2022-06-14 Renewal Quote Terrorism InsuranceQuote #:4824284-1 Quote Date: 06/09/2022
Underwriter:Donna Kirchoff Producer Name:Alexandria Lucente
Underwriter Phone#:(312) 258-3361 Company Name:Apex Insurance Services
Underwriter Email:Donna.Kirchoff@Markel.com Insuring Company:Evanston Insurance Company
Applicant Name:Costa Mesa Sanitary District Quote Expires:07/01/2022
Mailing Address: 628 W 19th St
Costa Mesa , CA -92627-2716
Policy Period: 07/01/2022 To 07/01/2023
Coverage Name: Lead Excess Retro Date: n/a
Policy Basis: Occurrence
LIMITS AND PREMIUM
Per Occurrence: $10,000,000
Aggregate: $10,000,000
Excess of: Underlying Insurance
Premium: $27,500
TRIA Premium: $1,375
Total Premium: $28,875 + taxes/fees = $55,388.79/$52,977.38 w/o TRIA
Min Earned Premium: 25 %
Payment Plan: Full Pay
Premium Type: Flat
UNDERLYING INSURANCE
# Coverage Carrier Effective - Expiration
Date
Limit Type Underlying Limit
1 General Liability Special District Risk
Management Authority
07/01/2022 -
07/01/2023 General Aggregate $10,000,000
Occurrence $10,000,000
2 Automobile Liability Special District Risk
Management Authority
07/01/2022 -
07/01/2023 Combined Single Limit $10,000,000
3 Employee Benefits Liability Special District Risk
Management Authority
07/01/2022 -
07/01/2023 Each Employee $10,000,000
Aggregate $10,000,000
CONDITIONS
1.Evanston Insurance Company maintains the right to adjust terms and conditions in the event conflicting information is received.
2.Prior to binding: Receipt and UW review of all underlying quotes
3.All underlying carriers must be A-VI rated by AM Best
4.A signed Umbrella/Excess Acord 131 application or Acord 63 acknowledging Fraud Statement within 30 days of binding
5.Signed application, including supplemental application if submitted, within 30 days of binding
6.A signed/dated copy of Terrorism Disclosure MKL TERR 4 is required to bind
7.The Terrorism Risk Insurance Act (TRIA), requires insurance companies to offer limited terrorism coverage. The endorsements MAUB 1696 -
Exclusion of Certified Acts of Terrorism, MUB Terr-2 - Confirmation of Exclusion of Certified Acts of Terrorism Coverage on this quote reflect TRIA
being rejected. If TRIA is accepted, MAUB 1696 and MUB Terr-2 will be removed and the following endorsements will apply: MAUB 1292 - Cap on
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Total Taxes and Fees: $3,935.18Total Taxes and Fees: $3,898.13 w/o TRIA
Losses from Certified Acts of Terrorism, MAUB 1697 - Exclusion of Punitive Damages Related to a Certified Act of Terrorism and MUB Terr-1 -
Confirmation of Certified Acts of Terrorism Coverage. Where required by law, titles and terms of TRIA will be state specific
8.We require 5 years of currently valued insurance company loss runs confirming the loss information previously submitted within 30 days of
binding
9.A copy of underlying binder(s) and/or policies within 30 days upon binding
10.A signed and completed Home State and Surplus Lines Tax Payer Information form MLIL 1000 within 30 days of binding
FORMS
Edition Name
MJIL 1000 08 10 Policy Jacket
MPIL 1007 01 20 Privacy Notice
MADUB 1000 04 17 Commercial Excess Liability Policy Declarations
MDIL 1001 08 11 Forms Schedule
MEIL 1225 10 11 Change - Civil Union
MPIL 1041 02 20 How To Report A Claim
MPIL 1083 04 15 U.S. Treasury Department's Office Of Foreign Assets Control ("OFAC") Advisory Notice To Policyholders
MAUB 1851 07 19 Exclusion - Wild Fire
MADUB 1003 04 17 Schedule Of Underlying Insurance
MAUB 0001 01 15 Commercial Excess Liability Policy
MAUB 1241 01 15 Expenses Included Within Limits
MAUB 1243 04 17 Unimpaired Aggregate Limit
MAUB 1255 01 15 Non-Drop Down Provision
MAUB 1264 04 17 25% Minimum Earned Premium (Excess)
MAUB 1268 01 15 Employee Benefits Liability Limitation
MAUB 1306 01 15 Exclusion - Public Officials
MAUB 1308 01 15 Exclusion - Breach Of Contract
MAUB 1309 03 20 Exclusion - Communicable Disease
MAUB 1310 04 17 Exclusion - Prior Incidents And Prior Construction Defects
MAUB 1355 01 15 Exclusion - Nuclear Energy Liability
MAUB 1384 01 15 Exclusion - Employment-Related Practices
MAUB 1386 01 15 Exclusion - ERISA
MAUB 1391 01 15 Exclusion - Computer Related And Other Electronic Problems
MAUB 1615 01 15 Exclusion - Damage To Property
MAUB 1618 04 17 Exclusion - Sublimited Underlying Coverage
MAUB 1621 01 15 Exclusion - Recording And Distribution Of Material Or Information In Violation Of Law
MAUB 1638 01 15 Exclusion - Fungi Or Bacteria
MAUB 1642 01 15 Exclusion - Lead
MAUB 1663 01 15 Exclusion - Professional Services
MAUB 1665 01 15 Exclusion - Auto No-Fault And Similar Laws
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Thanks & Regards,
Donna Kirchoff
Senior Underwriter
Commercial Excess Casualty
Markel Specialty
MAUB 1666 01 15 Exclusion - War Liability
MAUB 1678 01 15 Exclusion - Pollution
MAUB 1692 01 15 Exclusion - Punitive Damages
MAUB 1696 01 15 Exclusion - Certified Acts of Terrorism
MAUB 1804 01 15 Exclusion - Silica Or Mixed Dust
MAUB 1811 04 17 Exclusion - Abuse Or Molestation
MAUB 1813 01 15 Exclusion - Asbestos
MAUB 1822 04 17 Exclusion - Unmanned Aircraft
MAUB 1242 01 15 Non-Accumulation Of Limits
MAUB 1503 01 15 Policy Changes ;
Manuscript - Municipal Amendatory Endorsement
MAUB 1503-A 01 15 Policy Changes ;
Manuscript - Dams Exclusion
MAUB 1600 10 20 Exclusion - Cyber Incident, Data Compromise, and Violation of Statutes Related to Personal Data
MEIL 1200 02 20 Service Of Suit
MUB Terr-2 01 15 Confirmation Of Exclusion Of Certified Acts Of Terrorism Coverage - Terrorism Risk Insurance Act
MIL 1214 09 17 Trade or Economic Sanctions
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