Insurance - Terrorism Coverage - 2013-05-08 DISCLOSURE NOTICE OF TERRORISM INSURANCE COVERAGE
May 3,2013
To Whom It May Concem:
We are required to send you this notice pursuant to federal legislation concerning terrorism insurance.
You are hereby notified that under the Terrorism Risk Insurance Act,as amended,that 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 ts 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% 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 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.
SELECTION OR REJECTION OF TERRORISM INSURANCE COVERAGE
PLEASE"X"ONE OF THE BOXES BELOW AND TAKE THE ACTION INDICATED.
I herby elect to purchase the Terrorism Coverage required to be offered under TRIPRA for a premium of
$469(plus applicable taxes and fees).
Action:Please sign and return this form with your payment for premium to your insurance agent.
I decline to purchase the Terrorism Coverage required to be offered under TRIPRA.
Action:Please sign and return this form to your insurance agent.
x Date: 5/5 1 7--01.
Policy Holder/Applicant's Signature
Print Name S lJ"Ll Cam, 1 V II I V/1,Q)4/1 (4,) kaniateK
Insured: Costa Mesa Sanitary District Submission#: 734045/bs
' INTERLINE
MARKE6
CALIFORNIA SHORT RATE CANCELLATION PENALTY DISCLOSURE
Please be advised that there may be a short rate cancellation penalty of up to 25%applied to your
policy premium if you request cancellation of your policy prior to the expiration date.
Please refer to your policy for specific terms and conditions.
MPIL 1042-CA 03 12 Page 1 of 1
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Underlying Coverage:
Commercial General Liability Coverage(s):
Insurer: SDRMA Policy Period: 7/1/2013-7/1/2014 Retroactive Date:
$10,000,000 Per Occurrence _ N/A
Limits: $10,000,000 General Aggregate
Per Member
Commercial Automobile Liability Coverage(s):
Insurer: SDRMA Policy Period: 7/1/2013-7/1/2014
Limits: $10,000,000 Per Member
Employers Liability Coverage(s):
Insurer: SDRMA Policy Period: 7/1/2013-7/1/2014
$1,000,000 Each Accident
Limits: $1,000,000 Policy Limit Aggregate
$1,000,000 Each Employee
Coverage(s): Employee Benefits
Insurer: SDRMA Policy Period: 7/1/2013-7/1/2014 Retroactive Date:
Limits: $10,000,000 Occurrence $10,000,000 Aggregate N/A
Paso 7 nFG
ATTENTION:
Please review this Quotation carefully.The terms&conditions may differ from the terms originally requested in your application.The
proposal presented here is valid for thirty(30)days from the date the quote was issued or until the effective date of the stated policy
period,whichever comes first and is subject to no material change in the risk to be insured.
After review of actual policies,we will endorse any exclusion,restrictions or limitations found,in order to avoid a drop-down potential.
If an Additional Insured Endorsement is used on our policy please note the following wording:
Due to the varying terms required by certificate holders,the obstacles when attempting to include contract language via a Certificate of
Insurance and the difficulties involved when enforcing these requirements,Markel Corp.will not require copies of Certificates of
Insurance on behalf of our named insured.
Insureds are advised that Certificates of Insurance should be used only to provide evidence of insurance in lieu an actual copy of the
insurance policy.Certificates cannot be used to amend,expand,or otherwise alter the terms of the actual policy.
111 N.Canal,Suite#940,Chicago,IL 60606
(312)256-3362-Fax:312-234-9468
To: Yoli Stark Issue Date:May 3,2013
Apex
Fax Number: Revision#:
Reason:
From: Beverly Sullivan-Underwriter Manager-Excess&Umbrella
We are pleased to offer the following Renewal Quote.The submission#is: 734045
Renewal of: X0MW268512.
Insured: Costa Mesa Sanitary District Company:Evanston Ins Co.(Non-Admitted)
Costa Mesa,CA
Coverage: Following Form Excess Liability(Occurrence Form)
Policy Period: 7/12013 To: 7/1/2014 Retroactive Date: N/A
Limit: $10,000,000 occ./agg. P/O:N/A X/S:Primary GL,AL&EL
*Premium Charge Excluding Terrorism Coverage: $11,885 Flat Rate
Additional Premium Including Terrorism: $469 Flat Rate
Total Premium Charge: $12,534 Flat Rate
Commission: 0% Note:A 25%minimum earned premium applies
*All taxes,fees,and filings(if applicable)are the responsibility of the broker.
Mandatory and Applicable Forms and Endorsements:
Exclusions:
In Jacket(MEU 2000 01 09):Asbestos Exclusion;ERISA Exclusion;Mold Exclusion;Nuclear Exclusion;Pollution-Absolute Exclusion;
Punitive Exclusion;Uninsured/Under-insured Motorists Exclusion;War Exclusion;
Exclusion Endorsements:Blast Faxing Exclusion-MEU 5445 04 05;Care,Custody or Control Exclusion-MEU 5070 08 95;Computer
Related and Other Electronic Products Exclusion-MEU 5409 01 09;Cross Suits Exclusion-MEU 5419 12 00;Employment Practices
Liability Exclusion-MEU 5444 03 05;Intellectual Property Hazard Exclusion-MEU 5405 02 05;Lead Contamination Exclusion-MEU
5093 08 95;Prior Incidents and Prior Construction Defects Exclusion-MEU 5418 10 00;Professional Liability Exclusion-MEU 5250 08 95;
Public Officials Exclusion-MEU 5156 08 95;Silica Exclusion-MEU 5303 08 95;Terrorism Exclusion-MEU 5451 12 07;
Limitations:
Other:California Surplus Lines Notice-MPIL 1005 01 10;Changes-Civil Union-MEIL 1225 10 11;Defense within the Limit of Liability-
MRE 017 01 09;Municipal Amendatory Endorsement-MEU 5414 10 99;Non-Drop Down Provision -MEU 7069 05 01;Punitive Damages
Limitation-MEU6055 0109;Privacy Notice-MPIL 1007 04 10;Service of Suit-MEIL 1200 01 10;
Quote/Binder is subject to:Signed accord applications,including supplemental applications if submitted,within 30 days if bound.A copy of
the underlying policies within 90 days if bound.
*The TERRORISM FORM MUST BE SIGNED and RETURNED PRIOR TO BINDING!!!
We require within thirty days of binding,5 years of current&valued hard copy insurance company loss runs
confirming the loss information previously submitted
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