOF 0416 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE **Law Enforcement Liability Coverage Occurrence Not Applicable Not Applicable Participation Schedule: CARRIER Safety Specialty Insurance Company Safety National Casualty Corporation Coverage: DESCRIPTION AMOUNT Annual Aggregate Limit $2,000,000 Each Occurrence Limit $2,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Retention Each Occurrence (including LAE) ALAE Within Retention Paid By Insured $1,250,000 Endorsements include, but are not limited to: DESCRIPTION LEL Coverage Form - LELPOF 0416 Coverage Retention Form - ILSIR 0716 Mandatory State Forms Non-Stacking of Limits Endorsement – Form - ILNONSTACK 0416 Binding Requirements: DESCRIPTION Subject to: - Self-Administration of Claims application and supporting documention must be submitted and subsequent approval for the self- administration of claims must be provided as a condition to binding Page 44 of 144 SP1.Page 47 of 152 City of Evanston 41 Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: Safety Specialty Insurance Company Premium $82,974.00** ESTIMATED PROGRAM COST $82,974.00** **SLT applies; however is not included in the above premium. Page 45 of 144 SP1.Page 48 of 152 City of Evanston 42 Package - Excess Liability - Safety Specialty Insurance Company, (More) Coverage: Package - Excess Liability Carrier: Safety Specialty Insurance Company Safety National Casualty Corporation Policy Period: 1/1/2022 to 1/1/2023 Participation Schedule: CARRIER Safety Specialty Insurance Company Safety National Casualty Corporation Coverage: DESCRIPTION AMOUNT General Aggregate Limit $3,000,000 Each Occurrence Limit $3,000,000 Underlying Policies: COVERAGE DESCRIPTION LIMIT CARRIER NAME EFFECTIVE DATE EXPIRATION DATE General Liability Limits of Liability $2,000,000/$4,000,00 Safety National Casualty Corporation 1/1/2022 1/1/2023 Commercial Automobile Limits of Liability/Combined single limit $2,000,000 Safety National Casualty Corporation 1/1/2022 1/1/2023 Public Officials Liability Limits of Liability $2,000,000/$2,000,000 Safety Specialty Insurance Company 1/1/2022 1/1/2023 Law Enforcement Liability Limits of Liability $2,000,000/$2,000,000 Safety Specialty Insurance Company 1/1/2022 1/1/2023 Endorsements include, but are not limited to: DESCRIPTION Commercial Excess Coverage Form - CX 00 01 Exclusions include, but are not limited to: DESCRIPTION Workers' Compensation, Auto No Fault, Uninsured/ Underinsured Motorists, Disability, and Unemployment Compensation Laws Pollution (Hostile Fire Exception) Asbestos Physical Damage to Property in Insured’s Care, Custody, or Control Auto First-party Coverage Page 46 of 144 SP1.Page 49 of 152 City of Evanston 43 Exclusions include, but are not limited to: DESCRIPTION Pollution (Auto) Products Recall Employment Related Practices Exclusion Total Pollution Exclusion Professional Liability Exclusion Retained Limit Terrorism - CX 21 33 Failure to Supply - XLM 001 / Manuscript Binding Requirements: DESCRIPTION Subject to: - Policyholder Disclosure Notice of Terrorism Insurance Coverage - City Must Maintain an Excess Workers Compensation Relationship with Safety National Other Significant Terms and Conditions/Restrictions: DESCRIPTION Carrier: Safety National Casualty Corporation Self-Insured Retention Program All underlying coverages must be bound through Safety National Casualty Corporation or Safety Specialty Insurance Company. Premium $55,958.00 ESTIMATED PROGRAM COST $55,958.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) $2,238.00 Page 47 of 144 SP1.Page 50 of 152 City of Evanston 44 Package - Automobile - Safety Specialty Insurance Company, (More) Coverage: Package - Automobile Carrier: Safety Specialty Insurance Company Safety National Casualty Corporation Policy Period: 1/1/2022 to 1/1/2023 Participation Schedule: CARRIER Safety Specialty Insurance Company Safety National Casualty Corporation Coverage: DESCRIPTION AMOUNT COVERED AUTOS BASIS Auto Liability - Combined Single Limit Bodily Injury & Property Damage $2,000,000 1 Any One Accident Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Retention Auto Liability - Any One Accident $1,250,000 Covered Autos: SYMBOL SYMBOL NAME DESCRIPTION OF COVERED AUTO DESIGNATION SYMBOLS 1 Any Auto 2 Owned Autos Only Only those autos you own (and for Liability Coverage any trailers you don't own while attached to power units you own). This includes those autos you acquire ownership of after the policy begins. 3 Owned Private Passenger Autos Only Only the private passenger autos you own. This includes those private passenger autos you acquire ownership of after the policy begins. 4 Owned Autos Other Than Private Passenger Autos Only Only those autos you own that are not of the private passenger type (and for Liability Coverage any trailers you don't own while attached to power units you own). This includes those autos not of the private passenger type you acquire ownership of after the policy begins. 5 Owned Autos Subject To No-Fault Only those autos you own that are required to have No-Fault benefits in the state where they are licensed or principally garaged. This includes those autos you acquire ownership of after the policy begins provided they are required to have No- Fault benefits in the state where they are licensed or principally garaged. 6 Owned Autos Subject To A Compulsory Uninsured Motorists Law Only those autos you own that because of the law in the state where they are licensed or principally garaged are required to have and cannot reject Uninsured Motorists Coverage. This includes those autos you acquire ownership of after the policy begins provided they are subject to the same state uninsured motorists’ requirement. 7 Specifically Described Autos Only those autos described in Item Three of the Declarations for which a premium charge is shown (and for Liability Coverage any trailers you don't own while attached to any power unit described in Item Three). 8 Hired Autos Only Only those autos you lease, hire, rent or borrow. This does not include any auto you lease, hire, rent, or borrow from any of your employees, partners (if you are a partnership), members (if you are a limited liability company) or members of their households. Page 48 of 144 SP1.Page 51 of 152 City of Evanston 45 Covered Autos: SYMBOL SYMBOL NAME DESCRIPTION OF COVERED AUTO DESIGNATION SYMBOLS 9 Nonowned Autos Only Only those autos you do not own, lease, hire, rent or borrow that are used in connection with your business. This includes autos owned by your employees, partners (if you are a partnership), members (if you are a limited liability company), or members of their households but only while used in your business or your personal affairs. 19 Mobile Equipment Subject To Compulsory Or Financial Responsibility Or Other Motor Vehicle Insurance Law Only Only those autos that are land vehicles and that would qualify under the definition of mobile equipment under this policy if they were not subject to a compulsory or financial responsibility law or other motor vehicle insurance law where they are licensed or principally garaged. Endorsements include, but are not limited to: DESCRIPTION Self-Insured Retention Endorsement - SNCA 022 Public Entity Endorsement - SNCA 029 Broad Form Named Insured - SNCA 038 Unintentional Failure to Disclose Material Facts - SNCA 028 Unintentional Failure to Provide Notice of Accident or Loss - SNCA 030 Audio, Visual, & Data Electronic Equipment Coverage- Fire, Police, & Emergency Vehicles - CA 20 02 Amphibious Vehicles - CA 23 97 Public Transportation Autos - CA 24 02 Hired Autos Specified as Covered Autos you Own - CA 99 16 Waiver of Premium Audit Condition - Manuscript Exclusions include, but are not limited to: DESCRIPTION Excluded Drivers Expected or Intended Injury Contractual Workers’ Compensation Employers' Liability Property Damage to Property Owned or Transported by you Pollution Other standard policy exclusions apply Terrorism Exclusion of Federal Employees Using Autos in Government Business - CA 04 42 Emergency Services - Volunteer Firefighters’ and Workers’ Injuries Excluded - CA 20 30 Silica Exclusion - CA 23 94 Nuclear Energy Liability Exclusion - IL 00 21 Page 49 of 144 SP1.Page 52 of 152 City of Evanston 46 Binding Requirements: DESCRIPTION Subject to: - Self-Administration of Claims application and supporting documention must be submitted and subsequent approval for the self-administration of claims must be provided as a condition to binding. - Signed UM/UIM Selection/Rejection Form Premium $56,232.00 ESTIMATED PROGRAM COST $56,232.00 Subject to Audit: Annually Page 50 of 144 SP1.Page 53 of 152 City of Evanston 47 Excess Liability ($5M x Primary) - Old Republic Union Insurance Company Coverage: Excess Liability ($5M x Primary) Carrier: Old Republic Union Insurance Company Policy Period: 1/1/2022 to 1/1/2023 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE Excess Liability Occurrence Not Applicable Not Applicable Defense Limitations: COVERAGE TYPE DEFENSE COST DOLLAR LIMIT DEFENSE LIMIT Excess Liability Applies Other / Inside the Underlying Limits and Inside the Limits of Insurance Coverage: DESCRIPTION AMOUNT BASIS Automobile Liability $5,000,000 Per Accident General Liability $5,000,000 Per Occurrence General Liability $5,000,000 Annual Aggregate Law Enforcement Liability $5,000,000 Per Occurrence Law Enforcement Liability $5,000,000 Annual Aggregate Errors and Omissions Liability $5,000,000 Per Occurrence Errors and Omissions Liability $5,000,000 Annual Aggregate Employment Practices Liability Included - Public Officials Liability Included - Sexual Abuse Liability Includes in General Liability Per Occurrence Sexual Abuse Liability Includes in General Liability Annual Aggregate Employee Benefits Liability Includes in General Liability Per Occurrence Employee Benefits Liability Includes in General Liability Annual Aggregate Underlying Policies: COVERAGE DESCRIPTION LIMIT CARRIER NAME EFFECTIVE DATE EXPIRATION DATE Automobile Liability Per Accident $6,250,000 TBD 1/1/2022 1/1/2023 General Liability Per Occurrence $6,250,000 TBD 1/1/2022 1/1/2023 General Liability Annual Aggregate $6,250,000 TBD 1/1/2022 1/1/2023 Law Enforcement Liability Per Occurrence $6,250,000 TBD 1/1/2022 1/1/2023 Page 51 of 144 SP1.Page 54 of 152 City of Evanston 48 Underlying Policies: COVERAGE DESCRIPTION LIMIT CARRIER NAME EFFECTIVE DATE EXPIRATION DATE Law Enforcement Liability Annual Aggregate $6,250,000 TBD 1/1/2022 1/1/2023 Errors and Omissions Liability Per Occurrence $6,250,000 TBD 1/1/2022 1/1/2023 Errors and Omissions Liability Annual Aggregate $6,250,000 TBD 1/1/2022 1/1/2023 Sexual Abuse Liability Per Occurrence Included in General Liability TBD 1/1/2022 1/1/2023 Sexual Abuse Liability Annual Aggregate Included in General Liability TBD 1/1/2022 1/1/2023 Employee Benefits Liability Per Occurrence Included in General Liability TBD 1/1/2022 1/1/2023 Employee Benefits Liability Annual Aggregate Included in General Liability TBD 1/1/2022 1/1/2023 Endorsements include, but are not limited to: DESCRIPTION Signature Page - AR XS ORU 10 20 Commercial Excess Liability Declarations - AR XS DS 01 03 21 Commercial Excess Liability Coverage Form - CX 00 01 04 13 Common Policy Conditions - IL 00 17 11 98 Disclosure of Premium - IL 09 99 01 15 Claim Notice - AR XS 20 00 06 21 Service of Process - AR XS 20 14 05 21 Illinois Changes – Defense Costs - CX 01 22 09 08 Illinois Changes – Cancellation and Nonrenewal - CX 02 01 09 08 Terrorism Endorsements Exclusions include, but are not limited to: DESCRIPTION Workers' Compensation, Auto No Fault, Uninsured/ Underinsured Motorists, Disability, and Unemployment Compensation Laws Pollution (Hostile Fire Exception) Asbestos Physical Damage to Property in Insured’s Care, Custody, or Control Auto First-party Coverage Pollution (Auto) Products Recall Employment Related Practices Exclusion Page 52 of 144 SP1.Page 55 of 152 City of Evanston 49 Exclusions include, but are not limited to: DESCRIPTION Total Pollution Exclusion Professional Liability Exclusion Retained Limit Asbestos Exclusion - AR XS 20 06 09 19 Failure to Supply Utilities Exclusion - AR XS 20 09 09 19 Lead Contamination Exclusion - AR XS 20 11 09 19 War Exclusion - AR XS 20 16 09 19 Earth or Land Movement Exclusion - AR XS 20 30 09 19 Nuclear, Biological, Chemical and Radiological Exclusion - AR XS 20 46 01 21 Nuclear Energy Liability Exclusion Endorsement (Broad Form) - CX 21 01 09 08 Total Pollution Exclusion with a Hostile Fire Exception - CX 21 03 04 13 Exclusion – Fungi or Bacteria - CX 21 13 04 13 Exclusion – Silica or Silica-Related Dust - CX 21 16 04 13 Exclusion – Communicable Disease - CX 21 17 04 13 Exclusion – Access or Disclosure of Confidential or Personal Information - CX 21 43 05 14 Exclusion – Unmanned Aircraft - CX 21 71 06 15 Cannabis Exclusion - CX 21 79 12 20 Binding Requirements: DESCRIPTION Complete and Signed Old Republic Specialty Insurance Underwriters Renewal Business Supplemental Application Copy of 2022-2023 Underlying Policy (required if bound) Signed Terrorism Select/Reject Form. (required if bound) Premium $248,000.00 Taxes SLT $8,680.00 Stamping Fee $186.00 Total Taxes $8,866.00 ESTIMATED PROGRAM COST $256,866 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) $1,844.00 Page 53 of 144 SP1.Page 56 of 152 City of Evanston 50 Excess Liability ($5M x $10M) – Arch Specialty Insurance Company Coverage: Excess Liability ($5M x $10M) Carrier: Arch Specialty Insurance Company Policy Period: 1/1/2022 to 1/1/2023 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE Excess Liability Occurrence Not Applicable Not Applicable Defense Limitations: COVERAGE TYPE DEFENSE COST DOLLAR LIMIT DEFENSE LIMIT Umbrella Applies Other / In Addition to limits Coverage: DESCRIPTION AMOUNT Each Occurrence Limit $5,000,000 Aggregate Limit $5,000,000 Additional Coverage: DESCRIPTION Aggregate Limits Follow Form Underlying Policies Exclusions include, but are not limited to: DESCRIPTION Workers' Compensation, Auto No Fault, Uninsured/ Underinsured Motorists, Disability, and Unemployment Compensation Laws Pollution (Hostile Fire Exception) Asbestos Physical Damage to Property in Insured’s Care, Custody, or Control Auto First-party Coverage Pollution (Auto) Products Recall Employment Related Practices Exclusion Total Pollution Exclusion Professional Liability Exclusion Retained Limit Page 54 of 144 SP1.Page 57 of 152 City of Evanston 51 Binding Requirements: DESCRIPTION Subject to Signed Diligent Effort Affidavit (AJG to Complete) Subject to Signed Illinois Brokers Service Contract Subject to Signed and Dated “Acceptance or Rejection of Terrorism” form Premium $140,000.00 Taxes SLT $4,900.00 Stamping Office Fee $105.00 Total Taxes $5,005.00 ESTIMATED PROGRAM COST $145,005.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) $2,500.00 Page 55 of 144 SP1.Page 58 of 152 City of Evanston 52 Property - Affiliated FM Insurance Company Coverage: Property Carrier: Affiliated FM Insurance Company Policy Period: 1/1/2022 to 1/1/2023 Coverage: SUBJECT OF INSURANCE AMOUNT Policy Limit (Any One Occurrence) $464,000,000 Earth Movement (Annual Aggregate) $5,000,000 - Not To Exceed Data Service Provider - Business Interruption, Data Service Provider - Property Damage, Errors And Omissions, Off-Premises Service Interruption - Business Interruption, Off-Premises Service Interruption - Property Damage, Supply Chain And Unnamed Property, Combined (Annual Aggregate) $50,000 Flood (Annual Aggregate) $5,000,000 - Not To Exceed Data Service Provider - Business Interruption, Data Service Provider - Property Damage, Errors And Omissions, Off-Premises Service Interruption - Business Interruption, Off-Premises Service Interruption - Property Damage, Supply Chain And Unnamed Property, Combined (Annual Aggregate) $50,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Deductible Qualifying Periods - Deductible Boiler and Machinery 1 Days Deductible Communicable Disease - Property Damage and Communicable Disease - Business Interruption 48 Hours Deductible Data Restoration 48 Hours Deductible Data Service Provider - Property Damage and Data Service Provider - Business Interruption 48 Hours Deductible Off-Premises Service Interruption - Property Damage and Off-Premises Service Interruption - Business Interruption 48 Hours Deductible Owned Network Interruption 48 Hours Deductible The Following Deductible Amounts Shall Apply Per Occurrence, Unless Otherwise Stated, For Insured Loss or Damage Under This Policy - Deductible Boiler and Machinery - Deductible Property Damage $50,000 Deductible Earthquake - Per Location $100,000 Deductible Fine Arts $10,000 Deductible Flood - Per Location $100,000 Deductible All Other Losses $50,000 Additional Coverage: DESCRIPTION AMOUNT Unless Otherwise Stated Below Or Elsewhere In This Policy, The Following Sub-Limits Of Liability, Including Any Insured Business Interruption Loss, Will Be The Maximum Payable And Will Apply On A Per Occurrence Basis - Accounts Receivable $1,000,000 Page 56 of 144 SP1.Page 59 of 152 City of Evanston 53 Additional Coverage: DESCRIPTION AMOUNT Arson Or Theft Reward $100,000 Attraction Property $100,000 Boiler And Machinery Policy Limit Brand Protection Policy Limit Business Interruption Not To Exceed The Following: $26,000,000 -Ordinary Payroll $26,000,000 for Gross Earnings, not to exceed 30 days -Gross Profits Not To Exceed The Following $26,000,000 A. Months 12 Months B. Ordinary Payroll 30 Days -Rental Income $26,000,000 -Extra Expense $5,000,000 Change Of Temperature $100,000 Civil Or Military Authority 30 Days Communicable Disease - Property Damage And Communicable Disease - Business Interruption Combined $1,000 Annual Aggregate, Not to Exceed 12 Months Contractual Penalties $100,000 Crisis Management $100,000, Not to Exceed 30 Days Cyber Event -Data Restoration And Owned Network Interruption Combined (Annual Aggregate) $1,000 -Data Service Provider - Property Damage And Data Service Provider - Business Interruption Combined (Annual Aggregate) $1,000 -Loss Or Damage To Stock In Process Or Finished Goods Manufactured By Or For The Insured Caused By Or Resulting From Cyber Event That Impacts The Processing, Manufacturing, Or Testing Of Such Property Or While It Is Otherwise Being Worked On (Annual Aggregate) $50,000 Data Restoration (Annual Aggregate) $500,000 Data Service Provider - Property Damage And Data Service Provider - Business Interruption Combined (Annual Aggregate) $50,000 Debris Removal Policy Limit Decontamination Costs Policy Limit Deferred Payment $100,000 Demolition And Increased Cost Of Construction Policy Limit Errors And Omissions $1,000,000 Expediting Expenses $250,000 Extended Period Of Liability 90 Days Fine Arts $2,500,000, Not to Exceed $10,000 Per Item for Irreplaceable Fine Arts Page 57 of 144 SP1.Page 60 of 152 City of Evanston 54 Additional Coverage: DESCRIPTION AMOUNT Green Coverage $50,000 not to exceed 25% of the amount of the property damage loss Ingress/Egress $500,000 Land And Water Clean Up Expense (Annual Aggregate) $50,000 Leasehold Interest $250,000 Locks And Keys $100,000 Logistics Extra Cost $100,000 Money And Securities $100,000 Newly Acquired Property $2,500,000 Off-Premises Service Interruption - Business Interruption $500,000 Off-Premises Service Interruption - Property Damage $500,000 Owned Network Interruption Included in Cyber Event Limit Professional Fees $250,000 Property Removed From A Location Policy Limit Protection And Preservation Of Property - Business Interruption Policy Limit Protection And Preservation Of Property - Property Damage Policy Limit, Not to Exceed $250,000 for Security Costs Research And Development $250,000 Soft Costs $100,000 Supply Chain $500,000 Tax Treatment $100,000 Tenants Legal Liability $100,000 Terrorism (Annual Aggregate) $100,000 -Not To Exceed Flood And Property Removed From A Location Combined $100,000 Terrorism: Supplemental United States Certified Act Of Terrorism Endorsement(S) $464,000,000 for Property Located in the United States of America Transit $500,000, Not to Exceed $250,000 for Business Interruption Unnamed Property $10,000,000 Valuable Papers And Records $500,000, Not to Exceed $10,000 Per Item for Irreplaceable Valuable Papers and Records Perils Covered: TYPE DESCRIPTION Special Form Perils Applies Page 58 of 144 SP1.Page 61 of 152 City of Evanston 55 Valuations: TYPE DESCRIPTION Physical Loss to Property Replacement Cost Contractors Equipment Actual Cash Value (ACV) Endorsements include, but are not limited to: DESCRIPTION Contractor’s Equipment - PRO 202 (04/15) Library Books, Periodicals, and Rare Books - PRO 75 (04/15) Fine Arts Schedule - PRO 13 (01/17) United States Certified Act of Terrorism - PRO 207 (01/20) Declarations Page - PRO DEC 4100 (04/15) Declarations - PRO S-1 4100 (01/20) Fine Arts Schedule, Appendix A - Version 001 All Risk Coverage - PRO AR 4100 (06/21) Supplemental United States Certified Act of Terrorism Endorsement - AFM 7312 (06/21) Illinois Amendatory Endorsement - AFM 1726 (06/21) Exclusions include, but are not limited to: DESCRIPTION Earth Movement Exclusion Flood Exclusion Government Action Exclusion War Exclusion Nuclear Hazard, Power Failure Transmission and Distribution Systems Exclusion - PRO 132 (01/19) Binding Requirements: DESCRIPTION Policyholder Disclosure Notice of Terrorism Insurance Coverage Other Significant Terms and Conditions/Restrictions: DESCRIPTION Policy Territory : Coverage Provided by This Policy is Limited to Property While Located Within the United States of America Total Premium Includes TRIA premium $11,000 Page 59 of 144 SP1.Page 62 of 152 City of Evanston 56 Other Significant Terms and Conditions/Restrictions: DESCRIPTION Premium $264,525.00 ESTIMATED PROGRAM COST $264,525.00 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) INCLUDED Page 60 of 144 SP1.Page 63 of 152 City of Evanston 57 Cyber Liability - Obsidian Specialty Insurance Company Coverage: Cyber Liability Carrier: Obsidian Specialty Insurance Company Policy Period: 1/1/2022 to 1/1/2023 Form Number: PRIME 250SL 001 10 20 Form Type: COVERAGE FORM TYPE RETROACTIVE DATE Liability Expense - Liability Costs, PCI Costs, Regulatory Costs Claims Made and Reported Full Prior Acts Coverage Endorsements - California Consumer Privacy Act, General Data Protection Regulation, Media Liability Claims Made and Reported Full Prior Acts Reputational Harm Expense Claims Made and Reported Full Prior Acts Defense Limitations: COVERAGE TYPE DEFENSE COST DOLLAR LIMIT DEFENSE LIMIT Cyber Liability Applies Other / Reduce and May Exhaust the Limit of Liability Coverage: DESCRIPTION AMOUNT Aggregate Limit $1,000,000 Liability Expense Liability Costs $1,000,000 PCI Costs $1,000,000 Regulatory Costs $1,000,000 First Party Expense Cowbell Breach Fund $1,000,000 Data Restoration $1,000,000 Extortion Costs $1,000,000 Business Impersonation Costs $1,000,000 Reputational Harm Expense $500,000 First Party Loss Business Interruption Loss $1,000,000 Contingent Business Interruption Loss $1,000,000 System Failure $1,000,000 Cyber Crime Loss $250,000 Bricking Costs $1,000,000 Criminal Reward Costs $100,000 Page 61 of 144 SP1.Page 64 of 152 City of Evanston 58 Coverage: DESCRIPTION AMOUNT Coverage Endorsements - California Consumer Privacy Act $1,000,000 General Data Protection Regulation $1,000,000 Utility Fraud Attack $100,000 Media Liability $1,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Deductible Liability Expense - Deductible Liability Costs $50,000 Deductible PCI Costs $50,000 Deductible Regulatory Costs $50,000 Deductible First Party Expense - Deductible Cowbell Breach Fund $50,000 Deductible Data Restoration $50,000 Deductible Extortion Costs $50,000 Deductible Business Impersonation Costs $50,000 Deductible Reputational Harm Expense - Waiting Period 24 Hours Deductible First Party Loss - Deductible Business Interruption Loss $50,000 Deductible Business Interruption Loss - Waiting Period 24 Hours Deductible Contingent Business Interruption Loss $50,000 Deductible Contingent Business Interruption Loss - - Waiting Period 24 Hours Deductible System Failure $50,000 Deductible System Failure - Waiting Period 24 Hours Deductible Contingent System Failure $50,000 Deductible Contingent System Failure - - Waiting Period 12 Hours Deductible Cyber Crime Loss $50,000 Deductible Bricking Costs $50,000 Deductible Coverage Endorsements - Deductible California Consumer Privacy Act $50,000 Deductible General Data Protection Regulation $50,000 Deductible Utility Fraud Attack $50,000 Deductible Media Liability $50,000 Page 62 of 144 SP1.Page 65 of 152 City of Evanston 59 Claims Made Coverage: Should you elect to change carriers (if a new retroactive date is provided) or non-renew this policy, a supplemental extended reporting endorsement may be available subject to policy terms and conditions. You must request the extended reporting period in writing to the carrier within (30) days of the expiration date. The cost of this extended reporting period is 100% of the annual premium and is fully earned. The extended reporting period extends only to those claims made during the extended reporting period for wrongful acts that occurred prior to the expiration date and would have been covered by the policy. Claims must be reported to the carrier within (30) days of the end of the policy period. The extended reporting period does not increase the limits of liability and is subject to all policy terms, conditions and exclusions. Definition of Claim: DESCRIPTION Claim means any (1) written demand for Money or non-monetary relief, written demand for arbitration or written request to toll or waive a statute of limitations received by the Insured; (2) civil proceeding in a court of law or equity, including any appeal therefrom, which is commenced by the filing of a complaint , motion for judgment or similar pleading, against the Insured; (3) administrative or regulatory investigation, inquiry, suit, pr oceeding, prosecution or governmental actions against the Insured solely with respect to a Privacy Incident; (4) an arbitration or other alternative dispute resolution proceeding against the Insured for monetary damages or nonmonetary or injunctive relief, commenced by the Insured’s receipt of a request or demand for such proceeding, including any appeal thereof; or (5) written notice received by the Insured for PCI Costs from a third party, with whom the Insured Organization has entered i nto a Payment Card Services Agreement, as a result of actual or alleged non-compliance with the PCI DSS. Incident or Claim Reporting Provision: DESCRIPTION 1. Notice to Insurer As a condition precedent to coverage under this Policy (a) the Insured must provide written notice to the Insurer of any Privacy Incident, Network Security Incident or Cyber Crime Incident as soon as possible after the Insured is made aware of such Priva cy Incident, Network Security Incident or Cyber Crime Incident but in no event more than ninety (90) days after the Privacy Incident, Network Security Incident or Cyber Crime Incident is discovered by the Insured. The Insured will not incur any Firs t Party Loss and First Party Expense without the Insurer’s consent; and (b) the Insured must provide written notice to the Insurer of any Claim as soon as possible after the Insured is made aware of such Claim but no later than ninety (90) days after the e nd of the Policy Period or end of the Extended Reporting Period (if applicable). The Insured will no t incur any Liability Expense without the Insurer’s consent. 2. Notice of Circumstance If, during the Policy Period or Extended Reporting Period (if applicable) any Insured first becomes aware of a Privacy Incide nt, Network Security Incident or Media Incident which may reasonably give rise to a future Claim under this Policy and gives written notice to the Insurer of: a) the nature of the Privacy Incident, Network Security Incident or Media Incident; b) the parties involved; c) the injury or damages that has or may result therefrom; and d) the circumstances by which the Insured first became aware thereof; then any Claim arising out of an Interrelated incident that involves a Privacy Incident, Network Security Incident or Media Incident that is subsequently made against the Insured will be related back to and be deemed to have been made at the time any Insured gave such written notice of circumstances to the Insurer. The Insured will provide written notice to the Insurer either to the mailing or email address set forth in Item 10. of the Declarations. Communication or assistance in connection with any Incident Consultation DOES NOT constitute Notice to Insurer or Notice of Circumstance under this Policy. Page 63 of 144 SP1.Page 66 of 152 City of Evanston 60 Run Off Provisions: DESCRIPTION PREMIUM AMOUNT % OF EXPIRING PREMIUM Extended Reporting Period 12 Months Additional 75% of Premium Extended Reporting Period 24 Months Additional 125% of Premium Extended Reporting Period 36 Months Additional 150% of Premium Endorsements include, but are not limited to: DESCRIPTION Cowbell Cyber Risk Insurance Policy Declarations - Prime 250 - PRIME 250SL 002 07 20 Notice to Policyholders - OFAC - PN006SL 09 20 Customer Notice of Privacy Policy & Producer Compensation Practices Disclosure - PN007SL OB 09 20 Cowbell Cyber Risk Insurance Policy - Prime 250 - PRIME 250SL 001 10 20 Service of Process - PRIME 250SL 075 12 20 California Consumer Privacy Act - PRIME 250SL 004 09 20 General Data Protection Regulation - PRIME 250SL 005 09 20 Utility Fraud Attack - PRIME 250SL 006 09 20 Media Liability - PRIME 250SL 007 09 20 Amend Product or Service Failure Exclusion - PRIME 250SL 046 10 21 Disclosure Pursuant to Terrorism Risk Insurance Act - PRIME 250SL 028 10 20 Cap on Losses From Certified Acts of Terrorism - PRIME 250SL 029 10 20 Amend Cooperation Clause Endorsement - PRIME 250SL 019 09 20 Cancellation/Reinstatement Endorsement - PRIME 250SL 030 09 20 Add/Delete Endorsement - PRIME 250SL 027 09 20 Full System Failure Endorsement - PRIME 250SL 008 09 20 Amendatory Construction Endorsement - PRIME 250SL 015 09 20 Additional Insured Coverage - PRIME 250SL 018 09 20 Additional Extended Reporting Period Endorsement - PRIME 250SL 017 09 20 Contingent Bodily Injury and Property Damage Endorsement - PRIME 250SL 010 09 20 Blanket Additional Insured Coverage - PRIME 250SL 021 09 20 Contractual Damages Endorsement (Manufacturing Industry) - PRIME 250SL 013 09 20 Cryptojacking - PRIME 250SL 009 09 20 Exclusions include, but are not limited to: DESCRIPTION Trade or Economic Sanctions Exclusion Endorsement - PRIME 250SL 032 09 20 Exclusion for Certified Acts of Terrorism Under the Terrorism Risk Insurance Act - PRIME 250SL 043 07 20 Page 64 of 144 SP1.Page 67 of 152 City of Evanston 61 Binding Requirements: DESCRIPTION Cowbell Cyber Risk Insurance Application Please provide the intended Policyholder's contact information: Name, Email, and Phone Number; this is necessary prior to binding. Cowbell Application signed and dated within 30 days prior to binding. Completed Surplus Lines Tax Documentation Form prior to binding. Required to have an Incident Response Plan in place that has been tested. Please confirm that this control has been met or th at it will be fully implemented within 30 days posting. Cowbell has a complimentary template to download and our Risk Eng ineering team can assist. Full network backup restoration to be tested within 30 days of the effective date and on a biannual basis thereafter. Other Significant Terms and Conditions/Restrictions: DESCRIPTION Reputational Harm Expense - Retro Active Period - 1 year Premium $49,605.00 Taxes SLT $1,736.18 Stamping Fee $37.20 Total Taxes $1,773.38 Fees Underwriting Fees $750.00 Broker Fee $250.00 Total Fees $1,000.00 ESTIMATED PROGRAM COST $52,378.38 TRIA/TRIPRA PREMIUM (+ Additional Surcharges, Taxes and Fees as applicable) Included Auditable Exposures: DESCRIPTION EXPOSURE Revenue $187,525,722.00 Number of Employees 800 Page 65 of 144 SP1.Page 68 of 152 City of Evanston 62 Underground Storage Tank - Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) Coverage: Underground Storage Tank Carrier: Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) Policy Period: 1/1/2021 to 1/1/2024 (3 Year Term) Form Number: F00738 102019 ed. Form Type: COVERAGE FORM TYPE RETROACTIVE DATE PENDING & PRIOR DATE Environmental Liability Claims Made and Reported 1/1/2019 Not Applicable Existing Pollution Conditions – (BI/PD and Cleanup), Existing Pollution Conditions – 1st Party Discovery Claims Made and Reported 1/1/2019 Not Applicable Transportation Claims Made and Reported 1/1/2019 Not Applicable Non-Owned Location Claims Made and Reported 1/1/2019 Not Applicable Defense Limitations: COVERAGE TYPE DEFENSE COST DOLLAR LIMIT DEFENSE LIMIT UST Applies Other / Within the Limits Coverage: DESCRIPTION AMOUNT Each Pollution Condition Limit $3,000,000 Aggregate Limit for the Policy Period $6,000,000 Deductibles / Self-Insured Retentions: TYPE COVERAGE AMOUNT Deductible Each Pollution Condition Deductible $50,000 Deductible I.F. Deductible Period 5 Days Deductible Financial Responsibility for Storage Tank Systems - Deductible Each Pollution Condition - with respect to Cleanup Costs and Damages $1,000,000 Deductible Each Pollution Condition - with respect to Claims Expenses $250,000 Deductible Aggregate for the Policy Period - with respect to Cleanup Costs and Damages $3,000,000 Deductible Aggregate for the Policy Period - with respect to Claims Expenses $250,000 Claims Made Coverage: Should you elect to change carriers (if a new retroactive date is provided) or non -renew this policy, a supplemental extended reporting endorsement may be available subject to policy terms and conditions. You must request the extended reporting period in writing to the carrier within (90) days of the expiration date. The cost of this extended reporting period is 100% of the annual premium and is fully earned. The extended reporting period extends only to those claims made during the extended reporting Page 66 of 144 SP1.Page 69 of 152 City of Evanston 63 period for wrongful acts that occurred prior to the expiration date and would have been covered by the policy. Claims must be reported to the carrier within (90) days of the end of the policy period. The extended reporting period does not increase the limits of liability and is subject to all policy terms, conditions and exclusions. Definition of Claim: DESCRIPTION “Claim” means: 1. a written demand received by an Insured for money or services or alleging liability or responsibility, including, but not limited to, the service of suit or institution of arbitration proceedings; or 2. a court or government agency order or government or regulatory action filed against the Insured. Incident or Claim Reporting Provision: DESCRIPTION If any Claim is made against an Insured, the Insured shall forward written notice as soon as practicable to the Underwriters but in no event shall such notice be provided after the expiration of the Policy Period or the time allowed, if applicable, under Section X. Notice shall be forwarded via facsimile, email or express or certified mail to the persons identified in Item 8.(a) of the Declarations. Such notice should include a copy of every demand, notice, summons or other process received by the Insured or the Insured’s representative. Run Off Provisions: DESCRIPTION PREMIUM AMOUNT % OF EXPIRING PREMIUM Extended Reporting Period Request from Carrier Request from Carrier Additional Coverage: DESCRIPTION AMOUNT Period of Restoration 365 Days Additional Claims Expenses Limit $1,500,000 Crisis and Reputation Expenses Coverage Each Pollution Condition Sublimit $250,000 Endorsements include, but are not limited to: DESCRIPTION Beazley ECLIPSE - F00738 102019 ed. Lloyd's Certificate - NMA 2868 (Env), SLC-3 (USA) NMA2868 (24/08/00) Lloyd's Security Schedule 2022 - SCHEDULE2022 Cyber Acts Clarification Endorsement - E14455 122020 ed. Additional Insured - E12463 012019 ed. Amend Prior Knowledge Exclusion Endorsement - E13000 062019 ed. Automatic Acquisition Endorsement - E12389 012020 ed. Disclosed Document Schedule - E12451 012019 ed. Minimum Earned Premium - E12411 012019 ed. Other Insurance-Primary Without Right of Contribution - E12453 012019 ed. Schedule of Covered Locations - E13031 062019 ed. Page 67 of 144 SP1.Page 70 of 152 City of Evanston 64 Endorsements include, but are not limited to: DESCRIPTION Financial Responsibility for Storage Tank Systems - E12432 062020 ed. Endorsement of Insurance to Demonstrate Financial Responsibility for Storage Tanks State of Illinois - E13633IL 122019 ed. U.S. Terrorism Risk Insurance Act of 2002 As Amended - Not Purchased Clause - E06694 082020 ed., (LMA 5390) Exclusions include, but are not limited to: DESCRIPTION Nuclear Incident Exclusion Clause-Liability-Direct (Broad) (U.S.A.) - NMA1256 17/3/60 Radioactive Contamination Exclusion Clause-Liability-Direct (U.S.A.) - NMA1477 13/2/64 War and Terrorism Exclusion Endorsement - NMA2918 08/10/01 PFC, PFAS And Related Chemicals Or Products Exclusion - E13653 072021 ed. Repair, Replace, Upgrade And/Or Voluntary Removal Of Underground Storage Tank Exclusion Endorsement Inapplicable To Storage Tank System Pollution Liability Coverage - E14674 022021 ed. Binding Requirements: DESCRIPTION The application notes construction of a new gas storage system. Can the Insured provide more information? Are there any plans or requirements for investigation, upgrade, replacement, removal or closure of any UST system? Policyholder Disclosure Notice of Terrorism Insurance Coverage Other Significant Terms and Conditions/Restrictions: DESCRIPTION No Material Change in Risk Term - 3 Years Coverage I.A.1. New Pollution Conditions – (BI/PD and Cleanup) I.A.2. New Pollution Conditions – 1st Party Discovery I.B.1. Existing Pollution Conditions – (BI/PD and Cleanup) I.B.2. Existing Pollution Conditions – 1st Party Discovery I.C. Transportation I.D. Non-Owned Location I.E. Crisis and Reputation Management Expense I.F. Business Interruption Costs TRIA - (if elected): 1% (not included in quoted Premium) Choice of Law: New York Covered Location Type: Municipal Site Premium $37,340.00 Taxes SLT $1,307.00 Total Taxes $1,307.00 ESTIMATED PROGRAM COST $38,647.00 Page 68 of 144 SP1.Page 71 of 152 City of Evanston 65 Auditable Exposures: DESCRIPTION EXPOSURE Automatic Acquisition - Municipal Site $0.051/sq ft with a minimum of $750 Pro-Rated Tank ID AST/UST Capacity (gal) Contents Storage Tank Address Installation Date Retroactive Date Deductible 1 UST 10,000 Gasoline 2020 Asbury,Avenue,Evanston, IL 1981 1/1/2018 $250,000 2 UST 10,000 Gasoline 2020 Asbury,Avenue,Evanston, IL 1981 1/1/2018 $250,000 3 UST 10,000 Diesel fuel 2020 Asbury,Avenue,Evanston, IL 1981 1/1/2018 $250,000 4 UST 10,000 Biodiesel 2020 Asbury,Avenue,Evanston, IL 1981 1/1/2018 $250,000 5 UST 10,000 Gasoline 2020 Asbury,Avenue,Evanston, IL 1981 1/1/2018 $250,000 6 UST 10,000 Gasoline 2020 Asbury,Avenue,Evanston, IL 1981 1/1/2018 $250,000 7 UST 10,000 Diesel 2020 Asbury,Avenue,Evanston, IL 1981 1/1/2018 $250,000 8 UST 10,000 Biodiesel 2020 Asbury,Avenue,Evanston, IL 1981 1/1/2018 $250,000 Page 69 of 144 SP1.Page 72 of 152 City of Evanston 66 Premium Summary The estimated program cost for the options are outlined in the following table: EXPIRING PROGRAM PROPOSED PROGRAM(S) LINE OF COVERAGE ESTIMATED COST PROGRAM 1 Package with Liberty PROGRAM 2 Package with Safety National Package Premium SLT/Fee Estimated Cost TRIA Premium Argonaut Insurance Company (Argo Group International Holdings, Ltd) $209,084.00 N/A $209,084.00 $933.00 Liberty Mutual Fire Insurance Company (Liberty Mutual Holding Company, Inc.) LM Insurance Corporation (Liberty Mutual Holding Company, Inc.) $545,080.00 N/A $545,080.00 Included Safety Specialty Insurance Company (Tokio Marine Holdings, Inc.) Safety National Casualty Corporation (Tokio Marine Holdings, Inc.) $308,627.00 $5,386.00 $314,013.00 $4,067.00 Excess Liability ($5M x Primary) Premium SLT/Fee Estimated Cost TRIA Premium Old Republic Union Insurance Company (Old Republic Insurance Group) $205,000.00 $7,329.00 $212,329.00 $1,775.00 Old Republic Union Insurance Company (Old Republic Insurance Group) $248,000.00 $8,866.00 $256,866.00 $1,844.00 Old Republic Union Insurance Company (Old Republic Insurance Group) $248,000.00 $8,866.00 $256,866.00 $1,844.00 Excess Liability ($5M x $10M) Premium SLT/Fee Estimated Cost TRIA Premium Arch Specialty Insurance Company (Arch Insurance Group) $113,500.00 $4,058.00 $117,558.00 $3,884.00 Arch Specialty Insurance Company (Arch Insurance Group) $140,000.00 $5,005.00 $145,005.00 $2,500.00 Arch Specialty Insurance Company (Arch Insurance Group) $140,000.00 $5,005.00 $145,005.00 $2,500.00 Property Premium SLT/Fee Estimated Cost TRIA Premium Affiliated FM Insurance Company (Factory Mutual Insurance Company) $233,938.00 N/A $233,938.00 $11,000.00 Affiliated FM Insurance Company (Factory Mutual Insurance Company) $264,525.00 N/A $264,525.00 Included Affiliated FM Insurance Company (Factory Mutual Insurance Company) $264,525.00 N/A $264,525.00 Included Page 70 of 144SP1.Page 73 of 152 City of Evanston 67 EXPIRING PROGRAM PROPOSED PROGRAM(S) LINE OF COVERAGE ESTIMATED COST PROGRAM 1 Package with Liberty PROGRAM 2 Package with Safety National Cyber Liability Premium SLT/Fee Estimated Cost TRIA Premium Travelers Casualty and Surety Co of America (The Travelers Companies, Inc.) $21,494.00 N/A $21,494.00 Included Obsedian Specialty Insurance Company $49,605.00 $1,773.38 $52,378.38 Included Obsedian Specialty Insurance Company $49,605.00 $1,836.18 $52,341.18 Included Underground Storage Tank (3 Year Term) Premium SLT/Fee Estimated Cost TRIA Premium Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) $35,598.00 $1,273.00 $36,871.00 N/A Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) $37,340.00 $1,307.00 $38,647.00 N/A Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) $37,340.00 $1,307.00 $38,647.00 N/A *AJGRMS Fee $32,500.00 $32.500.00 $32.500.00 Total Estimated Program Cost $863,774.00 $1,335,001.38 $1,103,934.38 *AJGRMS Fee paid in full in October 2021 Page 71 of 144SP1.Page 74 of 152 City of Evanston 68 Quote from Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) is valid until 1/1/2022 Quote from Old Republic Union Insurance Company (Old Republic Insurance Group) is valid until 11/26/2021 Quote from is valid until XX/XX/XXXX Quote from Affiliated FM Insurance Company (Factory Mutual Insurance Company) is valid until 1/1/2022 Quote from is valid until 1/8/2022 Quote from is valid until XX/XX/XXXX Quote from Liberty Mutual Fire Insurance Company (Liberty Mutual Holding Company, Inc.), etc... is valid until 1/1/2022 Quote from Liberty Insurance Corporation (Liberty Mutual Holding Company, Inc.) is valid until 1/1/2022 Quote from Ironshore Specialty Insurance Co (Ironshore Specialty Insurance Co) is valid until 1/1/2022 Gallagher is responsible for the placement of the following lines of coverage: Package Excess Liability ($5M x Primary) Excess Liability ($5M x $10M) Excess Liability ($5M x $15M) Umbrella - $4M Property Cyber Liability Underground Storage Tank Special Events Coverage It is understood that any other type of exposure/coverage is either self-insured or placed by another brokerage firm other than Gallagher. If you need help in placing other lines of coverage or covering other types of exposures, please contact your Gallagher representative. Page 72 of 144SP1.Page 75 of 152 City of Evanston 69 Payment Plans CARRIER / PAYABLE CARRIER LINE OF COVERAGE PAYMENT SCHEDULE PAYMENT METHOD Liberty Mutual Fire Insurance Company (Liberty Mutual Holding Company, Inc.) LM Insurance Corporation (Liberty Mutual Holding Company, Inc.) Package Annual Agency Bill Safety Specialty Insurance Company (Tokio Marine Holdings, Inc.) Safety National Casualty Corporation (Tokio Marine Holdings, Inc.) Package Annual Agency Bill Old Republic Union Insurance Company (Old Republic Insurance Group) Excess Liability ($5M x Primary) Annual Agency Bill Arch Specialty Insurance Company Excess Liability ($5M x $10M) Annual Agency Bill Affiliated FM Insurance Company (Factory Mutual Insurance Company) Property Annual Agency Bill Obsidian Specialty Insurance Company Cyber Liability Annual Agency Bill Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) Underground Storage Tank Annual Agency Bill Ironshore Specialty Insurance Co (Ironshore Specialty Insurance Co) Underground Storage Tank Annual Agency Bill Page 73 of 144 SP1.Page 76 of 152 City of Evanston 70 Carrier Ratings and Admitted Status PROPOSED INSURANCE COMPANIES A.M. BEST'S RATING & FINANCIAL SIZE CATEGORY * ADMITTED/NON-ADMITTED ** Affiliated FM Insurance Company A+ XV Admitted Arch Specialty Insurance Company A+ XV Non-Admitted Ironshore Specialty Insurance Co A XV Non-Admitted Liberty Insurance Corporation A XV Admitted Liberty Mutual Fire Insurance Company A XV Admitted Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) A XV Non-Admitted LM Insurance Corporation A XV Admitted Obsidian Specialty Insurance Company A-VII Non-Admitted Old Republic Union Insurance Company A+ XV Non-Admitted Safety National Casualty Corporation A++ XV Admitted Safety Specialty Insurance Company A++ XV Non-Admitted *Gallagher companies use A.M. Best rated insurers and the rating listed above was verified on the date the proposal document was created. Best's Credit Ratings™ reproduced herein appear under license from A.M. Best and do not constitute, either exp ressly or impliedly, an endorsement of Gallagher’s service or its recommendations. A.M. Best is not responsible for transcription error s made in presenting Best's Credit Ratings™. Best’s Credit Ratings™ are proprietary and may not be reproduced or distribu ted without the express written permission of A.M. Best. A Best’s Financial Strength Rating is an independent opinion of an insurer’s financial strength and ability to meet its ongoi ng insurance policy and contract obligations. It is not a warranty of a company’s financial strength and ability to meet its obligations to policyholders. Best's Credit Ratings™ are under continuous review and subject to change and/or affirmation. For the lat est Best’s Credit Ratings™ and Guide to Best’s Credit Ratings, visit the A.M. Best website at http://www.ambest.com/ratings. **If coverage placed with a non-admitted carrier, it is doing business in the state as a surplus lines or non-admitted carrier, and is neither subject to the same regulations as an admitted carrier nor do they participate in any state insurance guarantee fund. Gallagher companies make no representations and warranties concerning the solvency of any carrier, nor does it make any representation or warranty concerning the rating of the carrier which m ay change. Page 74 of 144 SP1.Page 77 of 152 City of Evanston 71 Proposal Disclosures Proposal Disclosures Page 75 of 144 SP1.Page 78 of 152 City of Evanston 72 Proposal Disclosures The following disclosures are hereby made a part of this proposal. Please review these disclosures prior to signing the Client Authorization to Bind or e-mail confirmation. Proposal Disclaimer IMPORTANT: The proposal and/or any executive summaries outline certain terms and conditions of the insurance proposed by the insurers, based on the information provided by your company. The insurance policies themselves must be read to fully understand the terms, coverages, exclusions, limitations and/or conditions of the actual policy contract of insurance. Policy forms will be made available up on request. We make no warranties with respect to policy limits or coverage considerations of the carrier. Compensation Disclosure 1. Gallagher Companies are primarily compensated from the usual and customary commissions, fees or, where permitted, a combin ation of both, for brokerage and servicing of insurance policies, annuity contracts, guarantee contracts and surety bonds (collectively “insurance coverages”) handled for a client’s account, which may vary based on market conditions and the insurance product placed for th e client. 2. In placing, renewing, consulting on or servicing your insurance coverages, Gallagher companies may participate in contingent and supplemental commission arrangements with intermediaries and insurance companies that provide for additional compensation if certain underwriting, profitability, volume or retention goals are achieved. Such goals are typically based on the total amount of certain insurance coverages placed by Gallagher with the insurance company, not on an individual policy basis. As a result, Gallagher may be c onsidered to have an incentive to place your insurance coverages with a particular insurance company. If you do not wish to have your commercial insurance placement included in consideration for additional compensation, contact your producer or service team for an Opt -out form. 3. Gallagher Companies may receive investment income on fiduciary funds temporarily held by them, or from obtaining or generating premium finance quotes, unless prohibited by law. 4. Gallagher Companies may also access or have an ownership interest in other facilities, including wholesalers, reinsurance intermediaries, captive managers, underwriting managers and others that act as intermediaries for both Gallagher and other brokers in the ins urance marketplace some of which may earn and retain customary brokerage commission and fees for their work. If you have specific questions about any compensation received by Gallagher and its affiliates in relation to your insurance placements, please contact your Gallagher representative for more details. In the event you wish to register a formal complaint regarding compensation Gallagher receives from insurers or third-parties, please contact Gallagher via e-mail at Compensation_Complaints@ajg.com or by regular mail at: Chief Compliance Officer Gallagher Global Brokerage Arthur J. Gallagher & Co. 2850 Golf Rd. Rolling Meadows, IL 60008 TRIA/TRIPRA Disclaimer If this proposal contains options to purchase TRIA/TRIPRA coverage, the proposed TRIA/TRIPRA program may not cover all terror ism losses. While the amendments to TRIA eliminated the distinction between foreign and domestic acts of terrorism, a number of lines of coverage excluded under the amendments passed in 2005 remain excluded including commercial automobile, burglary and theft insurance; s urety insurance, farm owners multiple perils and professional liability (although directors and officers liability is specifically included). If such excluded coverages are required, we recommend that you consider purchasing a separate terrorism policy. Please note that a separate terrorism policy for these excluded coverages may be necessary to satisfy loan covenants or other contractual obligations. TRIPRA includes a $100 billion cap on insurers' aggregate liability. TRIPRA is set to expire on December 31, 2027. There is no certainty of extension, thus the coverage provided by your insurers may or may not extend beyond December 31, 2027. In the event you have loan covenants or other contractual obligations requiring that TRIA/TRIPRA be maintained throughout the duration of your policy period, we recommend that a separate ""Stand Alone"" terrorism policy be purchased to satisfy those obligations. Property Estimator Disclaimer Page 76 of 144 SP1.Page 79 of 152 City of Evanston 73 These property values were obtained using a desktop Property Estimator software operated by non-appraisal professionals. These property values represent general estimates which are not to be considered a certified appraisal. These property values include genera lities and assumptions that may produce inaccurate values for specific structures. Page 77 of 144 SP1.Page 80 of 152 City of Evanston 74 Client Signature Requirements Client Signature Requirements Page 78 of 144 SP1.Page 81 of 152 City of Evanston 75 Coverages for Consideration Overview • A proposal for any of the coverages can be provided. • The recommendations and considerations summarized in this section are not intended to identify all exposu res. • Since Gallagher does not handle your complete insurance program, these recommendations only reflect items within our scope of responsibility. Other Coverage Considerations • Crisis Protect • Builders Risk Page 79 of 144 SP1.Page 82 of 152 City of Evanston 76 Client Authorization to Bind Coverage After careful consideration of Gallagher's proposal dated 12/2/2021, we accept the following coverage(s). Please check the desired coverage(s) and note any coverage amendments below: COVERAGE/CARRIER ☐ Accept ☐ Reject Package ☐ Option # 1 Liberty Mutual Fire Insurance Company, LM Insurance Corporation ☐ Option # 2 Safety Specialty Insurance Company, Safety National Casualty Corporation ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Excess Liability ($5M x Primary) Old Republic Union Insurance Company ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Excess Liability ($5M x $10M) Arch Specialty Insurance Company ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Property Affiliated FM Insurance Company ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Cyber Liability ☐ Option # 1 Obsidian Specialty Insurance Company ☐ Option # 2 Travelers (Coverage Extension to 1/31/22 – AP $1,767.00) ☐ Accept ☐ Reject TRIA ☐ Accept ☐ Reject Underground Storage Tank ☐ Option # 1 Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) ☐ Option # 2 Ironshore Specialty Insurance Co- $3M Each Occ/ 1 Year ☐ Option # 3 Ironshore Specialty Insurance Co - $3M Each Occ/ 3 Year ☐ Option # 4 Ironshore Specialty Insurance Co - $6M Each Occ/ 1 Year ☐ Option # 5 Ironshore Specialty Insurance Co - $6M Each Occ/ 3 Year ☐ Accept ☐ Reject TRIA 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: _____________________________________________________________________________________________ Page 80 of 144 SP1.Page 83 of 152 City of Evanston 77 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. Provide Quotations or Additional Information on the Following Coverage Considerations: Gallagher recommends that you purchase the following additional coverages for which you have exposure. By rejecting a quotation for this valuable coverage, you understand that there will be no coverage and agree to hold Gallagher harmless in t he event of a loss. Other Coverages to Consider ☐ Yes ☐ No - Crisis Protect ☐ Yes ☐ No - Builders Risk Other Services to Consider ☐ Yes ☐ No - CORE360™ Loss Control Portal ☐ Yes ☐ No - eRiskHub Gallagher's liability to Client arising from any acts or omissions of Gallagher shall not exceed $20 million in the aggregate. Gallagher shall only be liable for actual damages incurred by Client, and shall not be liable for any indirect, consequential or punitive damages or attorneys' fees. No claim or cause of action, regardless of form (tort, contra ct, statutory, or otherwise), arising out of, relating to or in any way connected with this Agreement or any Services provided hereunder may be brought by either party any later than two (2) years after the accrual of such claim or cause of action. 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/. Page 81 of 144 SP1.Page 84 of 152 City of Evanston 78 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: _______________________________________________________________________ Name _______________________________________________________________________ Title _______________________________________________________________________ Signature Date: _______________________________________________________________________ Page 82 of 144 SP1.Page 85 of 152 City of Evanston 79 Appendix Appendix Page 83 of 144 SP1.Page 86 of 152 City of Evanston 80 Bindable Quotations & Compensation Disclosure Schedule Client Name: City of Evanston COVERAGE(S) CARRIER NAME(S) WHOLESALER, MGA, OR INTERMEDIARY NAME1 EST. ANNUAL PREMIUM2 COMM.% OR FEE3 GALLAGHER U.S. OWNED WHOLESALER, MGA, OR INTERMEDIARY % Package Liberty Mutual Fire Insurance Company (Liberty Mutual Holding Company, Inc.) LM Insurance Corporation (Liberty Mutual Holding Company, Inc.) N/A $545,080.00 0 % 0 % Package Safety Specialty Insurance Company (Tokio Marine Holdings, Inc.) Safety National Casualty Corporation (Tokio Marine Holdings, Inc.) NA $308,627.00 0 % 0 % Excess Liability ($5M x Primary) Old Republic Union Insurance Company (Old Republic Insurance Group) N/A $248,000.00 0 % 0 % Excess Liability ($5M x $10M) Arch Specialty Insurance Company Risk Placement Services $140,000.00 0 % 10 % Property Affiliated FM Insurance Company (Factory Mutual Insurance Company) N/A $264,525.00 0 % 0 % Cyber Liability Obsidian Specialty Insurance Company N/A $49,605.00 13.3 % 6.7 % Underground Storage Tank Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) N/A $37,340.00 17.5 % 0 % Page 84 of 144SP1.Page 87 of 152 City of Evanston 81 COVERAGE(S) CARRIER NAME(S) WHOLESALER, MGA, OR INTERMEDIARY NAME1 EST. ANNUAL PREMIUM2 COMM.% OR FEE3 GALLAGHER U.S. OWNED WHOLESALER, MGA, OR INTERMEDIARY % Underground Storage Tank Ironshore Specialty Insurance Co (Ironshore Specialty Insurance Co) N/A $42,856.00 17.5 % 0 % AJGRMS Fee PNP $32,500.00 0 % 0 % 1 We were able to obtain more advantageous terms and conditions for you through an intermediary/ wholesaler. 2 If the premium is shown as an indication: The premium indicated is an estimate provided by the market. The actual premium and acceptance of the coverage requested will be determined by the market after a thorough review of the completed application. * A verbal quotation was received from this carrier. We are awaiting a quotation in writing. 3 The commission rate is a percentage of annual premium excluding taxes & fees. * Gallagher is receiving ___% commission on this policy. The fee due Gallagher will be reduced by the amount of the commissions received. Page 85 of 144SP1.Page 88 of 152 City of Evanston 82 Binding Requirements COVERAGE (ISSUING CARRIER) BINDING REQUIREMENT Package Liberty Mutual Fire Insurance Company LM Insurance Corporation Governmental Entity Supplemental Application/Confirming receipt of the corrected proposal and Government Supp with COVID Questionnaire. If the Named Insured’s signature is required for any of the policies or coverages included in this proposal, they must be signed by the proposed Named Insured and returned to us by the effective date of the policy, or within 30 days of receipt, whichever is later. Prior approval of TPA and Self-Administration. Please forward a contact name at the insured’s and the TPA so that an interview or visit may be arranged. A Liberty Mutual Supplemental Application, with the General Information and all other applicable sections completed, signed by the Insured. Signed TRIA forms (if rejecting). Insured Contact (Name, Email, Phone) for risk control, premium/loss billing, claims, as applicable. Favorable results or compliance with recommendations from any risk control survey which may be provided to the insured during the policy year. Package Safety Specialty Insurance Company Safety National Casualty Corporation Need retroactive dates for EBL and POL/EPL coverages Self-Administration of Claims Application and Supporting Documentation must be Submitted and Subsequent Approval for the Self-Administration of Claims Must be Provided as a Condition to Binding TRIA Per attached disclosure- Signed copy must be received prior to binding of coverage City Must Maintain an Excess Workers Compensation Relationship with Safety National Signed UM/UIM Selection/Rejection Form Excess Liability ($5M x Primary) Old Republic Union Insurance Company Complete and Signed Old Republic Specialty Insurance Underwriters Renewal Business Supplemental Application Copy of 2022-2023 Underlying Policy (required if bound) Signed Terrorism Select/Reject Form. (required if bound) Excess Liability ($5M x $10M) Arch Specialty Insurance Company Subject to Signed Diligent Effort Affidavit (AJG to Complete) Subject to Signed Illinois Brokers Service Contract Subject to Signed and Dated “Acceptance or Rejection of Terrorism” Form Property Affiliated FM Insurance Company Subject to Signed Illinois Brokers Service Contract Cyber Liability Obsidian Specialty Insurance Company Subject to Signed and Dated “Acceptance or Rejection of Terrorism” form Page 86 of 144 SP1.Page 89 of 152 City of Evanston 83 COVERAGE (ISSUING CARRIER) BINDING REQUIREMENT Underground Storage Tank Lloyds' Syndicate 2623/623 (Beazley Furlonge Ltd) The application notes construction of a new gas storage system. Can the Insured provide more information? Are there any plans or requirements for investigation, upgrade, replacement, removal or closure of any UST system? Policyholder Disclosure Notice of Terrorism Insurance Coverage Underground Storage Tank Ironshore Specialty Insurance Co Written request to bind prior to policy effective date Signed Terrorism Policyholder Disclosure Surplus Lines License Information Signed and completed Ironshore application Copy of Mold/Indoor Air Quality Plans List of any capital improvements planned during the policy term Please confirm no firing ranges in the portfolio Page 87 of 144 SP1.Page 90 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 1 of 16 1.NAME OF ENTITY 2.MAILING ADDRESS 3.WEBSITE 4.EFFECTIVE DATE 5.QUOTE DUE DATE 6.AGENCY/BROKER 7.PRODUCER/CONTACT Please provide completed ACORD® applications for all lines of business desired. Complete all general sections of the supplemental application and those coverage sections for which a quote is desired. GOVERNMENTAL ENTITY GENERAL INFORMATION 1. Type Entity: ☐City ☐Village ☐Town ☐Township ☐County ☐Fire District ☐Water District ☐Sewer District ☐Other 2.Entity population: 3.Total number of employees:a.# Law Enforcement:b.# Fire Fighters: 4.Person responsible for risk management/safety:Email: 5.Person responsible for claims:Email: 6.For each group specified indicate below if the following written employment policy includes: Group Application Criminal Background/ Sexual Registry Checks MVR Drug Testing Employee Reference Checks Pre- Placement Physicals All Employees ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N Law Enforcement ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N Transit Drivers ☐ Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N Volunteers ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N ☐Y ☐ N 7.Is the risk manager full-time (FT) or part-time (PT)?☐FT ☐ PT 8.Does the entity have a formalized safety / risk management program?☐Y ☐N 9.If yes, does the program include: a.Written safety or loss prevention manual?☐Y ☐N b.Training program for general safety, drivers and equipment operators?☐Y ☐N c.New employee orientation / training?☐Y ☐N d.Property or equipment inspection and maintenance program?☐Y ☐N e.Formal accident investigation program?☐Y ☐N f.Prompt reporting of claims to insurance carrier within 48 hours of the incident occurrence?☐Y ☐N 10.Does the entity have a formal mutual aid agreement with any other entity? ☐ Y ☐N If "yes", give details and indicate services involved, equipment provided and the community(ies) served: GOVERNMENTAL ENTITY EXPOSURE CHECKLIST Please check the operational exposures which exist for the governmental entity. Coverage may not be available for all operations. ** Requires completion of additional information in the supplemental application appendix. Governmental Entity Supplemental Application Page 88 of 144 SP1.Page 91 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 2 of 16 1.Airport and Related Facilities**☐Y ☐ N 21. Museum ☐Y ☐ N 2.Ambulance/Emergency Medical Services ☐Y ☐ N 22. Nurse/Jail Nurse ☐Y ☐ N 3.Bleachers, Grandstands or Stadiums ☐Y ☐ N 23. Nursing Home/Assisted Living ☐ Y ☐ N 4.Camps**☐Y ☐ N 24. Owned Aircraft (including drones)** ☐Y ☐ N 5.Carnivals, Fairs ☐Y ☐ N 25. Parks & Recreation**☐Y ☐ N 6.Cemeteries If yes, # acres ☐Y ☐ N 26. Port Authority, Docks, Piers**☐Y ☐ N 7.Parades ☐Y ☐ N 27. Rifle/Shooting Range (public use)** ☐Y ☐ N 8.Dams, Dikes, Levees, Reservoirs**☐Y ☐ N 28. Sanitation, Garbage Collection ☐ Y ☐ N 9.Daycare Center **☐Y ☐ N 29. Skate Park**☐Y ☐ N 10.Emergency Shelters**☐Y ☐ N 30. Special Events**☐Y ☐ N 11.Fire Department**☐Y ☐ N 31. Swimming Pool, Beach**☐Y ☐ N 12.Fireworks**☐Y ☐ N 32. Transit Systems ☐Y ☐ N 13.Golf Course**☐Y ☐ N 33. Utility-Gas**☐Y ☐ N 14.Hospital, Medical Clinic ☐Y ☐ N 34. Utility – Electric**☐Y ☐ N 15.Housing Authority**☐Y ☐ N 35. Utility-Water**☐Y ☐ N 16.Ice or Roller Skating Rinks**☐Y ☐ N 36. Vacant Property (other than seasonal)** ☐Y ☐ N 17.Jail, Holding Cell or Detention Center**☐Y ☐ N 37. Wastewater Plant ☐Y ☐ N 18.Landfill**☐Y ☐ N 38. Watercraft/Boats ☐Y ☐ N 19.Law Enforcement ☐Y ☐ N 39. Waterslides ☐Y ☐ N 20.Liquor Liability Events**☐Y ☐ N 40. Zoo**☐Y ☐ N STREETS AND ROADS 1.Miles of roads owned: 2.Miles of roads maintained for others: 3.Number of railroad crossings: a.Controlled b.Uncontrolled 4.Who performs the following functions:Entity Contractor a.Street cleaning ☐☐ b.Grass cutting, tree pruning/removal, fertilizing ☐☐ c.Gravel spreading ☐☐ d.Installation and maintaining guard rails, markers, street sign ☐☐ e.Paving and resurfacing roads ☐☐ f.Snow removal ☐☐ g.Installation and maintenance of traffic lights ☐☐ h.Installation and maintaining street light and poles ☐☐ i.New road construction ☐☐ j.Ongoing inspection of traffic lights, signs and roads ☐☐ BRIDGES Check if N/A ☐ 1.Number of bridges owned/maintained by entity: a.Railway b.Street c.Highway d.Pedestrian e.Toll bridge Page 89 of 144 SP1.Page 92 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 3 of 16 2.Describe all bridges 50 feet or greater in length (classification, length, number of lanes): 3.Have any of the bridges been coded by the National Bridge Inventory as 1, 2 or 3?☐Y ☐N If yes, how many are #1 #2 #3 4.How often are the bridges inspected? 5.Who conducts the inspection? 6.Who performs bridge construction, repair and maintenance? SUBCONTRACTED MAINTENANCE / REPAIR / SERVICES 1.Do you require subcontractors to carry liability limits of insurance that are equal to or greater than your limits of insurance?☐Y ☐ N ☐ N/A If yes, what limits of insurance are required? $ 2.Are the subcontractors’ liability policies with an AM Best rated company of A- or better?☐Y ☐ N 3.Do you require hold harmless and indemnification agreements from subcontractors?☐Y ☐ N 4.Do you require subcontractors to name you as an additional insured on the subcontractor's liability policy?☐Y ☐ N 5.Do you require it include completed operations coverage?☐Y ☐ N 6.Are all contracts reviewed by your attorney before signing?☐Y ☐ N GENERAL LIABILITY (Complete if a quote is being requested): 1.If potentially hazardous chemicals are used such as pool chemicals or pesticides, what are the chemicals, how are they used and stored? 2.Do you have an environmental impairment policy?☐Y ☐ N If yes, what are the liability limits? $ 3.Facilities Use Agreements: a.Do groups other than the public entity use the building or facilities for functions?☐Y ☐ N If yes, provide details of use: b.How do you control building usage and premises security when outside groups rent or borrow your facilities? c.Do you utilize attorney-reviewed written facility use agreement when outside groups rent or borrow your facilities?☐Y ☐ N d.Do you receive a certificate of liability insurance from each group and is the public entity listed as an additional insured on the users general liability policy?☐Y ☐ N If so, what liability limits are required? e.Is the entity named as an additional insured on the facility users general liability ☐Y ☐ Ninsurance policy? CYBER SUITE COVERAGE (Complete if a quote is being requested): Limits of Insurance: 1.When requesting Aggregate Limits below $500,000, select the proposed Aggregate Limit from the drop-down above. No other information is required. 2.Please complete the following questions when requesting Aggregate Limits of $500,000 or $1,000,000: a.Have you, at any time during the past 36 months, experienced a cyber incident (hacking, intrusion, malware infection, fraud loss, breach of personal information, extortion, etc.) that cost you more than $10,000 or experienced a lawsuit or other formal dispute (with either a private party or government agency) arising from a cyber incident? ☐Y ☐ N b.Do you use up-to-date anti-virus and anti-malware protection on all of your endpoints (desktops, laptops, servers, etc.)?☐Y ☐ N c.Are all of your internet access points secured by firewalls?☐Y ☐ N d.Do you restrict employees' and external users' IT systems privileges and access to personal information on a business-need-to-know basis?☐Y ☐ N e.Do you perform backups of business critical data on at least a weekly basis?☐Y ☐ N f.Do you encrypt all of your mobile devices (laptops, flash drives, mobile phones, etc.) and confidential data?☐Y ☐ N Page 90 of 144 SP1.Page 93 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 4 of 16 3.Aggregate Limits above $1,000,000 may be requested by completing the Cyber Suite Supplemental Application (LC 88 02 or state version). Before completing LC 88 02, please review the questions under Item 2. above. Aggregate Limits above $1,000,000 will not be available if the answer to question 2.a. above is "yes" or if the answers to 3 or more of the remaining questions under 2. above are "no". SEXUAL MISCONDUCT LIABILITY (Complete if a quote is being requested): ☐Claims-Made1.Coverage Basis: ☐ Occurrence 2.If Claims-Made, Proposed Retroactive Date: 3.Limit of Insurance: 4.Deductible: 5.List the following prior carrier information: company name; policy period; limits; deductible and premium. 6.Do you have a written training program for all employees and volunteer workers outlining your sexual misconduct and molestation policies and procedures?☐Y ☐ N 7.Do you have a written policy statement that any act of physical, sexual abuse or harassment is not tolerated?☐Y ☐ N If yes, is this statement communicated to all employees and volunteers?☐Y ☐ N 8.Do you have written guidelines for the reporting of suspected abuse or neglect of children? ☐ Y ☐ N If yes, are these guidelines communicated to all employees & volunteers? ☐ Y ☐ N 9.Do you have a policy that at least two adults must share the supervisory responsibilities of children under the age of 18 at all times?☐Y ☐ N Historical Activity 1.Are you aware of any past or present notice, claim, written demand for damages, or lawsuit involving an alleged incident of sexual misconduct or allegations of sexual misconduct: a.Against you?;☐Y ☐ N b.Against any person or entity directly or indirectly associated with you (including but not limited to your past or present officials, members, commissioners, director, executive officers, trustees, employees, volunteers, vendors, and others on your premises or involved in your activities, events or programs)?; or ☐Y ☐ N c.Involving activities, events, or programs that you sponsor or that take place on your premises?☐Y ☐ N 2.Are you aware of any past or present alleged incident of sexual misconduct that was investigated by: a.You?;☐Y ☐ N b.Any person or entity where the alleged incident of sexual misconduct allegedly occurred during any activities, events, or programs that you sponsored or that took place on your premises?; or ☐Y ☐ N c.A governmental authority or law enforcement department or agency, whether federal, state, or local, arising out the alleged sexual misconduct of a person who was your past, present, or future official, member, commissioner, director, executive officer, trustee, employee, volunteer, vendor, or other person on your premises or involved in your activities, events or programs? ☐Y ☐ N 3.Are you aware of any fact or circumstance that could reasonably be expected to give rise to, or result in, a notice, claim, or a lawsuit involving allegations of sexual misconduct?☐Y ☐ N 4.If you answer ‘Yes’ to questions 1., 2., or 3. above, identify the role of the person(s) (i.e. official, employee, volunteer, etc.) involved in the sexual misconduct incident and provide a general description of the allegations, any investigation, and how the matter was resolved. EMPLOYMENT PRACTICES LIABILITY (Complete if a quote is being requested) ☐Claims-Made1.Coverage Basis: ☐ Occurrence 2.If Claims-Made, Proposed Retroactive Date: 3.Limit of Insurance: 4.Deductible: Page 91 of 144 SP1.Page 94 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 5 of 16 5.Do you conduct an orientation for all new employees?☐Y ☐ N If "yes", is an orientation checklist maintained for each employee?☐Y ☐ N 6.Do you provide an attorney reviewed employee handbook of personnel policies?☐Y ☐ N If yes, when was the handbook last reviewed by an attorney? 7.Do you have written policies, programs or procedures for the following? a.Regular performance evaluations of all employees?☐Y ☐ N b.Grievance programs available to employees?☐Y ☐ N c.Progressive disciplinary program including suspension and dismissal of staff?☐Y ☐ N d.Policies and procedures that prohibit discrimination against employees based on race, color, religion, creed, age, sex (including sexual orientation), gender (including gender identity), disability or handicap, pregnancy, physical appearance or national origin?☐Y ☐ N e.If "yes" to any of the above, do your supervisory employees receive regular training in the implementation of these policies and procedures?☐Y ☐ N 8.Is there a qualified independent legal review of all termination decisions?☐Y ☐ N 9.Are your employment policies reviewed by legal counsel prior to adopting?☐Y ☐ N 10.Have there been any actual or alleged claims or incidents within the past five years involving unfair or improper treatment, harassment or other rights violations?☐Y ☐ N If yes, describe the incident and the ultimate resolution including any payments made: PUBLIC OFFICIAL LIABILITY (Complete if a quote is being requested): ☐Claims-Made1.Coverage Basis: ☐ Occurrence 2.If Claims-Made, Proposed Retroactive Date: 3.Limit of Insurance: 4.Deductible: Public Officials – Non-Monetary Defense ☐ Yes ☐ No 5.Limit of Insurance: 6.Financial Information: a.What are the total projected expenditures for the current year (other than projects financed by bonds)? b.What is the total projected income for the current fiscal year (other than borrowed funds)? c.Total accumulated deficit (other than bonds)? $ d.Total accumulated surplus? $ e.Explain reasons for any current budget deficit and/or accumulated deficit: f.Describe plans for eliminating the budget deficit: 7.Total number of appointed or elected officials, board and committee members: 8.List all boards and committees sponsored or sanctioned by the entity and briefly describe their functions: 9.Do you have written by-laws governing the duties, responsibilities and conduct of your officials board and committee members?☐Y ☐ N 10.Have there been any actual or alleged claims or incidents within the past five years involving appraisals, zoning, design, code enforcement, eminent domain, antitrust, rights violations or other unfair or improper treatment?☐Y ☐ N If yes, describe the incident and the ultimate resolution including any payments made: COMMERCIAL AUTO (Complete if a quote is being requested) FLEET SAFETY MANAGEMENT PROGRAM 1.Does the entity have a transportation director on staff?☐Y ☐ N 2.Are drivers required to conduct and document a daily pre-trip inspection?☐Y ☐ N 3.Are drivers required to conduct and document a daily post-trip inspection? 4.Do you have criteria for MVR acceptability?☐Y ☐ N 5.Do you provide driver training for drivers of larger or specialized vehicles?☐Y ☐ N Page 92 of 144 SP1.Page 95 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 6 of 16 6.How many employees/volunteers use their personal vehicles on entity business?☐Y ☐ N 7.Please provide details on the nature of the personal vehicle use (e.g. running errands, volunteer firefighters, other: 8.Do you verify that each individual using a personal vehicle on entity business has valid automobile liability insurance?☐Y ☐ N If yes, what auto liability limits do you require each individual carry? $ 15 Passenger Vans 1.How many 15 passenger vans do you have in your vehicle fleet? 2.If you have 15 passenger vans: a.Describe the use of the van: b.Have any modifications been made to the vans to reduce the rollover potential?☐Y ☐ N If yes, please describe: Law Enforcement Vehicles 1.If law enforcement vehicles are included on the vehicle schedule, do you have policies and procedures for the following: a.Patrol driving and response?☐Y ☐ N b.Transportation of prisoners?☐Y ☐ N c.Vehicular pursuit policy including high speed?☐Y ☐ N If yes, describe policy: Passenger Transportation Service 1.If passenger transportation vehicles are included on the fleet schedule, what type of service is provided? Scheduled bus route ☐ Social services ☐ Demand response ☐Daycare/Day camp/ Recreation programs ☐ Para-transit ☐Van Pool ☐ 2.Are there written procedures and driver training for the transport of handicapped individuals?☐Y ☐ N 3.Are equipment tie-downs used for the transport of handicapped individuals?☐Y ☐ N 4.Are passenger restraints used for the transport of handicapped individuals?☐Y ☐ N 5.Is loading/unloading of handicapped individuals provided?☐Y ☐ N 6.Is door to door service of handicapped individuals provided?☐Y ☐ N 7.How many passengers are served on an annual basis? # LAW ENFORCEMENT PROFESSIONAL LIABILITY (Complete if a quote is being requested) ☐Claims-Made1.Coverage Basis: ☐ Occurrence 2.If Claims-Made, Proposed Retroactive Date: 3.Limit of Insurance: 4.Deductible: 5.Non-monetary coverage desired? ☐ Y N Limits: Deductible: Classification of Law Enforcement Personnel Law Enforcement Employees Law Enforcement Support Employees 1.Sheriff/chief:# 1.F/T or P/T jailers/matrons, dispatchers:# 2.Chief/deputy/deputy chief:# 2.Civil process staff:# 3.Personnel with rank of sergeant or higher: #3.Court security staff:# 4.Full-time personnel: patrol detectives and investigators: # 4.P/T staff; auxiliary/reserve officers armed/ arrest authority: # 5.Jail administrators:# 6.Police dogs:# Page 93 of 144 SP1.Page 96 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 7 of 16 Law Enforcement Support Employees All Other Employees 1.School crossing guards:# 1.Not otherwise listed:# 2.Animal control officers:# 3.Jail nurses/doctors/coroners:# 4.Unarmed; P/T; auxiliary/reserve officers/arrest authority:# 5.Communication/dispatcher personnel:# General - Law Enforcement 1.Does your police department authorize employees to engage in non-departmental security duties?☐Y ☐ N If yes, indicate what % employees to engage in non-departmental security duties and the types of jobs allowed and any types not allowed: 2.Do you have a policy and procedure manual?☐Y ☐ N If yes, how frequently is it updated? 3.Does the department monitor compliance on a regular basis?☐Y ☐ N If yes, describe process: 4.Is the manual distributed to and reviewed with all personnel?☐Y ☐ N Does the manual include direction on:☐Y ☐ N a.Deadly force (including procedures that have been banned)?☐Y ☐ N b.Non-deadly force?☐Y ☐ N c.Taser use?☐Y ☐ N d.Domestic violence?☐Y ☐ N e.Intoxicated individuals?☐Y ☐ N f.Protection of civil rights?☐Y ☐ N g.Vehicle pursuit including high speed?☐Y ☐ N 5.Does the department have minimum in-service training requirements?☐Y ☐ N If yes, describe the type and extent of training provided: 6.Do you provide law enforcement services for any other public or private entity by contract other than a mutual aid law?☐Y ☐ N If yes, describe: 7.Do you have an internal review process of any alleged violations involving use of undue force, violation of rights or other improper actions?☐Y ☐ N If yes, describe: 8.Are psychological evaluations completed as part of the law enforcement professional employment hiring process?☐Y ☐ N 9.Do you have any police, fire, or rescue boats?☐Y ☐ NIf yes, total number of boats? SEWER BACKUP INFORMATION (Complete if a quote is being requested) Limit of Insurance: $ Deductible: 1.What is the approximate age of the sewer system? 2.What is the material composition of the system? If more than one material used, provide a % breakdown of materials 3.How many miles of municipal sewer system does your municipality maintain? 4.Estimated number of residences connected? Estimated number of businesses connected? 5.Average number of connections made annually for residential? for commercial? 6.How many lift stations does your municipality have? 7.If your municipality has lift stations, do you have a monitored alarm system that: a.Identifies a power failure?☐Y ☐ N b.Identifies high water levels?☐Y ☐ N c.Reports to a central location?☐Y ☐ N d.How often is the monitored alarm system tested? Page 94 of 144 SP1.Page 97 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 8 of 16 8.Does your municipality have an emergency response plan when a back-up is reported?☐Y ☐ N 9.What is the breakdown by type of use of the annual wastewater treated? % Commercial % Residential 10.Does your municipality have a combined storm water and wastewater system ☐Y ☐ N If yes, explain how excess heavy rain is handled. (Tanks, retention ponds, etc.) 11.Does the sewer maintenance program include: a.A detailed and specific plan for routine maintenance of the sewer lines?☐Y ☐ N b.The video inspection of sewer lines ☐Y ☐ N If yes, what is the % video inspected each year?% c.Requiring the installation of grease traps in all grease producing commercial facilities? ☐ Y ☐ N 12.Does your sewer backup prevention program include: a.Identified problem areas and established procedures to address them?☐Y ☐ N What are the problem area’s you have identified? b.The required use of “backflow preventers” in any area of your district?☐Y ☐ N c.Educating residents on the proper backflow preventer inspection techniques?☐Y ☐ N d.Warning residential customers with clay sewer pipes of possible collapse?☐Y ☐ N If yes, do you suggest lateral replacements to the street? f.Rules prohibiting occupants from directing sump pumps into the sewer system?☐Y ☐ N g.A commercial effluent discharge-monitoring program designed to ensure against discharge of waste that may cause or contribute to corroding lines?☐Y ☐ N 13.Are any residential rain gutters connected to the sewer system?☐Y ☐ N If yes, approximately what % of total residential rain gutters are connected to sewer system? 14.Is there a notification policy in place to inform the insurance carrier of any sewer backup claim?☐Y ☐ N 15.What is the sewer back-up claim history for the last 5 years? Distinguish between mains and laterals if possible. List incident dates, resolution and amounts paid: WORKERS COMPENSATION (Complete if a quote is being requested): 1.Do you have a formal Return-To-Work program?☐Y ☐ N 2.Do you utilize the services of a managed care provider to control health care costs?☐Y ☐ N If yes, describe services provided: 3.What are the average number of employee travel days: Out of state:Out of country : 4.If the entity has the following operations, please describe the applicable practices: 5.Health Care Facilities/Services: Blood borne pathogens and safe lifting techniques: 6.Street Department/Utility Operations: Fall protection and confined space entry: UMBRELLA (Complete if a quote is being requested) 1.Limit requested $ 2.Do you own any aircraft?☐Y ☐ N 3.Do you haul any explosives, munitions, fuels or any hazardous material?☐Y ☐ N If yes, please describe: 4.Do you have underground storage tanks on premises owned or leased?☐Y ☐ N PROPERTY / EQUIPMENT BREAKDOWN (Complete if a quote is being requested) Please provide a completed ACORD application including a completed statement of values for property coverage. Provide an equipment breakdown application noting locations requiring jurisdictional inspections. Page 95 of 144 SP1.Page 98 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 9 of 16 1.Are there any historic buildings or buildings with unique architectural features, ornate facades ornamentation or slate/tile roofs? ☐Y ☐ N a.If yes, what is the age of building(s) b.Year of building services updates 2.Is the building(s) on the historic register?☐Y ☐ N The undersigned being authorized by, and acting on behalf of, the applicant and all persons/concerns seeking insurance, has read and understands this application, and declares all statements set forth herein are true, complete and accurate. Signed by: (APPLICANT/INSURED) (TITLE) (DATE) SIGNATURE CONSTITUTES A REPRESENTATION THAT ALL INFORMATION PROVIDED HEREIN IS ACCURATE AND COMPLETE. THE SIGNING OF THIS APPLICATION DOES NOT BIND THE UNDERSIGNED TO PURCHASE THE INSURANCE, NOR DOES THE REVIEW OF THIS APPLICATION BIND THE INSURANCE COMPANY TO ISSUE THE POLICY. INSURANCE FRAUD WARNING In completing this supplemental application, you are bound by the same obligation to avoid making fraudulent statements as outlined in the ACORD application form. Page 96 of 144 SP1.Page 99 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 10 of 16 APPENDIX If the box was marked "Yes" for a specific operation having ** in the "Public Entity Exposure Checklist" section of the application, please complete the appropriate additional questions. Airport 1.How many runways are present at the airport?Lengths? 2.Type of runways? a.☐ Grass strip b.☐ All weather strip 3.Is the airport owned and operated by the entity?☐Y ☐ N 4.Owned and leased to a third party?☐Y ☐ N ☐Y ☐ N a.Commercial Passenger b.☐ Non-Commercial ☐Y ☐ N☐Y ☐ N 5.If the airport is leased to a third party, does the operator have airport operator’s liability coverage with the entity named as an additional insured? 6.If airport operator’s liability coverage is provided, what are the limits of coverage? $ 7.Number of daily flights? 8.Is the airport owned and operated by the entity? 9.Is airport under the jurisdiction of the FAA? 10.What services are performed at the airport and by whom? (hangars, refueling, aircraft maintenance, etc.) 11.Are there any airshows or exhibitions conducted at the airport?☐Y ☐ N 12.Who writes the airport premises liability coverage? Liability limits? $ Dam/Levee Exposure 1.Describe each dam / levee exposure including the age, location, size and construction: 2.If the exposure is from a dam, please answer the following questions: a.When was each dam last inspected by the DNR? b.What is the DNR rating for each dam? c.If applicable, were all critical recommendations completed from the last inspection?☐Y ☐ N ☐ N/A d.Is there a regular maintenance program for each dam?☐Y ☐ N e.How often are maintenance and informal inspections completed for each dam? 3.What is the downstream effect if the dam / levee fails? 4.Is there an emergency response / evacuation plan in place in case of a dam / levee failure? ☐ Y ☐ N 5.Has the dam/levee ever failed? ☐Y ☐ N If yes, describe when, the cause of the failure, the extent of damage and the corrective action taken: Camps 1.Describe the activities provided as part of the camp: 2.Where are the camp activities conducted? 3.What is the number of staff employed including volunteers? 4.Age range of staff? 5.How many years have you been conducting camps? 6.What is the beginning and ending dates of the camp? 7.What are the operating hours of the camp? 8.Are there overnight activities?☐Y ☐ N If yes, please describe the activities: 9.Indicate the number of children and camp counselors for each group: a.2 to 5 years ## Staff b.6 to 10 years ## Staff c.11-15 years ## Staff Page 97 of 144 SP1.Page 100 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 11 of 16 d.16 years+## Staff e.Number of mentally or physically impaired children:## Staff f.What is the total number of annual camper days? 10.What procedures are in place to prevent unauthorized persons from picking up or removing camp participants? 11.Is a physical exam or medical certificate required before a child is accepted to the camp?☐Y ☐ N 12.Do you provide transportation to the camp for camp participants?☐Y ☐ N If yes, describe vehicles used, distance of travel and how drivers are screened? 13.Are there field trips away from the premises?☐Y ☐ N If yes, are signed permission slips obtained from parents before each trip? 14.Describe the emergency response and safety training provided to the camp counselors: Daycare Center 1.What is the number of staff employed including work study and volunteers? a.Full-time?b.Part-time? 2.Age range of staff? 3.How many years of experience has the insured had running a day care? 4.Indicate authority you are licensed with (check all that apply):☐City ☐State ☐ County 5.What are the operating hours of the day care? From To 6.Indicate the number of children and child care providers for each group: a.Infants (0-1)## Staff b.Toddlers (1-2)## Staff c.2 years ## Staff d.3 years ## Staff e.4 years ## Staff f.5 years ## Staff g.6 years and up ## Staff h.Number of mentally or physically impaired children:## Staff 7.What safeguards are in place to prevent children from leaving the building unnoticed? 8.What procedures are in place to prevent unauthorized persons from picking up or removing children? 9.Is there an outdoor play area?☐Y ☐ N What are dimensions? 10.Is it fenced?☐Y ☐ N Describe the type of fence, height and locking: 11.Is there playground equipment?☐Y ☐ N Describe the equipment: 12.Describe the surface beneath playground equipment (grass, concrete, asphalt, sand, mulch, other): 13.How many exits are there from the day care area? 14.Are fire drills conducted regularly?☐Y ☐ N 15.Are there smoke alarms on the premises?☐Y ☐ N 16.Are all electrical outlets covered?☐Y ☐ N 17.Are meals served?☐Y ☐ N Hot or cold? 18.If hot, how are children kept out of the cooking area? 19.Are any children on special diets?☐Y ☐ N If yes, how is this monitored so children are not mis-served? 20.What is the policy regarding sick children attendance? 21.Do day care employees or volunteers administer medicine?☐Y ☐ N If yes, describe: 22.How are medicines safeguarded? Page 98 of 144 SP1.Page 101 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 12 of 16 23.Is there a doctor on call?☐Y ☐ N 24.Is there a questionnaire to be completed prior to accepting a child?☐Y ☐ N 25.Is a physical exam or medical certificate required before a child is accepted?☐Y ☐ N 26.Does insured provide transportation to the facility for the children?☐Y ☐ N 27.Are there field trips?☐Y ☐ N 28.If any transportation is provided, how are drivers screened?☐Y ☐ N 29.Are health exams required of employees before being assigned child care duties?☐Y ☐ N 30.Has the day care ever been in violation of health or building codes?☐Y ☐ N 31.Describe the type of accident records kept? 32.Describe the child care and safety training provided to the employees and volunteers: Emergency Shelters 1.What is the location and capacity of the emergency shelter? 2.Describe the emergency shelter services provided: 3.Describe the security and premises control provided: Fire Department 1.Is the fire department?☐Paid ☐Volunteer ☐Paid/Volunteer 2.What is the total number of: a.Paid personnel b.Volunteer personnel 3.If separate EMT/Medical service personnel provided, what is the total number of: a.Paid personnel b.Volunteer personnel Fireworks 1.How many firework events are held annually? 2.Who operates the fireworks display? 3.If operated by a pyrotechnic company, does the company have general liability insurance coverage?☐Y ☐ N ☐ N/A 4.If general liability coverage is provided, what are the liability limits of coverage? $ 5.If yes, is the entity named as an additional insured on this policy?☐Y ☐ N ☐ N/A 6.Describe the law enforcement / security provided during the event? 7.How many and what type of medically trained personnel are present during the event? 8.Describe the extent of firefighting personnel including the equipment present during the display: Golf Course 1.How many golf courses does the entity own/operate? 2.What is the number of 18-hole rounds played annually? 3.Describe any additional facilities connected with the golf course(s) (e.g. swimming pool, tennis courts) Housing Authority 1.What is the number of locations? 2.What is the total number of housing units provided? 3.Is on-site management provided?☐Y ☐ N 4.Is the housing authority operated by a third party?☐Y ☐ N a.If yes, is general liability coverage is provided?☐Y ☐ N b.If yes, is the entity named as an additional insured on this policy?☐Y ☐ N 5.If general liability coverage is provided, what are the liability limits of coverage? $ Page 99 of 144 SP1.Page 102 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 13 of 16 Ice / Roller Skating Rink 1.What is the type of rink provided: ☐ Ice ☐Roller Skating 2.Is the rink ☐Inside ☐Outside 3.Is access to and usage of the rink: ☐ Controlled ☐ Uncontrolled Jail / Detention Center 1.What type of facility is operated? ☐Holding cell ☐Short-term (<14 days) ☐ Medium-term (15-365 days)☐Long-term (>365 days) 2.What is the average number of prisoners held in the jail? 3.What is the total number of jail cells 4.What is the total capacity of the jail? 5.What is the average duration of incarceration? 6.Is 24-hour supervision provided?☐Y ☐ N 7.Does the facility have recorded video monitoring?☐Y ☐ N 8.Is suicide prevention training provided for the staff?☐Y ☐ N 9.Do you have a written procedure manual for your jail operations?☐Y ☐ N Landfill 1.How many landfill sites does the entity own/operate? 2.What is the total size in acres of landfills owned/operated by the entity? 3.Are the landfills: a.Fenced?☐Y ☐ N b.Area secured / locked during non-operating hours?☐Y ☐ N c.Supervised during operating hours?☐Y ☐ N 4.Are the landfills currently open or closed?☐Open ☐Closed If closed, date of closing? 5.Describe the pollution monitoring performed at the landfill (type, frequency and who performs): 6.Does the entity have a pollution policy for the landfill?☐Y ☐ N 7.If yes, what are the liability limits? $ 8.Have there been any environmental incidents, violations, allegations involving a release, spill or leaching in the last five years?☐Y ☐ N If yes, describe the situation and any resulting claim activity, status, reserve or payment made: Liquor Liability Events 1.Describe the event(s) / activity (ies) at which liquor will be served: 2.Anticipated annual liquor revenue from event(s): $ 3.Describe controls used in the serving of liquor: (ID’s checked, TIPS training of servers, etc.) Owned Aircraft 1.For each aircraft owned/leased, list the: Model Year Seats (including pilot) 2.Describe who pilots each aircraft, their training, frequency of use, purpose of flights and who uses the aircraft: 3.Do you own any unmanned aerial systems (drones)?☐Y ☐ N If yes, for each unit, list the: Model: Purpose of use: Location of use: 4.Have you registered with the FAA for the use of drones?☐Y ☐ N Page 100 of 144 SP1.Page 103 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 14 of 16 Parks & Recreation 1.Describe the number of park facilities and the amenities provided: 2.What is the total acreage of the park facilities? 3.Is access to the park system:☐Controlled ☐Uncontrolled 4.Describe the presence and usage of any ponds, lakes or rivers connected with the parks: 5.If present, list the type of playground equipment. Describe the maintenance program, inspection frequency, inspector credentials and loose fill surface material under the equipment to ensure adequate protective depth: Port Authority / Docks / Piers 1.Describe the extent of the port authority operations: 2.What is the location(s) of the port authority operations? 3.Describe the facilities and services provided by the port authority: (e.g. cargo services, warehouse facilities, refueling stations, navigational assistance, security, waste disposal, grain terminals, repair facilities, etc) Rifle / Shooting Range 1.Describe the use of the facilities available to the public: (e.g. trap shooting, rifle range, archery, pistol, etc.) 2.What is the location of the range? 3.How many bays are available for use? 4.Is ammunition available for purchase?☐Y ☐ N 5.Are guns available for rent?☐Y ☐ N 6.Are there any organized contests, corporate outings or league shooting activities?☐Y ☐ N If yes, describe activities: 7.Is shooting instruction available?☐Y ☐ N 8.Is access to and usage of the range:☐Controlled ☐Uncontrolled 9.Is an attorney prepared participation waiver required to use the range?☐Y ☐ N Skate Park 1.How many skate parks does the entity own/operate? 2.Are the skate parks: a.Fenced / locked during non-operating hours?☐Y ☐ N b.Supervised during operating hours?☐Y ☐ N Special Event 1.What types of events are held by the entity? ☐Carnivals ☐Haunted House ☐Other ☐Donkey Basketball ☐Inflatable/Jump House ☐Seasonal Fair ☐Parade 2.Describe the nature of the event and activities conducted: 3.Days and hours of operation: 4.Location of event(s): 5.Number of attendees/participants: 6.Ages of attendees/participants: # All ages # < 5 years # <18 years # Adult Page 101 of 144 SP1.Page 104 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 15 of 16 Swimming Pools / Beaches 1.Number of Pools: 2.Number of beach swimming areas: 3.Depths of pool or swimming area: 4.Are safety rules posted?☐Y ☐ N 5.Is a lifeguard on duty when the pool(s)/swimming area is open?☐Y ☐ N 6.Is the pool / beach area locked after hours?☐Y ☐ N 7.Are there any diving boards?☐Y ☐ N If yes, describe number/height over water: 8.Are there water slides?☐Y ☐ N If yes, describe number/height: Utility - Electric 1.Does the entity generate electrical power?☐Y ☐ N If yes, what is the source of power generated?☐Fossil Fuel ☐ Hydro-Electric ☐ Nuclear ☐ Solar 2.Is the entity responsible for the electrical distribution?☐Y ☐ N 3.Describe the entities responsibility for the installation of electrical distribution lines; maintenance, and type of work done by subcontractors: 4.If work is performed by subcontractors, does the subcontractor have general liability coverage?☐Y ☐ N 5.If yes, is the entity named as an additional insured on this policy?☐Y ☐ N 6.If general liability coverage is provided, what are the liability limits of coverage? $ Utility Gas 1.Does the entity produce the gas?☐Y ☐ N 2.Does the entity own/operate a gas wellhead or pipeline?☐Y ☐ N 3.Does the entity buy and resell?☐Y ☐ N 4.Is the entity responsible for the gas distribution?☐Y ☐ N 5.Describe the entities responsibility for the installation of gas distribution lines; maintenance, and type of work done by subcontractors: 6.If work is performed by subcontractors, does the subcontractor have general liability coverage?☐Y ☐ N a.If yes, is the entity named as an additional insured on this policy?☐Y ☐ N b.If general liability coverage is provided, what are the liability limits of coverage? $ Utility Water 1.What is the source of the water? 2.Describe the water quality standards, who tests the water and the procedures followed to ensure water quality: 3.Is the Consumer Confidence Report current and posted on the entity website?☐Y ☐ N 4.Describe the entities responsibility for the installation of water/sewer lines; maintenance, and type of work done by subcontractors: 5.Describe the security measures taken to prevent access and potential contamination to water storage or treatment facilities: 6.Describe the steps taken to prevent "water hammer" or "surge": 7.If work is performed by subcontractors, does the subcontractor have general liability coverage?☐Y ☐ N a.If yes, is the entity named as an additional insured on this policy?☐Y ☐ N b.If general liability coverage is provided, what are the liability limits of coverage? $ Page 102 of 144 SP1.Page 105 of 152 LC 88 06 01 21 © 2020 Liberty Mutual Insurance Page 16 of 16 Vacant Property 1. What is the location(s) of the vacant property? 2. How long has the property been vacant? 3. What are the future use or disposal plans for the property? 4. What precautions are being taken to protect the property from loss including: physical security, alarms, police patrols, freezing water pipes, frequency of property site visits, etc.? Zoo 1. Describe the zoo facilities, amenities provided and number of exhibits/attractions: 2. What is the total acreage of the zoo? 3. Is access to the zoo: ☐ Controlled ☐ Uncontrolled 4. Describe the types of any rides, shows conducted or any unique features connected with the zoo: INSURANCE FRAUD WARNING In completing this supplemental application, you are bound by the same obligation to avoid making fraudulent statements as outlined in the ACORD application form. Page 103 of 144 SP1.Page 106 of 152 LC 88 05 05 20 Page 1 of 1 COVID-19 Questionnaire Government – CGL/Professional Liability *Please submit your completed questionnaires directly to your underwriter Applicant Name Street Address City, State, ZIP Code Policy Number CGL/Professional Liability: 1.Are there state Department of Corrections executive orders? Yes No 2.Is the guidance outlined by the Department of Corrections being adhered to as provided? Yes No 3.Do you have any inmates with a confirmed diagnosis or suspected case of COVID-19? Yes No If yes, number of inmates: 4.How have you revised your visitation policy and intake screening process to reduce infection sources? 5.Are you involving the local public health department if you suspect you have an inmate with COVID-19? Yes No 6.What is your facility wide shutdown procedure in the event of an outbreak? 7.What is your contingency plan in the event of staffing shortages? 8.Is there a plan in place to reduce the number of low risk inmates in your facility as a result of COVID-19? Yes No 9.How are you assessing and isolating suspected COVID-19 inmates? 10. Do you have separation protocols for high health risk inmates? Yes No If yes, please describe. 11.Does the facility have signage instructing the use of masks/tissues/hand sanitizer if needed? Yes No 12.Describe common area measures implemented to reduce the spread of COVID-19. (ie. Removing chairs between inmates in dining halls) Name Title Today’s Date Page 104 of 144 SP1.Page 107 of 152 PLEASE INDICATE YOUR ELECTION TO ACCEPT OR REJECT THIS OFFER BELOW: I hereby elect to purchase coverage for “certified acts of terrorism” for the policy period for $2,922 I hereby reject this offer of coverage. I understand that by rejecting this offer, I will have no coverage for losses arising from “certified acts of terrorism” and my policy will be endorsed accordingly. POLICYHOLDER ACKNOWLEDGEMENT I hereby acknowledge that I have received notice of TRIA, the federal share of compensation for “certified acts of terrorism,” and the premium charge for losses covered by TRIA. __________________________ _________ Policyholder/Applicant Signature Date __________________________ Print Name The summary of the Act and the coverage under your policy contained in this notice is necessarily general in nature. Your policy contains specific terms, definitions, exclusions and conditions. In case of any conflict, your policy language will control the resolution of all coverage questions. Please read your policy carefully. If you have any questions regarding this notice, please contact your sales representative or agent. Page 105 of 144 SP1.Page 108 of 152 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE 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 85 % through 2015; 84 % beginning on January 1, 2016; 83 % beginning on January 1, 2017; 82 % beginning on January 1, 2018; 81 % beginning on January 1, 2019 and 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 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 BILLON 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. Acceptance or Rejection of Terrorism Insurance Coverage FAILURE TO RETURN THIS SIGNED FORM, PRIOR TO POLICY INCEPTION, INDICATING AN ELECTION TO PURCHASE TERRORISM COVERAGE, AS DEFINED BY THE ACT, WILL BE DEEMED YOUR REJECTION OF TERRORISM COVERAGE. HOWEVER, PAYMENT OF THE TERRORISM PREMIUM PRIOR TO POLICY INCEPTION WILL BE DEEMED AN ACCEPTANCE OF THIS OFFER OF TERRORISM COVERAGE. Please indicate your selection by an : I hereby elect to purchase terrorism coverage for a prospective premium of $ . 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. City of Evanston Name of Insured Policyholder/Applicant’s Signature Old Republic Union Insurance Company Name of Insurer Print Name 822200 1133479 Policy Number Date 01/01/2022 – 01/01/2023 Effective Date/Expiration Date PIL PH 08 (01/15) Page 1 of 1 307 N. Michigan Avenue, Chicago, Illinois, 60601 | T: 312.346.8100 Page 106 of 144 SP1.Page 109 of 152 PRO S-1 4100 (01/20) Page 10 of 10 © 2019 AFM. All rights reserved. POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE Insured Name: City of Evanston Date: 28 September 2021 Account Number: 56446 Insurer Name: Affiliated FM Insurance Company The Terrorism Risk Insurance Act of 2002, as amended and extended, gives you the right as part of your property insurance program to elect or reject insurance coverage for locations within the United States or any territory or possession of the United States for losses arising out of acts of terrorism, as defined and certified in accordance with the provisions of the act. You should know that where coverage is provided 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. Under this formula, the United States government generally pays 80% of covered terrorism losses exceeding a statutorily established deductible paid by the insurer referenced above. The Terrorism Risk Insurance Act, as amended, contains a USD 100 billion cap that limits the 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 program year exceeds USD 100 billion. If the aggregate insured losses for all insurers exceed USD 100 billion, your coverage may be reduced. The premium charged for this coverage is provided below and does not include any charges for the portion of loss covered by the federal government under the act. Acceptance or rejection of terrorism insurance coverage: under federal law, you have the right to accept or reject this offer of coverage for terrorist acts covered by the act as part of your property insurance program. If we do not receive this signed disclosure form prior to property insurance program inception date of 1 January 2022, then your property insurance program will reflect your decision not to purchase the terrorism coverage provided by the act. ______I hereby elect to purchase coverage for terrorist acts covered by the act for a premium of USD 11,000. This premium does not include applicable taxes or surcharges. ______I hereby decline this offer of coverage for terrorist acts covered by the act. _________________________________ ______________________________ Policyholder/Applicant Signature Date _________________________________ Print Name Page 107 of 144 SP1.Page 110 of 152 NOTICE: This application is for claims-made and reported coverage. With respect to Insuring Agreement C. This policy provides coverage on a claims made and reported basis and apply only to claims first made against the Insured during the policy period or the optimal extension period (if applicable) and reported to the Insurer in accordance with the terms of this policy. Amounts incurred as First Party Expense and First Party Loss under this policy with reduce and may exhaust the limit of liability and are subject to deductibles. If a policy is issued, this application will attach to and become part of the policy. therefore, it is important that all questions are answered truthfully and accurately. Name of Insured: Web Domain(s): Address: Industry: Revenue (expected over the 12 months): General Information 1. Security Assessment - (check appropriate box) 1. Does the organization assign a person responsible for information security? 2. Does the organization hold mandatory cybersecurity training with all employees at least annually? 3. Does the organization encrypt all external communications containing sensitive information? 4. Does the organization encrypt sensitive information stored on the cloud? [Yes] [No] [Yes] [No] [Yes] [No] [Yes] [No] COWBELL CYBER RISK INSURANCE APPLICATION PRIME 250 ™PRIME 250 003 07 20 Page 1 of 8 5.a. How often does the organization perform backups of business-critical data? Backups are: [Weekly] [Quarterly] [Monthly] [Every 6 Months] [Never] If your organization performs backups, please select all that apply (Other: Please specify) [Encrypted][Tested][Separate either offline or in a designated cloud service] [Other] City of Evanston [cityofevanston.org] 2100 Ridge Ave, Evanston, IL, 60201-2700 Public Administration $187,525,722.00 Page 108 of 144 SP1.Page 111 of 152 3. Optional: Cyber Crime (applicable only for I.B.5.) - (check appropriate box) 1. Does the organization verify vendor/supplier bank accounts before adding to their accounts payable systems?[Yes] [No] [NA] 2. Past Activities - (check appropriate box) 1. Has the organization filed any claims due to a cyber event in last five years? If yes, attach loss detail herewith. 2. Has the organization ever been a party to any of the following: a. Civil or criminal action or administrative proceeding alleging violation of any federal, state, local or common law? b. Is there currently any pending litigation, administrative proceeding or claim against the named applicant, organization and/or any of the prospective insureds? 3. During the last three years, has the organization suffered loss of business income as a result of unscheduled system downtime? 4. During the last three years, has the organization suffered a security breach requiring customer or third-party notification according to state or federal regulations? [Yes] [No] [Yes] [No] [Yes] [No] [Yes] [No] [Yes] [No] 7. Does the organization have an incident response plan - tested and in-effect - setting forth specific action items and responsibilities for relevant parties in the event of a cyber incident or data breach matter? 6. Do you enforce Multi-Factor Authentication (MFA) for all employees, contractors, and partners on the following? If yes, please select all that apply (Other: Please specify) [Yes] [No] [Yes] [No] [Email][Cloud Deployments][Mission-Critical Systems][Other] 3. Does the organization prevent unauthorized employees from initiating wire transfers? 2. Does the organization authenticate funds transfer requests (e.g. by calling a customer to verify the request at a predetermined phone number)? [Yes] [No] [NA] [Yes] [No] [NA] 5.b. How often does the organization apply updates to critical IT-systems and applications (“security patching”)? [Weekly] [Quarterly] [Monthly] [Every 6 Months] [Never] ™PRIME 250 003 07 20 Page 2 of 8 · Enroll Users in MFA platform: October 2021 · Enforce MFA for Remote Access: November 2021 · Enforce MFA for Administrators: December 2021 · Enforce MFA for Remote Access to Email: January 2022 Page 109 of 144 SP1.Page 112 of 152 ™PRIME 250 003 07 20 Page 3 of 8 2. Do agreements with third-party service providers require levels of security commensurate with the organization’s information security standard? 4. Optional: System Failure Contingent Business Interruption Loss (applicable only for I.B.4.) - (check appropriate box) 1. Are all internet-accessible systems (e.g. web-, email-servers) segregated from the organization’s trusted network (e.g. within a demilitarized zone (DMZ) or at a third-party service provider)? 5. Optional Endorsement: Full System Failure - (check appropriate box) 5.a. How often does the organization perform backups of business-critical data? Backups are: [Weekly] [Quarterly] [Monthly] [Every 6 Months] [Never] If your organization performs backups, please select all that apply (Other: Please specify) [Encrypted][Tested][Separate either offline or in a designated cloud service] [Other] 2. Are all internet-accessible systems (e.g. web-, email-servers) segregated from the organization’s trusted network (e.g. within a demilitarized zone (DMZ) or at a third-party service provider)? 3. Has the organization tested a full failover of the most critical servers? For the purpose of this Application, the undersigned authorized officer of the organization named in Section I. of this Application declares that, to the best of the organization’s knowledge, the statements herein are true, accurate and complete. The insurer is authorized to make any inquiry in connection with this Application. Signing this Application does not bind the insurer to issue, or the applicant to purchase, any insurance policy issued in connection with this Application. The information contained in and submitted with this Application is on file with the insurer. The insurer will have relied upon this Application and its attachments in issuing the Policy. If the information in this Application materially changes prior to the effective date of the Policy, the applicant will promptly notify the insurer, who may modify or withdraw the quotation. The undersigned declares that the individuals and entities proposed for this insurance have been notified that the limit of liability is reduced by amounts incurred as “Defense Expenses” (as defined in the Policy), and such expenses will be subject to the deductible amount. Misrepresentation of any material fact in this Application may be grounds for the rescission of this Policy. Notice to Applicant - Please Read Carefully [Yes] [No] [NA] [Yes] [No] [NA] [Yes] [No] [NA] [Yes] [No] [NA] Page 110 of 144 SP1.Page 113 of 152 ™PRIME 250 003 07 20 Page 4 of 8 General Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. (Not applicable in AL, AK, AZ, AR, CA, CO, DE, DC, FL, ID, IN, HI, KS, KY, LA, ME, MD, MN, NH, NJ, NM, NY, OH, OK, OR, PA, PR, RI, TN, TX, UT,, TN, TX, UT, VA, VT, WA and, WV) Fraud Warnings Alabama Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof. Alaska Fraud Warning A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law. Arizona Fraud Warning For your protection Arizona law requires the following statement to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. Arkansas Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. California Fraud Warning For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Colorado Fraud Warning It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties 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. Delaware Fraud Warning Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. District Of Columbia Fraud Warning 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 addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. Florida Fraud Warning Any person who, knowingly and with intent to injure, defraud, or deceive an 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. Page 111 of 144 SP1.Page 114 of 152 ™PRIME 250 003 07 20 Page 5 of 8 Idaho Fraud Warning Any person who knowingly, and with intent to defraud or deceive any insurance company, files a statement containing any false, incomplete, or misleading information is guilty of a felony. Indiana Fraud Warning A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony. Hawaii Fraud Warning For your protection, Hawaii law requires you to be informed that any person who presents a fraudulent claim for payment of a loss or benefit is guilty of a crime punishable by fines or imprisonment, or both. Kansas Fraud Warning We will not pay for any loss or damage if you or any other insured in relation to an insurance application, rating, claim or coverage under this policy knowingly and with intent to defraud: 1. Presents, causes to be presented or prepares with the knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any material fact; or 2. Conceals information concerning any material fact for the purpose of misleading. Kentucky Fraud Warning Any person who knowingly 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. Louisiana Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Maine Fraud Warning 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 benefits. Maryland Fraud Warning Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Minnesota Fraud Warning A person who files a claim with intent to defraud, or helps commit a fraud against an insurer, is guilty of a crime. New Hampshire Fraud Warning Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. New Jersey Fraud Warning Any person who includes false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Page 112 of 144 SP1.Page 115 of 152 ™PRIME 250 003 07 20 Page 6 of 8 New Mexico Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. New York Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. Ohio Fraud Warning Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. Oklahoma Fraud Warning WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. Oregon Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison. In order for us to deny a claim on the basis of misstatements, misrepresentations, omissions or concealments on your part, we must show that: A. The misinformation is material to the content of the policy; B. We relied upon the misinformation; and C. The information was either: 1. Material to the risk assumed by us; or 2. Provided fraudulently. For remedies other than the denial of a claim, misstatements, misrepresentations, omissions or concealments on your part must either be fraudulent or material to our interests. Misstatements, misrepresentations, omissions or concealments on your part are not fraudulent unless they are made with the intent to knowingly defraud. Pennsylvania Fraud Warning Any person who knowingly and with intent to defraud any insurance company or other 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 such person to criminal and civil penalties. Puerto Rico Fraud Warning 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 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 with the penalty of a fine 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. Should 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 minimum of two (2) years. Rhode Island Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Page 113 of 144 SP1.Page 116 of 152 Tennessee Fraud Warning 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. Texas Fraud Warning Workers Compensation: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. Utah Fraud Warning Workers Compensation: 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 may be subject to fines and confinement in state prison. Vermont Fraud Warning Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. Virginia Fraud Warning 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. Washington Fraud Warning 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. West Virginia Fraud Warning Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. ™PRIME 250 003 07 20 Page 7 of 8 ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE/SHE IS FACILITATING A FRAUD AGAINST THE INSURERS, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT MAY BE GUILTY OF INSURANCE FRAUD. Warning Signature Date (MM/DD/YYYY) Name of Authorized Representative Title Insured Name Email <CustomerEmail>City of Evanston Page 114 of 144 SP1.Page 117 of 152 ™PRIME 250 003 07 20 Page 8 of 8 Agent’s Name (only applicable in FL and IA): Agent’s License Number (only applicable in FL): Agent’s Signature (only applicable in NH): Page 115 of 144 SP1.Page 118 of 152 Coverages Beazley (expiring): Beazley (renewal): Ironshore (renewal):Third Party Bodily Injury and Property Damage for New Pollution EventsIncludedIncludedIncludedThird Party Bodily Injury and Property Damage for Pre-Existing ConditionsNot Included (Retroactive Date: 1/1/2019) Not Included (Retroactive Date: 1/1/2019) Not Included (Retroactive Date: 1/1/2019)Cleanup Costs for New Pollution EventsIncludedIncludedIncludedCleanup Costs for Pre-Existing ConditionsNot Included (Retroactive Date: 1/1/2019) Not Included (Retroactive Date: 1/1/2019) Not Included (Retroactive Date: 1/1/2019)Retroactive Date January 1, 2019January 1, 2019January 1, 2019Covered Locations 31 locations as per “CityofEvanston 10-17-2018 SOV" 58 locations as per SOV entitled “Property List Updated (1).xlsx” on file with the Company 58 locations as per SOV entitled “Property List Updated (1).xlsx” on file with the CompanyDefense Additional Defense Costs included ($750,000 for Each Pollution Condition, and $1,500,000 Policy Aggregate) Additional $1,500,000 in defense outside the limit of liability Additional $1,500,000 in defense outside the limit of liability Non-Owned Disposal Site IncludedIncludedIncludedTransportation IncludedIncludedIncludedIncludedIncludedIncluded5 Day Deductible5 Day Deductible5 Day DeductibleEmergency Response Costs IncludedIncludedIncludedDisinfection Costs Coverage Not Included Not Included Disinfection costs and fees (limit of $25,000) to disinfect presence of bacteria or virus associated with 1. An outbreak of communicable virus or communicable bacteria at a Covered Property that requires reporting by the Insured of such outbreak to the applicable local, state or federal governmental or public health agency or entity; and 2. The dispersal or release of human blood or fluids as the direct result of a suicide, homicide or other violent crime.Crisis and Reputation Management ExpensesIncluded ($250,000 Sublimit) for Crisis and Reputation Management Expenses. Included ($250,000 Sublimit) for Crisis and Reputation Management Expenses. Included ($250,000 Sublimit) for Image Restoration.Coverage included for the scheduled Underground Storage Tanks (USTs), with Financial Responsibility provided ($1MM/$2MM limit).Coverage included for the scheduled Underground Storage Tanks (USTs), with Financial Responsibility provided ($1MM/$2MM limit).Coverage included for the scheduled Underground Storage Tanks (USTs), with Financial Responsibility provided ($1MM/$2MM limit).Eight (8) USTs at 2020 Asbury Ave., Evanston, IL scheduled (installed in 1981) Eight (8) USTs at 2020 Asbury Ave., Evanston, IL scheduled (installed in 1981) Eight (8) USTs at 2020 Asbury Ave., Evanston, IL scheduled (installed in 1981) with a 1/1/2019 Retroactive Date1. $50,000 Retention for any Pollution Incident due to or associated with any Underground Storage Tank which was installed less than twenty (20) years prior to the Inception Date;2. $100,000 Retention for any Pollution Incident due to or associated with any Underground Storage Tank which was installed twenty (20) or more years prior to the Inception Date but less than twenty-five (25) years prior to the InceptionDate; and3. $250,000 Retention for any Pollution Incident due to or associated with any Underground Storage Tank which was installed twenty-five (25) or more years prior to the Inception Date.$1,000,000 retention applies for Capital Improvement and Voluntary Site Investigation associated with the USTs. Mold and Legionella Coverage IncludedIncluded ($50,000 Deductible for Mold) Included ($75,000 Deductible for Mold)Site-Specific Mold Exclusion No site-specific Mold exclusion for the vacant buildings. No site-specific Mold exclusion for the vacant buildings.Mold is Excluded at the following properties, which are vacant buildings:Scheduled Covered Property(ies)729 Howard Street, Evanston, IL633 Howard, Evanston, IL2222 Oakton Street, Evanston, IL2603 Sheridan Road, Evanston, ILCleanup Costs Coverage AmendmentCleanup Costs coverage includes "Microbial Matter, methamphetamines or other chemicals associated with methamphetamine laboratories, legionella pneumophilia, viruses and bacteria, reasonable and necessary costs, charges and expenses (if by an Insured, then only with the prior written consent of the Underwriters, such consent not to be unreasonably withheld or delayed) required by Indoor Air Quality Clean-Up Standards). Cleanup Costs coverage includes "Microbial Matter, methamphetamines or other chemicals associated with methamphetamine laboratories, legionella pneumophilia, (not viruses and bacteria), reasonable and necessary costs, charges and expenses (if by an Insured, then only with the prior written consent of the Underwriters, such consent not to be unreasonably withheld or delayed) required by Indoor Air Quality Clean-Up Standards). Policy form definition of Pollutants includes Methamphetamines. Illicit Abandonment Coverage Definition of Pollution Condition includes illicit abandonment. Definition of Pollution Condition includes illicit abandonment. Definition of Pollution Incident includes illicit abandonment.Asbestos and Lead-Based Paint CoverageCoverage included for (1) bodily injury and property damage, (2) cleanup costs for soil, watercourse, body of water, or groundwater, and (3) cleanup costs arising from the accidental disturbance of asbestos or any materials containing asbestos that are not the subject of an abatement project. Coverage included for (1) bodily injury and property damage, (2) cleanup costs for soil, watercourse, body of water, or groundwater, and (3) cleanup costs arising from the accidental disturbance of asbestos or any materials containing asbestos that are not the subject of an abatement project. Coverage included for (1) bodily injury and property damage, (2) cleanup costs for soil, watercourse, body of water, or groundwater (can request inadvertent disturbance)Included (90-day reporting)Included (90-day reporting)Included (90-day reporting)Municipal Site: $0.051 per square foot ($750 minimum premium) Municipal Site: $0.051 per square foot ($750 minimum premium) Municipal Site: $0.051 per square foot ($750 minimum premium)Automatic Acquisition EndorsementBusiness InterruptionTable III: Coverage ComparisonUnderground Storage Tank Coverage (including Financial Responsibility)$250,000 deductible applies to these tanks, as well as a 1/1/2018 Retroactive Date $250,000 deductible applies to these tanks, as well as a 1/1/2018 Retroactive DatePage 116 of 144 SP1.Page 119 of 152 Prior Knowledge ExclusionExclusion for loss arising out of or resulting from any actual or alleged Pollution Condition existing prior to the Inception Date of this Policy and known by a Responsible Insured.However, this exclusion does not apply to any Pollution Condition existing prior to the Inception Date and known bya Responsible Insured and disclosed in the Application or other documents provided that such Pollution Condition has received a No Further Action letter or similar release under Environmental Laws or any federal or state voluntary cleanup program.Exclusion for loss arising out of or resulting from any actual or alleged Pollution Condition existing prior to the Inception Date of this Policy and known by a Responsible Insured.However, this exclusion does not apply to any Pollution Condition existing prior to the Inception Date and known bya Responsible Insured and disclosed in the Application or other documents provided that such Pollution Condition has received a No Further Action letter or similar release under Environmental Laws or any federal or state voluntary cleanup program.Exclusion for any Pollution Incident or Disinfection Event:1. Which is known by a Responsible Insured prior to the Inception Date and not specifically disclosed in or attached to an Ironshore Specialty Insurance Company SPILLS application submitted by the Named Insured in connection with this Policy prior to the Inception Date, or which the Responsible Insured first becomes aware of after submitting its application but before the Inception Date;2. Due to or associated with a Covered Property first covered by the Policy after the Inception Date to the extent such Pollution Incident was known by a Responsible Insured and not specifically disclosed to the Company in writing prior to the Policy first providing coverage for such Covered Property;Disclosed Documents Schedule List of disclosed documents scheduled onto the policy. List of disclosed documents scheduled onto the policy. Not specifiedBroad Named Insured“Named Insured” means:1. the person or entity specified in the Declarations; and2. all subsidiaries, limited partnerships or limited liability companies of the First Named Insured, and their trustees, members, partners, spouses, employees, executive officers and directors, and all proprietary and affiliated companies ocorporations as have existed at any time, or as now or hereafter may exist during the Policy Period, and in which the First Named Insured did or does have at least a fifty percent (50%) ownership interest or outstanding securities representing the present right to vote for the election of directors, or direct or indirect management control, and all affiliated organizations for which the First Named Insured has the responsibility of placing insurance and for which coverage is not otherwise more specifically provided; but only with respect to liability arising out of the ownership, operation, maintenance or use of a Covered Location.“Named Insured” means:1. the person or entity specified in the Declarations; and2. all subsidiaries, limited partnerships or limited liability companies of the First Named Insured, and their trustees, members, partners, spouses, employees, executive officers and directors, and all proprietary and affiliated companies ocorporations as have existed at any time, or as now or hereafter may exist during the Policy Period, and in which the First Named Insured did or does have at least a fifty percent (50%) ownership interest or outstanding securities representing the present right to vote for the election of directors, or direct or indirect management control, and all affiliated organizations for which the First Named Insured has the responsibility of placing insurance and for which coverage is not otherwise more specifically provided; but only with respect to liability arising out of the ownership, operation, maintenance or use of a Covered Location.Named Insured means:1. The person or entity identified in the Declarations;2. Any business entity in which the person or entity listed in the Declarations has an ownership interest of 50% or moreduring the Policy Period; and3. Any other person or entity listed as a Named Insured by endorsement to this Policy.Additional Insured Blanket where required by written contract. Blanket where required by written contract.Requesting.Perfluoroalkyl or polyfluoroalkylsubstance (PFAS) ExclusionNo PFAS exclusionExclusion for any loss relating to PFC, PFAS and Related Chemicals or Products(arising out of or resulting from any perfluorinated chemicals (PFC) or per and polyfluoroalkylsubstances (PFAS)). Exclusion for any loss relating to any perfluoroalkyl or polyfluoroalkyl substance (PFAS), including but not limited to perfluoroalkyl acids (PFAAs), perfluorooctanoic acid (PFOA), perfluorooctane sulfonate (PFOS), perfluoroheptanoic acid (PFHpA), perfluorononanoic acid (PFNA), perfluorohexanesulfonic acid (PFHxS), GenX, “C8”, “ADONA,” perfluoroalkane sulfonyl fluoride (PASF), perfluorobutanesulfonic acid (PFBS), polytetrafluoroethylene (PTFE), perfluoropolyethers (PFPEs), fluoropolymers, perfluorononanoic acid, ammonium perfluorooctanoate, or any associated salts, acids, alcohols, precursor chemicals or related higher homologue chemicals. Further, Pollutants shall not include aqueous film forming foam (AFFF) containing PFAS (at any concentration) or any additives or component materials contained therein or degradation by-products thereof.COVID-19 Exclusion Not ApplicableNot ApplicableExclusion for any loss relating to the disease known as Coronavirus disease 19 or COVID-19, or any other condition, disease or sickness caused by the virus responsible for COVID-19 or by any mutation of that virus.Page 117 of 144 SP1.Page 120 of 152 E06671 082020 ed. Page 1 of 1 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended ("TRIA"), that you now have a right to purchase insurance coverage for losses arising out of acts of terrorism,as defined in Section 102(1) of the Act, as amended: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 an air carrier or vessel 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. Any coverage you purchase for "acts of terrorism" shall expire at 12:00 midnight December 31, 2027, the date on which the TRIA Program is scheduled to terminate, or the expiry date of the policy whichever occurs first, and shall not cover any losses or events which arise after the earlier of these dates. YOU SHOULD KNOW THAT COVERAGE PROVIDED BY THIS POLICY FOR LOSSES CAUSED BY CERTIFIED ACTS OF TERRORISM IS PARTIALLY REIMBURSED BY THE UNITED STATES 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 THIS FORMULA, THE UNITED STATES PAYS 80%; OF COVERED TERRORISM LOSSES EXCEEDING THE STATUTORILY ESTABLISHED DEDUCTIBLE PAID BY THE INSURER(S) PROVIDING THE COVERAGE. YOU SHOULD ALSO KNOW THAT THE TERRORISM RISK INSURANCE ACT, AS AMENDED, CONTAINS A USD100 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 USD100 BILLION. IF THE AGGREGATE INSURED LOSSES FOR ALL INSURERS EXCEED USD100 BILLION, YOUR COVERAGE MAY BE REDUCED. THE PREMIUM CHARGED FOR THIS COVERAGE IS PROVIDED BELOW AND DOES NOT INCLUDE ANY CHARGES FOR THE PORTION OF LOSS COVERED BY THE FEDERAL GOVERNMENT UNDER THE ACT. I hereby elect to purchase coverage for acts of terrorism for a prospective premium of . I hereby elect to have coverage for acts of terrorism excluded from my policy. I understand that I will have no coverage for losses arising from acts of terrorism. _____________________________________ ___________________________________ Policyholder/Applicant’s Signature _____________________________________ ___________________________________ Print Name Policy Number _________________________ Date (LMA 9184) Page 118 of 144 SP1.Page 121 of 152 RE: City of Evanston TO: ARTHUR J GALLAGHER RISK MNGT SERV INC Quotation for: Ironshore Environmental® - SPILLS Select September 21, 2021 SPILLS.QTP.SEL.001 (0521) Page 6 of 8 POLICYHOLDER DISCLOSURE NOTICE OF OFFER TO PURCHASE TERRORISM INSURANCE FOR POLICY PERIOD This notice contains important information about the Terrorism Risk Insurance Act and your option to purchase terrorism insurance coverage. Please read it carefully. THE TERRORISM RISK INSURANCE ACT The Terrorism Risk Insurance Act, including all amendments (“TRIA” or the “Act”) establishes a program to spread the risk of catastrophic losses from certain acts of terrorism between insurers and the federal government. If an individual insurer’s losses from “certified acts of terrorism” exceed a specified deductible amount, the government will reimburse the insurer for a percentage of losses (the “Federal Share”) paid in excess of the deductible, but only if aggregate industry losses from such acts exceed the “Program Trigger”. An insurer that has met its insurer deductible is not liable for any portion of losses in excess of $100 billion per year. Similarly, the federal government is not liable for any losses covered by the Act that exceed this amount. If aggregate insured losses exceed $100 billion, losses up to that amount may be pro-rated, as determined by the Secretary of the Treasury. Beginning calendar year 2020, the Federal Share is 80% and Program Trigger is $200,000,000. MANDATORY OFFER OF COVERAGE FOR “CERTIFIED ACTS OF TERRORISM” AND DISCLOSURE OF PREMIUM TRIA requires insurers to offer coverage for losses resulting from “certified acts of terrorism” that could otherwise be excluded and to specify the premium for this coverage. You have the option to accept or reject this coverage. A “certified act of terrorism” means: [A]ny 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 (i) to be an act of terrorism; (ii) to be a violent act or an act that is dangerous to – (I) human life; (II) property; or (III) infrastructure; (iii) to have resulted in damage within the United States, or outside of the United States in the case of – (I) an air carrier (as defined in section 40102 of title 49, United States Code) or United States flag vessel (or a vessel based principally in the United States, on which United States income tax is paid and whose insurance coverage is subject to regulation in the United States); or (II) the premises of a United States mission; and (iv) 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. HOW THE ACT AFFECTS YOUR POLICY AND WHAT YOU MUST DO SELECTION OR REJECTION OF OPTIONAL TERRORISM INSURANCE COVERAGE You have the option of purchasing coverage for losses resulting from “certified acts of terrorism.” The premium for optional terrorism coverage is in addition to any mandatory premium shown on the attached Terrorism Coverage Election Form. Coverage for losses from “certified acts of terrorism” is still subject to, and may be limited by, all other terms, conditions and exclusions contained in your policy. The premium charge for this coverage for the policy period is 3.00%. Page 119 of 144 SP1.Page 122 of 152 RE: City of Evanston TO: ARTHUR J GALLAGHER RISK MNGT SERV INC Quotation for: Ironshore Environmental® - SPILLS Select September 21, 2021 SPILLS.QTP.SEL.001 (0521) Page 7 of 8 Note: With respect to Excess, Umbrella, or Umbrella Excess Liability policies, this offer of coverage pertains only to those lines of business covered by TRIA and, more specifically, does not apply to commercial automobile insurance. In addition, this offer of TRIA coverage is expressly conditioned upon your acceptance of coverage for “certified acts of terrorism” on all underlying insurance policies that are subject to TRIA. If you reject such coverage on your primary liability policies, you must also reject it on your Excess, Umbrella or Umbrella Excess policy. If you reject this offer, you will not be covered for losses resulting from “certified acts of terrorism.” Please indicate on the attached coverage election form, whether you accept or reject this offer. If we do not receive a completed Terrorism Coverage Election Form from you, coverage for “certified acts of terrorism” will be excluded from your policy. Page 120 of 144 SP1.Page 123 of 152 RE: City of Evanston TO: ARTHUR J GALLAGHER RISK MNGT SERV INC Quotation for: Ironshore Environmental® - SPILLS Select September 21, 2021 SPILLS.QTP.SEL.001 (0521) Page 8 of 8 TERRORISM COVERAGE ELECTION FORM PLEASE INDICATE YOUR ELECTION TO ACCEPT OR REJECT THIS OFFER BELOW: I hereby elect to purchase coverage for “certified acts of terrorism” for the policy period for 3.00%. I hereby reject this offer of coverage for the policy period. I understand that by rejecting this offer, I will have no coverage for losses arising from “certified acts of terrorism.” MANDATORY PREMIUM DISCLOSURE STATEMENT Even if you decline coverage for “certified acts of terrorism,” certain states require us to provide you with coverage for fire losses that result from an act of terrorism. This mandatory coverage is provided at no additional charge.” POLICYHOLDER ACKNOWLEDGEMENT I hereby acknowledge that I have received notice of TRIA, the federal share of compensation for “certified acts of terrorism,” the premium charge for losses covered by TRIA, and the Company’s limit of liability should losses covered by TRIA exceed $100 billion. Policyholder/Applicant Signature Date Print Name The summary of the Act and the coverage under your policy contained in this notice is necessarily general in nature. Your policy contains specific terms, definitions, exclusions and conditions. In case of any conflict, your policy language will control the resolution of all coverage questions. Please read your policy carefully. If you have any questions regarding this notice, please contact your sales representative or agent. Page 121 of 144 SP1.Page 124 of 152 8 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE (General Liability) You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended, extended, and/or re-authorized, 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 concurrence with the Secretary of State 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% 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 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. IF THE AGGREGATE INSURED LOSS FOR ALL INSURERS EXCEEDS $100 BILLION IN A CALENDAR YEAR, YOUR COVERAGE MAY THUS BE REDUCED. Acceptance or Rejection of Terrorism Insurance Coverage with regard to General Liability I hereby elect to purchase terrorism coverage for a prospective premium of $1,829. 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. _____________________________________Safety National Casualty Corporation® Applicant’s Signature Insurance Company _____________________________________ Insured Name ____________________________________ Date Signed Page 122 of 144 SP1.Page 125 of 152 14 POLICYHOLDER DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE (Excess Liability) You are hereby notified that under the Terrorism Risk Insurance Act of 2002, as amended, extended, and/or re-authorized, 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 concurrence with the Secretary of State 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% 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 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. IF THE AGGREGATE INSURED LOSS FOR ALL INSURERS EXCEEDS $100 BILLION IN A CALENDAR YEAR, YOUR COVERAGE MAY THUS BE REDUCED. Acceptance or Rejection of Terrorism Insurance Coverage with regard to Excess Liability I hereby elect to purchase terrorism coverage for a prospective premium of $2,238. 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. _____________________________________Safety National Casualty Corporation® Applicant’s Signature Insurance Company _____________________________________ Insured Name ____________________________________ Date Signed Page 123 of 144 SP1.Page 126 of 152 APPROVAL APPLICATION TO SELF-ADMINISTER LIABILTY CLAIMS 1 Approval to self-administer liability claims requires acceptable responses to the questions below. In addition, acknowledgement of the key requirements noted in this section are mandatory (check boxes to confirm). Confirmation the organization and staff are licensed/approved to administer claims where applicable, and there is full compliance with all jurisdictional requirements Agreement to life of claims administration, inclusive of claims administration below and above the applicable retention(s) You understand and agree to carrier reporting requirements and will submit loss data for all claims under applicable policies You understand that the carrier name must be referenced in certain claim payments and/or settlement documents and you will comply as directed by Safety National Lines of Business (LOB) where approval is requested (check all that apply): Commercial Auto – BI PD APD Commercial General Liability Professional lines (Educators Legal, Law Enforcement Legal and Public Officials Legal Liability) Type of Coverage where approval is requested (check all that apply). Please note that approval criteria varies based on the LOB and type of coverage selected. Large Deductible Endorsement SIR Endorsed Please thoroughly answer all questions using additional paper if necessar y, and provide the following documents: (Approval will not be considered until we have received all requested documents) 1. Organizational chart of claims personnel involved in the administration of liability claims 2. Resumes and contact information for claims adjusters on selected lines of business 3. Copy of your liability claim handling procedures and/or best practices 4. Litigation guidelines (if no guidelines are in place, please advise and we can assist) 5. Sample of your data layout for comparison against our da ta requirements 1) General information Company name: Address: Phone #: Fax #: Will this be the office handling claims: Yes No If not, please provide details for the claims office(s) using a separate sheet if necessary: Length of time administering Auto/GL claims: Length of time administering LEL, POL, and EL: 2) Claims department structure Claims Manager or Primary Contact: Name: Title: Address same as Company above: Yes No Address: Email Address: Phone Number: Average pending caseload per adjuster: Auto Liability: General Liability: Professional Lines: Are caseloads assigned by LOB, or do adjusters handle multiple lines (please explain): Are claims monitored on a diary system: Yes No Please provide details for either answer: Do claims receive supervisor oversight: Yes No Please provide details for either answer: Page 124 of 144 SP1.Page 127 of 152 2 Please describe your training protocols for adjusters administering claims : Please provide reserve, settlement and payment authority details for your claims organization: Does your organization utilize Best Practice guidelines: Yes No Please provide details for either answer: Where required by law, and considering administration of claims over the SIR on behalf of the carrier, Safety National requires entities and claims staff to obtain required licenses. If licensing is not in place as a claims administrator or for claim handlers for applicable jurisdictions, please explain why: Please complete the grid below by selecting the applicable choices for each LOB and jurisdiction: O: Organization licensed in the state C: Claims handler(s) licensed in the state S: Claims administration subcontracted O C S O C S O C S O C S O C S AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY If claims are subcontracted in any state, please provide details on the company(ies) and the process for capturing data and overseeing the claims: 3) Reserving practices Please describe your reserving philosophy: How does contributory and comparative negligence factor into your reserving: Do you use a reserve worksheet: Yes No If yes, please provide a copy. If no, please describe how reserves are calculated: How often are reserves reviewed for accuracy: 4) Claim management systems and Loss reporting * What type of risk management software do you use: Custom program: Yes No Commercial program: Yes No Other: Yes No Do you allow carriers access to your claims system: Yes No If not, please explain why: Does your claim system capture carrier policy numbers and effective dates of coverage : Yes No If no, how do you distinguish between carrier programs: * SN requires monthly Electronic Data Interface (EDI) concurrent with the policy term(s) until all claims are closed and/or all Carrier-reporting requirements are fulfilled, as defined by the carrier. * SN requires inclusion of ALL claims in applicable policy term(s) in the EDI. Are you able to provide EDI loss runs to Safety National as defined above: Yes No If we have questions about your claim data, who should we contact: Name Title Email Does your organization undergo any external audit process to address Service Organization Controls (SOC) attestations (generally referred to as SSAE 16 or SSAE 18): Yes No If yes, please include a copy with your response. If not, why: Does your organization have a formal business continuity plan as it pertains to the administration of claims : Yes No Does your organization utilize analytics to assist in the exposure evaluation on claims: Yes No If yes, please include details regarding the analytical process and engagement protocols based on findings: Page 125 of 144 SP1.Page 128 of 152 3 5) Carrier reporting Do you have any experience in dealing with carriers for the applicable LOBs: Yes No Please provide details: Describe your system or procedures for monitoring and reporting claims to the carrier: Who is responsible for monitoring and reporting claims to the carrier? Please provide details on the process: Do you have any experience dealing with Claims Made coverages? If so, how do you track the claims: 6) Cost containment and other services List vendors or firms used for the following: A. Outside adjuster/investigation: B. Surveillance/activity checks: C. Law firms: D. Structured Settlements: E. Mandatory Insurer Reporting (MIR) [Medicare Secondary Payer compliance]: Medicare reporting procedures: The insured is the RRE for claim payments within the SIR layer and they are responsible for reporting MIR to CMS. The carrier is the RRE on specific claims in excess of the SIR and when applicable, you must cooperate in making sure our designated Reporting Agent, which is ExamWorks, receives the necessary data for reporting and compliance purposes. What is your procedure for handling recoveries for subrogation, contributions, salvage, etc.: 7) Miscellaneous Please provide details or comments for anything else we should consider in the approval process : Applicant Name: Tittle: Date: Page 126 of 144 SP1.Page 129 of 152 SPECIMEN THIS ENDORSEMENT CHANGES THE POLICY. PLEASE READ IT CAREFULLY. SNGL 054 0514 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Safety National Casualty Corporation Page 1 of 6 EMPLOYEE BENEFITS LIABILITY COVERAGE WITH SELF-INSURED RETENTION (“SIR”) THIS ENDORSEMENT PROVIDES CLAIMS-MADE COVERAGE. PLEASE READ THE ENTIRE ENDORSEMENT CAREFULLY. This endorsement modifies insurance provided under the following: COMMERCIAL GENERAL LIABILITY COVERAGE PART SCHEDULE Coverage Limit Of Insurance Each Employee SIR Premium Employee Benefits Programs $ each employee $$$ aggregate Retroactive Date: Information required to complete this Schedule, if not shown above, will be shown in the Declarations. A.The following is added to Section I – Coverages: COVERAGE – EMPLOYEE BENEFITS LIABILITY 1. Insuring Agreement a.We will pay those sums that the insured becomes legally obligated to pay as dam- ages because of any act, error or omission, of the insured, or of any other person for whose acts the insured is legally liable, to which this insurance applies. We will have the right and duty to defend the insured against any "suit" seeking those damages. However, we will have no duty to defend the insured against any "suit" seeking dam- ages to which this insurance does not apply. We may, at our discretion, investigate any report of an act, error or omission and settle any "claim" or "suit" that may result. But: (1)The amount we will pay for damages is limited as described in Paragraph D. (Section III – Limits Of Insurance); and (2)Our right and duty to defend ends when we have used up the applicable limit of insurance in the payment of judgments or settlements. No other obligation or liability to pay sums or perform acts or services is covered un- less explicitly provided for under Supplementary Payments. b.This insurance applies to damages only if: (1)The act, error or omission, is negligently committed in the "administration" of your "employee benefit program"; (2)The act, error or omission, did not take place before the Retroactive Date, if any, shown in the Schedule nor after the end of the policy period; and (3)A "claim" for damages, because of an act, error or omission, is first made against any insured, in accordance with Paragraph c.below, during the policy period or an Extended Reporting Period we provide under Paragraph F.of this endorsement. c.A "claim" seeking damages will be deemed to have been made at the earlier of the following times: (1)When notice of such "claim" is received and recorded by any insured or by us, whichever comes first; or Page 127 of 144 SP1.Page 130 of 152 SPECIMENPage 2 of 6 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Safety National Casualty Corporation SNGL 054 0514 (2)When we make settlement in accordance with Paragraph a.above. A "claim" received and recorded by the insured within 60 days after the end of the policy period will be considered to have been received within the policy period, if no subsequent policy is available to cover the claim. d.All "claims" for damages made by an "employee" because of any act, error or omission, or a series of related acts, errors or omissions, including damages claimed by such "employee's" dependents and beneficiaries, will be deemed to have been made at the time the first of those "claims" is made against any insured. 2. Exclusions This insurance does not apply to: a. Dishonest, Fraudulent, Criminal Or Malicious Act Damages arising out of any intentional, dis- honest, fraudulent, criminal or malicious act, error or omission, committed by any insured, including the willful or reckless violation of any statute. b. Bodily Injury, Property Damage, Or Personal And Advertising Injury "Bodily injury", "property damage" or "personal and advertising injury". c. Failure To Perform A Contract Damages arising out of failure of performance of contract by any insurer. d. Insufficiency Of Funds Damages arising out of an insufficiency of funds to meet any obligations under any plan included in the "employee benefit pro- gram". e. Inadequacy Of Performance Of Investment/Advice Given With Respect To Participation Any "claim" based upon: (1)Failure of any investment to perform; (2)Errors in providing information on past performance of investment vehicles; or (3)Advice given to any person with respect to that person's decision to participate or not to participate in any plan included in the "employee benefit program". f. Workers' Compensation And Similar Laws Any "claim" arising out of your failure to comply with the mandatory provisions of any workers' compensation, unemployment compensation insurance, social security or disability benefits law or any similar law. g. ERISA Damages for which any insured is liable because of liability imposed on a fiduciary by the Employee Retirement Income Security Act of 1974, as now or hereafter amended, or by any similar federal, state or local laws. h. Available Benefits Any "claim" for benefits to the extent that such benefits are available, with reasonable effort and cooperation of the insured, from the applicable funds accrued or other collectible insurance. i. Taxes, Fines Or Penalties Taxes, fines or penalties, including those imposed under the Internal Revenue Code or any similar state or local law. j. Employment-Related Practices Damages arising out of wrongful termination of employment, discrimination, or other employment-related practices. B.For the purposes of the coverage provided by this endorsement: 1.All references to Supplementary Payments – Coverages A and B are replaced by Supplementary Payments – Coverages A, B and Employee Benefits Liability. 2.Paragraphs 1.b.and 2.of the Supplementary Payments provision do not apply. C.For the purposes of the coverage provided by this endorsement, Paragraphs 2.and 3.of Section II – Who Is An Insured are replaced by the following: 2.Each of the following is also an insured: a.Each of your "employees" who is or was authorized to administer your "employee benefit program". b.Any persons, organizations or "employees" having proper temporary authorization to administer your "employee benefit program" if you die, but only until your legal representative is appointed. Page 128 of 144 SP1.Page 131 of 152 SPECIMENSNGL 054 0514 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Safety National Casualty Corporation Page 3 of 6 c.Your legal representative if you die, but only with respect to duties as such. That representative will have all your rights and duties under this Endorsement. 3.Any organization you newly acquire or form, other than a partnership, joint venture or limited liability company, and over which you maintain ownership or majority interest, will qualify as a Named Insured if no other similar insurance applies to that organization. However: a.Coverage under this provision is afforded only until the 90th day after you acquire or form the organization or the end of the policy period, whichever is earlier. b.Coverage under this provision does not apply to any act, error or omission that was committed before you acquired or formed the organization. D.For the purposes of the coverage provided by this endorsement, Section III – Limits Of Insurance is replaced by the following: 1. Limits Of Insurance a.The Limits of Insurance shown in the Schedule and the rules below fix the most we will pay regardless of the number of: (1)Insureds; (2)"Claims" made or "suits" brought; (3)Persons or organizations making "claims" or bringing "suits"; (4)Acts, errors or omissions; or (5)Benefits included in your "employee benefit program". b.The Aggregate Limit is the most we will pay for all damages because of acts, errors or omissions negligently committed in the "administration" of your "employee benefit program". c.Subject to the Aggregate Limit, the Each Employee Limit is the most we will pay for all damages sustained by any one "employee", including damages sustained by such "employee's" dependents and beneficiaries, as a result of: (1)An act, error or omission; or (2)A series of related acts, errors or omissions negligently committed in the "administration" of your "employee benefit program". However, the amount paid under this endorsement shall not exceed, and will be subject to, the limits and restrictions that apply to the payment of benefits in any plan included in the "employee benefit program". The Limits of Insurance of this endorsement apply separately to each consecutive annual period and to any remaining period of less than 12 months, starting with the beginning of the policy period shown in the Declarations of the policy to which this endorsement is attached, unless the policy period is extended after issuance for an additional period of less than 12 months. In that case, the additional period will be deemed part of the last preceding period for purposes of determining the Limits Of Insurance. 2. Self-Insured Retention (“SIR”) a.Our obligation to pay damages on behalf of the insured applies only to the amount of damages in excess of the SIR amount stated in the Schedule as applicable to Each Employee. The limits of insurance shall not be reduced by the amount of this SIR. b.The SIR amount stated in the Schedule applies to all damages sustained by any one "employee", including such "employee's" dependents and beneficiaries, because of all acts, errors or omissions to which this insurance applies. c.The terms of this insurance, including those with respect to: (1)Our right and duty to defend any "suits" seeking those damages; and (2)Your duties, and the duties of any other involved insured, in the event of an act, error or omission, or "claim" apply irrespective of the application of the SIR amount. d.We may pay any part or all of the SIR amount to effect settlement of any "claim" or "suit" and, upon notification of the action taken, you shall promptly reimburse us for such part of the SIR amount as we have paid. E.For the purposes of the coverage provided by this endorsement, Conditions 2.and 4.of Section IV – Commercial General Liability Conditions are replaced by the following: 2. Duties In The Event Of An Act, Error Or Omission, Or "Claim" Or "Suit" a.You must see to it that we are notified as soon as practicable of an act, error or omission which may result in a "claim". To the extent possible, notice should include: (1)What the act, error or omission was and when it occurred; and Page 129 of 144 SP1.Page 132 of 152 SPECIMENPage 4 of 6 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Safety National Casualty Corporation SNGL 054 0514 (2)The names and addresses of anyone who may suffer damages as a result of the act, error or omission. b.If a "claim" is made or "suit" is brought against any insured, you must: (1)Immediately record the specifics of the "claim" or "suit" and the date received; and (2)Notify us as soon as practicable. You must see to it that we receive written notice of the "claim" or "suit" as soon as practicable. c.You and any other involved insured must: (1)Immediately send us copies of any demands, notices, summonses or legal papers received in connection with the "claim" or "suit"; (2)Authorize us to obtain records and other information; (3)Cooperate with us in the investigation or settlement of the "claim" or defense against the "suit"; and (4)Assist us, upon our request, in the enforcement of any right against any person or organization which may be liable to the insured because of an act, error or omission to which this insurance may also apply. d.No insured will, except at that insured's own cost, voluntarily make a payment, assume any obligation or incur any expense without our consent. 4. Other Insurance If other valid and collectible insurance is avail- able to the insured for a loss we cover under this endorsement, our obligations are limited as follows: a. Primary Insurance This insurance is primary except when Paragraph b.below applies. If this insurance is primary, our obligations are not affected un-less any of the other insurance is also primary. Then, we will share with all that other insurance by the method described in Paragraph c.below. b. Excess Insurance (1)This insurance is excess over any of the other insurance, whether primary, excess, contingent or on any other basis that is effective prior to the beginning of the policy period shown in the Schedule of this insurance and that applies to an act, error or omission on other than a claims- made basis, if: (a)No Retroactive Date is shown in the Schedule of this insurance; or (b)The other insurance has a policy period which continues after the Retroactive Date shown in the Schedule of this insurance. (2)When this insurance is excess, we will have no duty to defend the insured against any "suit" if any other insurer has a duty to defend the insured against that "suit". If no other insurer defends, we will undertake to do so, but we will be entitled to the insured's rights against all those other insurers. (3)When this insurance is excess over other insurance, we will pay only our share of the amount of the loss, if any, that exceeds the sum of the total amount that all such other insurance would pay for the loss in absence of this insurance; and the total of all deductible and self-insured amounts under all that other insurance. (4)We will share the remaining loss, if any, with any other insurance that is not de- scribed in this Excess Insurance provision and was not bought specifically to apply in excess of the Limits of Insurance shown in the Schedule of this endorsement. c. Method Of Sharing If all of the other insurance permits contribution by equal shares, we will follow this method also. Under this approach each in-surer contributes equal amounts until it has paid its applicable limit of insurance or none of the loss remains, whichever comes first. If any of the other insurance does not permit contribution by equal shares, we will contribute by limits. Under this method, each insurer's share is based on the ratio of its applicable limits of insurance to the total applicable limits of insurance of all insurers. Page 130 of 144 SP1.Page 133 of 152 SPECIMENSNGL 054 0514 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Safety National Casualty Corporation Page 5 of 6 F.For the purposes of the coverage provided by this endorsement, the following Extended Reporting Period provisions are added, or, if this endorsement is attached to a claims-made Coverage Part, replaces any similar Section in that Coverage Part: EXTENDED REPORTING PERIOD 1.You will have the right to purchase an Extended Reporting Period, as described below, if: a.This endorsement is canceled or not renewed; or b.We renew or replace this endorsement with insurance that: (1)Has a Retroactive Date later than the date shown in the Schedule of this endorsement; or (2)Does not apply to an act, error or omission on a claims-made basis. 2.The Extended Reporting Period does not ex- tend the policy period or change the scope of coverage provided. It applies only to "claims" for acts, errors or omissions that were first committed before the end of the policy period but not before the Retroactive Date, if any, shown in the Schedule. Once in effect, the Ex- tended Reporting Period may not be canceled. 3.An Extended Reporting Period of five years is available, but only by an endorsement and for an extra charge. You must give us a written request for the endorsement within 60 days after the end of the policy period. The Extended Reporting Period will not go into effect unless you pay the additional premium promptly when due. We will determine the additional premium in accordance with our rules and rates. In doing so, we may take into account the following: a.The "employee benefit programs" insured; b.Previous types and amounts of insurance; c.Limits of insurance available under this endorsement for future payment of damages; and d.Other related factors. The additional premium will not exceed 100% of the annual premium for this endorsement. The Extended Reporting Period endorsement applicable to this coverage shall set forth the terms, not inconsistent with this Section, applicable to the Extended Reporting Period, including a provision to the effect that the insurance afforded for "claims" first received during such period is excess over any other valid and collectible insurance available under policies in force after the Extended Reporting Period starts. 4.If the Extended Reporting Period is in effect, we will provide an extended reporting period aggregate limit of insurance described below, but only for claims first received and recorded during the Extended Reporting Period. The extended reporting period aggregate limit of insurance will be equal to the dollar amount shown in the Schedule of this endorsement under Limits of Insurance. Paragraph D.1.b.of this endorsement will be amended accordingly. The Each Employee Limit shown in the Schedule will then continue to apply as set forth in Paragraph D.1.c. G.For the purposes of the coverage provided by this endorsement, the following definitions are added to the Definitions Section: 1."Administration" means: a.Providing information to "employees", including their dependents and beneficiaries, with respect to eligibility for or scope of "employee benefit programs"; b.Handling records in connection with the "employee benefit program"; or c.Effecting, continuing or terminating any "employee's" participation in any benefit included in the "employee benefit program". However, "administration" does not include handling payroll deductions. 2."Cafeteria plans" means plans authorized by applicable law to allow employees to elect to pay for certain benefits with pre-tax dollars. 3."Claim" means any demand, or "suit", made by an "employee" or an "employee's" dependents and beneficiaries, for damages as the result of an act, error or omission. Page 131 of 144 SP1.Page 134 of 152 SPECIMENPage 6 of 6 Includes copyrighted material of Insurance Services Office, Inc., with its permission. Safety National Casualty Corporation SNGL 054 0514 4."Employee benefit program" means a program providing some or all of the following benefits to "employees", whether provided through a "cafeteria plan" or otherwise: a.Group life insurance, group accident or health insurance, dental, vision and hearing plans, and flexible spending accounts, provided that no one other than an "employee" may subscribe to such benefits and such benefits are made generally available to those "employees" who satisfy the plan's eligibility requirements; b.Profit sharing plans, employee savings plans, employee stock ownership plans, pension plans and stock subscription plans, provided that no one other than an "employee" may subscribe to such benefits and such benefits are made generally available to all "employees" who are eligible under the plan for such benefits; c.Unemployment insurance, social security benefits, workers' compensation and disability benefits; d.Vacation plans, including buy and sell pro- grams; leave of absence programs, including military, maternity, family, and civil leave; tuition assistance plans; transportation and health club subsidies; and e.Any other similar benefits designated in the Schedule or added thereto by endorsement. H.For the purposes of the coverage provided by this endorsement, Definitions 5. and 18.in the Definitions Section are replaced by the following: 5."Employee" means a person actively employed, formerly employed, on leave of absence or disabled, or retired. "Employee" includes a "leased worker". "Employee" does not include a "temporary worker". 18."Suit" means a civil proceeding in which damages because of an act, error or omission to which this insurance applies are alleged. "Suit" includes: a.An arbitration proceeding in which such damages are claimed and to which the insured must submit or does submit with our consent; or b.Any other alternative dispute resolution proceeding in which such damages are claimed and to which the insured submits with our consent. Page 132 of 144 SP1.Page 135 of 152 00 MLT0031 00 12 19 Page 1 of 1 TERRORISM COVERAGE DISCLOSURE NOTICE TERRORISM COVERAGE PROVIDED UNDER THIS POLICY The Terrorism Risk Insurance Act of 2002 as amended and extended by the subsequent Terrorism Risk Insurance Program Reauthorization Acts (collectively referred to as the “Act”) established a program within the Department of the Treasury, under which the federal government shares, with the insurance industry, the risk of loss from future terrorist attacks. An act of terrorism is defined as any act 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 an air carrier or vessel 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. In accordance with the Act, we are required to offer you coverage for losses resulting from an act of terrorism that is certified under the federal program as an act of terrorism. The policy’s other provisions will still apply to such an act.This offer does not include coverage for incidents of nuclear, biological, chemical, or radiological terrorism which will be excluded from your policy. Your decision is needed on this question: do you choose to pay the premium for terrorism coverage stated in this offer of coverage, or do you reject the offer of coverage and not pay the premium? You may accept or reject this offer. If your policy provides commercial property coverage, in certain states, statutes or regulations may require coverage for fire following an act of terrorism. In those states, if terrorism results in fire, we will pay for the loss or damage caused by that fire, subject to all applicable policy provisions including the Limit of Insurance on the affected property. Such coverage for fire applies only to direct loss or damage by fire to Covered Property. Therefore, for example, the coverage does not apply to insurance provided under Business Income and/or Extra Expense coverage forms or endorsements that apply to those coverage forms, or to Legal Liability coverage forms or Leasehold Interest coverage forms. Your premium will include the additional premium for terrorism as stated in the section of this Notice titled DISCLOSURE OF PREMIUM. DISCLOSURE OF FEDERAL PARTICIPATION IN PAYMENT OF TERRORISM LOSSES The United States Government, Department of the Treasury, will pay a share of terrorism losses insured under the federal program.The federal share equals 80% in years 2020 through 2027 of that portion of the amount of such insured losses that exceeds the applicable insurer deductible during Calendar Year 2020 and each Calendar Year thereafter through 2027. DISCLOSURE OF CAP ON ANNUAL LIABILITY If the aggregate insured terrorism losses of all insurers exceed $100,000,000,000 during any Calendar Year provided in the Act, the Secretary of the Treasury shall not make any payments for any portion of the amount of such losses that exceed $100,000,000,000, and if we have met our insurer deductible, we shall not be liable for the payment of any portion of such losses that exceeds $100,000,000,000. DISCLOSURE OF PREMIUM Your premium for terrorism coverage is: $2,500.00 (This charge/amount is applied to obtain the final premium.) You may choose to reject the offer by signing the statement below and returning it to us.Your policy will be changed to exclude the described coverage. If you chose to accept this offer, this form does not have to be returned. REJECTION STATEMENT I hereby decline to purchase coverage for certified acts of terrorism. I understand that an exclusion of certain terrorism losses will be made part of this policy. Policyholder/Legal Representative/Applicant’s Signature Named Insured Print Name of Policyholder/Legal Representative /Applicant Insurance Company Date: Policy Number: Page 133 of 144 SP1.Page 136 of 152 Risk Placement Services, Ins. Broker - LA License #0C66724 1551 North Tustin Avenue, Suite 800 Santa Ana, CA 92705 Phone: Fax: Agent: AJG - Rolling Meadows Insured Name: City of Evanston, Illinois ILLINOIS BROKERS SERVICE CONTRACT 1. THE UNDERSIGNED INSURED HEREBY ENGAGES THE SERVICE OF Risk Placement Services, Inc., A LICENSED ILLINOIS INSURANCE PRODUCER/BROKER FOR THE PURPOSE OF SECURING, NEGOTIATING AND PROCURING THE PLACEMENT OF THE FOLLOWING DESCRIBED INSURANCE COVERAGES. THE INSURANCE COVERAGE REQUESTED IS: Company:Arch Specialty Insurance Company Policy No.: Effective Date: Type of Coverage:BRK Excess Liability 2. THE UNDERSIGNED INSURED AGREES TO PAY AS COMPENSATION TO THE BROKER ABOVE AND IN ADDITION TO THE COMMISSION RECEIVED FROM THE INSURED FOR THE VARIOUS SERVICES OF THE BROKER A FEE OF NOT MORE THAN $ THIS FEE IS 100% FULLY EARNED AT THE POLICY INCEPTION. 3. A BRIEF DESCRIPTION OF THOSE BROKER SERVICES PERFORMED AND NOT DESCRIBED IN PARAGRAPH 1 ABOVE IS ORDERING AND PAYING: FOR INSPECTIONS AND/OR AUDITS, COMPLIANCE WITH SURPLUS LINES LAW, TYPING AND ASSEMBLING OF POLICIES. DATED: Insured Signature DATED: Agent's Signature Page 134 of 144 SP1.Page 137 of 152 City of Evanston 135 Claims Reporting By Policy Immediately Report all claims. TPA – CCMSI (Package and 1st Layer XS ($5M x $5M) • Lori Mittelstaedt • Email: lmittelstaedt@ccmsi.com Casualty Package ◦ Liberty Mutual Insurance Companies ◦ Phone #: 800-362-0000/1-844-325-2467 ◦ Email: clclaimreports@libertymutual.com ◦ Website: https://business.libertymutualgroup.com/business -insurance/claims-process/report-a-claim ◦ Safety National Casualty Corporation, Safety Specialty Insurance Company ◦ Phone #: 888-995-5300 Excess ($5M x $5M) ◦ Old Republic Specialty Insurance Underwriters ◦ Address: 790 Township Road, Suite 230, Yardley, PA 19067 ◦ Phone #: 215-860-4960 ◦ Email: claims@orsiu.com Direct Reporting [Only When Applicable] Property • Affiliated FM Insurance Company • Phone # : 877-639-5677 • Email : newlossdallas@fmglobal.com Underground Storage Tank • Ironshore Specialty Insurance Company • Phone # : (888) 292-0249 • Fax# : 646-826-6601 • Email : USClaims@ironshore.com • Syndicate 2623/623 at Lloyd's • Email: enviro.claims@beazley.com • Fax #: 860-679-0247 • Phone #: 800-347-4384 Cyber Liability • Obsidian Specialty Insurance Company • Phone # : 833-633-8666 • Email : claims@cowbellcyber.ai • Website: https://console.cowbellcyber.ai Page 135 of 144 SP1.Page 138 of 152 City of Evanston 136 Page 136 of 144 SP1.Page 139 of 152 City of Evanston 137 Cyber Liability eRiskHub Features Page 137 of 144 SP1.Page 140 of 152 . 1 Excess Workers Compensation & Governmental Crime Insurance Proposal 12/31/2021 to 12/31/2022 From The Owens Group, Inc. Frederick D. Arkin fdarkin@toginsrisk.com (773)‐330‐5999 Page 138 of 144 SP1.Page 141 of 152 . 2 Contents I. Executive Summary II. Service Team III. Cost Comparison IV. Insurance Carriers Financial Ratings V. Payment Options Disclaimer This Proposal is issued as a matter of confirmation only and does not amend, extend or alter the coverage provided by the actual insurance policies. Page 139 of 144 SP1.Page 142 of 152 1 EExxeeccuuttiivvee SSuummmmaarryy Program Type: The City of Evanston’s Excess Workers Compensation program is self‐insured with Safety National as the carrier and CCMSI as the Third‐Party Administrator. The City maintains a retention of $750,000 for all Excess Workers Compensation losses and an Employers Liability Limit of $1,000,000. The City also has Crime Coverage with AIG. Expiring terms include a Liability Limit of $2,000,000 and single loss deductible of $25,000. Marketing Responses: Safety National and AIG provided terms for the City’s Commercial Insurance Program. AIG’s Crime proposal included $2,000,000 limits for Employee Theft, Forgery or Alterations, Computer Fraud, etc. with an annual premium of $7,803. This is the first increase in over 3 years. Safety National offered an Employers Liability limit of $1,000,000 with a $750,000 retention for $178,279. That is a 3.87% increase over expiring. Safety National also offered an $850,000 option for an annual premium of $160,022. Insurance Company Coverage Lines Requested Carrier’s Response Safety National Casualty Excess Workers Compensation Provided Terms‐ $1,000,000 Employers Liability Limit – Deposit Premium: $178,279 with $750,000 Retention and $160,022 with $850,000 Retention. National Union (AIG) Governmental Crime Provided Terms ‐ $2,000,000 Limit – Annual Premium $7,970. Page 140 of 144 SP1.Page 143 of 152 2 II.. SSeerrvviiccee TTeeaamm Phone Number: 312‐780‐1441 Fax Number: 312‐368‐5113 Office Hours: 8:30 a.m. to 5:00 p.m. Monday ‐ Friday 19 S. La Salle St., Suite 500 Chicago, IL 60603‐1438 David Macknin President 312-320-6688 dmacknin@toginsrisk.com Frederick D. Arkin Account Manager 773-330-5999 fdarkin@toginsrisk.com A service team approach will be implemented for the City of Evanston to provide senior level availability for all of your services and risk management needs as well as daily service requirements. Page 141 of 144 SP1.Page 144 of 152 III. Cost Comparison Expiring Carrier Proposed Carrier 2020‐21 Premium 2020‐21 Premium $ Change % Change Governmental Crime National Union (AIG) National Union (AIG) $6,812 $7,970 +1,158 17% Excess Workers Compensation Safety National Safety National $171,634 $178,279* +6,645 3.87% Total Cost $178,446$186,249 $7,803 4.37% *Safety National also offered $1,000,000 Employers Liability Limit with $850,000 Retention for $160,022 Deposit Premium.. Page 142 of 144 SP1.Page 145 of 152 IIVV.. IInnssuurraannccee CCoommppaanniieess FFiinnaanncciiaall RRaattiinnggss The A.M. Best’s Guide is the guidebook the insurance industry uses to determine the financial stability of an insurance company. A copy of the AM. Best’s Guide report on the quoted insurance companies is available upon your request. While we strive to be certain that your insurance is placed with reputable, highly rated insurance companies, we have no way of guaranteeing the financial accuracy of the A.M. Best’s Guide or the financial stability of the insurance company. For these reasons, we ask that you take into account the financial stability of all the insurance companies prior to making your selection as to who will write your insurance. Company Proposed 2020 AM Best’s Assigned Rating Safety National Casualty Co. A+ National Union (AIG) A Alphabetical Listing A+ = Superior A = Excellent B+ = Very Good B = Good C+ = Fairly Good C = Fair Page 143 of 144 SP1.Page 146 of 152 V. Payment Options (A) Payment in full due date of inception. I elect to accept the premium and conditions as explained in this proposal. Signature & Title Date Page 144 of 144 SP1.Page 147 of 152 Memorandum To: Honorable Mayor and Members of the City Council From: Audrey Thompson, Community Services Manager CC: Ike Ogbo, Health and Human Services Director Subject: Discussion Regarding Additional Funding to Support Youth Initiatives to Address Youth Violence Date: December 20, 2021 Recommended Action: City staff recommends City Council discuss the expansion of the “My City, Your City, Our City '' Initiative to address youth and families' violence prevention strategies and families impacted by violence. The estimated cost of the program expansion is $867,500. Council Action: For Discussion Summary: The City of Evanston has experienced an increase in youth viol ence during the COVID-19 pandemic. In 2021, nine youth between the ages of 14-24 have been victimized by gun violence, four of whom lost their lives. This increase in violence disparately impacts lower - income, African-American and people of color, consistent with the disparate impact of the coronavirus on these populations on overall health, housing stability, and loss of employment. One of the uses of ARPA funding in the Interim Final Rule is for “Evidence -based community violence intervention programs to prevent violence and mitigate the increase in violence during the pandemic.” A holistic program to address the underlying factors that result in youth violence must be applied. The World Health Organization (WHO) names youth violence as a global health problem with 200,000 homicides occurring in youth ages 10-29 (42% of the total number of homicides globally each year). Globally, 84% of youth homicide victims are males, and most perpetrators are also males. WHO lists risk factors within the individual, close relationships, and the community. Some individual risk factors include a low commitment to school, involvement in crime, unemployment, and exposure to violence in the family. As it pertains to risk factors of close relationships, WHO names limited involvement, monitoring, and supervision of children by parents, parental depression, low family income, and unemployment in the family as many of the culprits for youth violence. Finally, risk factors within the community/wider society include high-income inequality, poverty, access to and misuse of alcohol, illicit drugs, and firearms. SP2.Page 148 of 152 It is not enough to discuss risk factors without providing a holistic approach that includes the individual, family, and community as a whole. To name a few, WHO provides the following as some of the promising prevention and intervention strategies/program s to address community violence: • life skills and social development programs designed to help children and adolescents manage anger, resolve conflict, and develop the necessary social skills to solve problems; • whole school approaches to violence prevention in educational facilities; • programs that support parents and teach positive parenting skills; • preschool programs that provide children with academic and social skills at an early age; • therapeutic approaches for youths at high risk of being involved in violence; • community and problem-oriented policing; and • interventions to reduce concentrated poverty and to upgrade urban environments. The City’s Community Services Division staff is reassured by this research of proven violence prevention strategies as it yields strategies currently being utilized by the Youth and Young Adult Division. The Strategic Operational Plan includes Education, Civic Engagement, Workforce Development, and Alternative Recreation. This research, however, reveals that the Division’s current target age of youth ranging from 14-24 is no longer sufficient in addressing violence prevention in our community. I. My City, Your City, Our City” Initiative Expansion The My City, Your City, Our City Initiative began in 2021 to address summer activities for youth- related to social isolation caused by the COVID-19 pandemic that could contribute to youth violence. The initiative reached both youth and their families, with a targeted age of 13 to 18. Due to the success of the Initiative, staff evaluated the program and saw a need to expand the purpose and goals of the initiative to include more youth and their family members that are also in need of support and services. The expanded program will target age groups between 11 and 29 years of age and household family members of identified clients. A. New Position - Outreach Team To build and support the expanded offerings discussed below, an additional full -time outreach worker is required. This position with salary and benefits will be $100,000. Currently, the outreach team consists of four outreach staff and one supervisor. B. New or Expanded Program 1) Education: Support youth and family members through academic, vocational, certificate, and entrepreneurial internships, externships, and apprenticeship programming opportunities: • $30,000 to increase the number of non-violence camps from one to three provided annually to and by youth (stipends for youth facilitators included) • $90,000 for middle school liaison (staff costs to include a part-time employee) • $50,000 to support clients who need financial assistance with vocational training, certificates/licensure to fulfill a specific career path that does not qualify under local, state, and federal programs. Page 2 of 5 SP2.Page 149 of 152 2) Civic Engagement - Development and promotion of civic responsibility and engagement. • $40,500 ($15/hour X 15 youth for 15 hours/month) - Stipends for Youth Advisory Committee • $18,000 ($15/hour X 5 youth for 20 hours/month) - Junior Outreach Workers trained as seasonal employees. • $24,000 $20/hour X 5 parents for 20 hours/month) Stipends for parents to lead Parenting 4 Non-Violence classes. • Amend Restorative Practices to expand the program to include additional ages. 3) Workforce Development - Recruitment, training, and retention of an Evanston youth and young adult workforce that possesses in-demand career skill sets needed to compete in the 21st-century economy. • Expansion of iKit Careers Program to youth and families to ensure employment and career placement. • Commitment from each Department that as jobs become available, staff will work with the Community Services staff to hire Evanston residents with the goal of creating internal career paths for youth and families. Job descriptions will be evaluated and modified to remove barriers with preference given to youth and families who reside in Evanston. • Creation of a Second Chance Policy - Amend City of Evanston’s hiring policies to address systemic barriers to employment that prevent the hiring of nontraditional employees (e.g. lack of formal education, credentials or returning residents). While t he Illinois Employee Background Fairness Act passed in March 2021 prohibits the disqualification of job applicants solely based on background, the Second Chance Policy will highlight how the City of Evanston will use the Interactive process to work with the Community Services Division and other entities to ensure that returning citizens have an informed advocate in the overall hiring process. • $240,000 for Youth and Families Workforce Development Program - ability to pay an eight-week internship for any employers willing to hire individuals who are working with Youth and Young Adult Division to secure long-term employment/careers for youth and their families. • $75,000 ($1500/participant) - Sub-recipient agreement with local organizations to provide job readiness training and complete career pathways assessments for youth and family members during paid internships leading to long-term employment. 4) Alternative Recreation • $25,000 to assist 7-10 blocks to form block clubs and to plan/execute their first block club celebration during the summer. Representatives from current/established block clubs will be asked to support new clubs during their implementation stage. • $100,000 for staffing, food, and supplies for Robert Crown and Gibbs-Morrison After School Drop-In Centers. Culinary and entrepreneurial workforce development events will be scheduled for the kitchen space with local businesses such as C&W Market, Chef Q, Curt’s Café, Evanston Public Library, Northwestern University, Oakton Community College to name a few. • $75,000 for sub-recipient agreements with local organizations to execute programming for after-school and safe summer initiatives. Page 3 of 5 SP2.Page 150 of 152 II. Funding Source American Rescue Plan Act (ARPA) The initial implementation of the initiative can be funded through ARPA. Specific activities outline within the program expansion are eligible for funding through ARPA, according to the Treasury guidelines. The categories defined by the U.S. Treasury in th e Coronavirus Local Fiscal Recovery Funds (CLFRF) Interim Final Rule for eligibility and reporting include: • Public Health 1.9 - Payroll Costs for Public Health, Safety, and Other Public Sector Staff Responding to COVID-19 • Negative Economic Impacts 2.7 - Job Training Assistance • Disproportionately Impacted Communities 3.16 - Social Determinants of Health: Community Violence Interventions III. Background on Current Strategies • Target Age Group -14-24 years of age • Funding Source - Human Services Fund and CDBG-CV 1) Education • Annual Kingian Nonviolence Camp for youth facilitated in partnership with James B Moran Center. • Life Skills classes are currently being provided at middle schools. • iKit Careers Program – graduates of Evanston Township High School receive 12 weeks of paid internships in hopes of finding long-term employment related to a specific career. 2) Civic Engagement • Youth Advisory Committee • Restorative Justice Program • Youth receiving complaint tickets from Evanston Police Department volunteer at Youth and Young Adult activities (e.g. pop-up food pantry, violence prevention initiative activities, etc.) 3) Workforce Development • Mayor’s Summer Youth Employment Program (MSYEP) • iKit Careers Program in partnership with YJC and Mayor’s Employer Advisory Council (MEAC) • Career Pathways Program in partnership with YJC 4) Alternative Recreation • After-School Drop-in at Robert Crown for middle-school-aged youth • My City, Your City, Our City Safe Summer Initiative which includes programs in the CDBG-CV areas (predominately in all of the 2nd and 5th wards, as well other specified areas in the 8th and 9th wards. The progress of the program will be monitored and measured by positive outcomes, enrollment in training/apprenticeships, career/job placements, and retention at 1, 3, and 12 months, as well as a number of recreation, service referrals, civic engagement activities, and community engagement plans completed. Page 4 of 5 SP2.Page 151 of 152 At a minimum, the Program will be evaluated every six months to ensure that activities and operations are effective in reaching desired goals. The Community Services Division will furnish a report every six months to the Human Services Committee regarding the success and effectiveness of the established programs and services. The following organizations/agencies will work together to implement certain aspects of the aforementioned plan with more partnerships to be developed in the coming months: • Connections for the Homeless • Curt's Cafe • Erie Family Healthcare • Evanston Own It • Evanston Public Library (EPL) • Infant Welfare Society of Evanston • James B Moran Center for Youth Advocacy • McGaw YMCA • Mayor’s Employer Advisory Council (MEAC) • Northwestern University • PEER Services • YWCA Evanston/North Shore • Youth and Opportunities United (YOU) • Youth Job Center (YJC) • Evanston Collective Organizations Page 5 of 5 SP2.Page 152 of 152