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HomeMy WebLinkAbout173-23 RESOLUTION113 West Mountain Street Fayetteville, AR 72701 (479) 575-8323 Resolution: 173-23 File Number: 2023-961 RAILROAD LIABILITY POLICY (BUDGET ADJUSTMENT): A RESOLUTION TO AUTHORIZE THE PURCHASE OF A RAILROAD GENERAL LIABILITY POLICY TO COVER CURRENT AND FUTURE RAILROAD CROSSING IMPROVEMENTS AT A COST OF $54,000.00 FOR ONE YEAR OF COVERAGE, AND TO APPROVE A BUDGET ADJUSTMENT BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE, ARKANSAS: Section 1: That the City Council of the City of Fayetteville, Arkansas hereby authorizes the purchase of a railroad general liability policy to cover current and future railroad crossing improvements at a cost of $54,000.00 for one year of coverage. Section 2: That the City Council of the City of Fayetteville, Arkansas hereby approves a budget adjustment, a copy of which is attached to this Resolution. PASSED and APPROVED on August 15, 2023 Page 1 Attest: ���`es: i;;►���/� 7�EVILLE:�:U 'ara Paxton, City Clef- Treasurer � %• ,, `' •�fiN�P.•��p. /`���►11 itt►O�``` CITY OF FAYETTEVILLE ARKANSAS MEETING OF AUGUST 15, 2023 TO: Mayor Jordan and City Council THRU: Paul Becker, Chief Financial Officer Susan Norton, Chief of Staff FROM: Les McGaugh, Purchasing Director Chris Brown, Public Works Director DATE: CITY COUNCIL MEMO SUBJECT: Purchase of a Protective Railroad General Liability Policy RECOMMENDATION: 2023-961 A Resolution to authorize the purchase of a railroad general liability policy for current and future railroad crossing improvements utilizing the City's insurance broker HUB International, and to approve a budget adjustment. BACKGROUND: The City has historically carried a railroad protective liability policy for the Arkansas & Missouri railroad to protect the City and the Railroad during maintenance and improvements along the trails bordering the railroad property and at railroad crossings. DISCUSSION: As a result of the additional crossings at Futrall and Shiloh, the Arkansas & Missouri Railroad has requested a more comprehensive and larger general liability Policy. They City's insurance broker, HUB International solicited competitive rates and has provided the City with a quote of $54,600.00 for this Railroad General Liability Policy. BUDGET/STAFF IMPACT: A budget adjustment for this policy is attached. ATTACHMENTS: Staff Review Form - BA For RR Liability Policy, 2023-961 BA General Liability RR, COFGLapp, COFExcessLiabapp, City of Fayetteville RSUI XS Quote, City of Fayetteville RSUI GL Quote (003) Mailing address: 113 W. Mountain Street www.fayetteville-ar.gov Fayetteville, AR 72701 == City of Fayetteville, Arkansas y 113 West Mountain Street Fayetteville, AR 72701 (479)575-8323 - Legislation Text File #: 2023-961 Purchase of a Protective Railroad General Liability Policy A RESOLUTION TO AUTHORIZE THE PURCHASE OF A RAILROAD GENERAL LIABILITY POLICY TO COVER CURRENT AND FUTURE RAILROAD CROSSING IMPROVEMENTS AT A COST OF $54,000.00 FOR ONE YEAR OF COVERAGE, AND TO APPROVE A BUDGET ADJUSTMENT BE IT RESOLVED BY THE CITY COUNCIL OF THE CITY OF FAYETTEVILLE, ARKANSAS: Section 1: That the City Council of the City of Fayetteville, Arkansas hereby authorizes the purchase of a railroad general liability policy to cover current and future railroad crossing improvements at a cost of $54,000.00 for one year of coverage. Section 2: That the City Council of the City of Fayetteville, Arkansas hereby approves a budget adjustment, a copy of which is attached to this Resolution. Page 1 Les McGaugh Submitted By City of Fayetteville Staff Review Form 2023-961 Item ID 8/15/2023 City Council Meeting Date - Agenda Item Only N/A for Non -Agenda Item 7/27/2023 PURCHASING (160) Submitted Date Division / Department Action Recommendation: A Resolution to authorize the purchase of a railroad general liability policy for current and future railroad crossing improvements utilizing the City's insurance broker HUB International, and to approve a budget adjustment. 1010.520.5260-5311 Account Number N/A Project Number Budgeted Item? Yes Budget Impact: Total Amended Budget Expenses (Actual+Encum) Available Budget Does item have a direct cost? Yes Item Cost Is a Budget Adjustment attached? Yes Budget Adjustment Remaining Budget General Fund N/A Project Title $ 20,208.00 $ 20, 208.00 Fs $ 54,600.00 $ 54,600.00 V20221130 Purchase Order Number: Previous Ordinance or Resolution # Change Order Number: Approval Date: Original Contract Number: Comments: City of Fayetteville, Arkansas - Budget Adjustment (Agenda) Budget Year Division PURCHASING (160) Adjustment Number /Org2 2023 Requestor: Les McGaugh BUDGET ADJUSTMENT DESCRIPTION / JUSTIFICATION: A Resolution to authorize the purchase of a railroad general liability policy for current and future railroad crossing improvements utilizing the City's insurance broker HUB International, and to approve a budget adjustment. COUNCIL DATE: 8/15/2023 ITEM ID#: 2023-961 Nolly Black 712712023 7:00 P/71 Budget Division Date TYPE: D - (City Council) JOURNAL#: GLDATE: RESOLUTION/ORDINANCE CHKD/POSTED: TOTAL 54,600 54,600 v.202373 Increase / (Decrease) Project.Sub# Account Number Expense Revenue Project Sub.Detl AT Account Name 1010.520.5260-5311.00 54,600 - EX Insurance - Vehicles/Buildings 1010.001.0001-4999.99 - 54,600 RE Use Fund Balance - Current I of 1 DKING1 ACORO COMMERCIAL INSURANCE APPLICATION DATE(MM/DD/YYYY) APPLICANT INFORMATION SECTION 07/05/2023 AGENCY CARRIER NAIC CODE Hub International Mid -America N/A 6100 S. Yale Avenue Suite 1900 COMPANY POLICY OR PROGRAM NAME PROGRAM CODE Tulsa, OK 74136 POLICY NUMBER CONTACT NAME: UNDERWRITER UNDERWRITER OFFICE PHONE 359-6000 A/C No Ext(918) ((918) 359-6001 AIC A/C No QUOTE ISSUE POLICY RENEW E-MAIL ADDRESS: STATUS OF TRANSACTION te h Attach Give ae and/or ac d/ Da BOUND ( Copy): CODE: SUBCODE: CHANGE DATE TIME AM AGENCY CUSTOMER ID: FAYETTE-01 License # 100101891 CANCEL PM LINES OF BUSINESS INDICATE LINES OF BUSINESS PREMIUM PREMIUM PREMIUM BOILER & MACHINERY $ CYBER AND PRIVACY $ YACHT $ BUSINESS AUTO $ FIDUCIARY LIABILITY $ $ BUSINESS OWNERS $ GARAGE AND DEALERS $ $ X COMMERCIAL GENERAL LIABILITY $ LIQUOR LIABILITY $ $ COMMERCIAL INLAND MARINE $ MOTOR CARRIER $ $ COMMERCIAL PROPERTY $ TRUCKERS $ $ CRIME $ I I UMBRELLA $ $ ATTACHMENTS ACCOUNTS RECEIVABLE / VALUABLE PAPERS GLASS AND SIGN SECTION STATEMENT / SCHEDULE OF VALUES ADDITIONAL INTEREST SCHEDULE HOTEL / MOTEL SUPPLEMENT STATE SUPPLEMENT (If applicable) ADDITIONAL PREMISES INFORMATION SCHEDULE INSTALLATION / BUILDERS RISK SECTION VACANT BUILDING SUPPLEMENT APARTMENT BUILDING SUPPLEMENT INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT VEHICLE SCHEDULE CONDO ASSN BYLAWS (for D&O Coverage only) INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT CONTRACTORS SUPPLEMENT LOSS SUMMARY COVERAGES SCHEDULE OPEN CARGO SECTION DEALERS SECTION PREMIUM PAYMENT SUPPLEMENT DRIVER INFORMATION SCHEDULE PROFESSIONAL LIABILITY SUPPLEMENT ELECTRONIC DATA PROCESSING SECTION RESTAURANT / TAVERN SUPPLEMENT 1911 [wI.I Mo] N LTAet 0 [61.1 PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN METHOD OF PAYMENT AUDIT DEPOSIT MINIMUM POLICY PREMIUM PREMIUM 07/15/2023 07/15/2024 k $ $ $ DIRECT AGENCY ArrLwAry I lNrUKIVIA 11UN NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC # City of Fayetteville 9121 921120 113 W Mountain, Room 306 BUSINESS PHONE#: (479) 575-8289 Fayetteville, AR 72701 WEBSITE ADDRESS CORPORATION JOINT VENTURE HLLC NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION NO OF MEMBERS INDIVIDUAL AND MANAGERS: PARTNERSHIP TRUST NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION INDIVIDUAL LLC NO OF MEMBERS AND MANAGER 4 S: PARTNERSHIP TRUST NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS CORPORATION JOINT VENTURE HLLC NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION INDIVIDUAL NO. OF MEMBERS AND MANAGERS: PARTNERSHIP TRUST ACORD 125 (2016/03) Page 1 of 4 © 1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CONTACT INFORMATION AGENCY CUSTOMER ID: FAYETTE-01 DKING1 CONTACT TYPE: CONTACT NAME: CONTACT TYPE: CONTACT NAME: PH0 ER# [I HOME u BUS El CELL PHONE# RY ❑HOME ❑BUS ❑CELL EPRIMAR# ❑HOME ❑BUS ❑CELL NDAPHO PHONE# RY [I HOME [I BUS El CELL PRIMARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS: PRIMARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS: YKtMI,t, INFUKMA I IUN Attacn AL;UKU 5ZJ Tor AtIaitional t'remiseS LOC # STREET CITY LIMITS INTEREST Futrall Drive and Gregg St, 1 X INSIDE OWNER BLD# ciTY:Fayetteville STATE: AR OUTSIDE TENANT 1 COUNTY: ZIP: DESCRIPTION OF OPERATIONS: STREET LOC # Shiloh Drive and Gregg St CITY LIMITS INTEREST 2 INSIDE OWNER BLD# ciTY:Fayetteville STATE: AR OUTSIDE TENANT 1 COUNTY: ZIP: DESCRIPTION OF OPERATIONS: STREET LOC # Razorback Road & W. 15th. St CITY LIMITS INTEREST 3 INSIDE OWNER BLD# ciTY:Fayetteville STATE: AR OUTSIDE TENANT 1 COUNTY: ZIP: DESCRIPTION OF OPERATIONS: STREET LOC # CITY LIMITS INTEREST Various -Walking Trail 4 X INSIDE OWNER BLD# ciTY:Fayetteville STATE: AR OUTSIDE TENANT 1 COUNTY: ZIP: DESCRIPTION OF OPERATIONS: IATURE OF BUSINESS APARTMENTS DESCRIPTION OF PRIMARY OPERATIONS Walking trail, railroad crossings RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES: DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS # FULL TIME EMPL ANNUAL REVENUES: $ OCCUPIED AREA: SQ FT # PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT TOTAL BUILDING AREA: SQ FT ANY AREA LEASED TO OTHERS? Y / N # FULL TIME EMPL ANNUAL REVENUES: $ OCCUPIED AREA: SQ FT # PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT TOTAL BUILDING AREA: SQ FT ANY AREA LEASED TO OTHERS? Y / N # FULL TIME EMPL # PART TIME EMPL ANNUAL REVENUES: $ OCCUPIED AREA: SQ FT OPEN TO PUBLIC AREA: SQ FT TOTAL BUILDING AREA: SQ FT ANY AREA LEASED TO OTHERS? Y / N # FULL TIME EMPL # PART TIME EMPL ANNUAL REVENUES: $ OCCUPIED AREA: SQ FT OPEN TO PUBLIC AREA: SQ FT TOTAL BUILDING AREA: SQ FT ANY AREA LEASED TO OTHERS? Y / N SERVICE LX WHOLESALE INSTALLATION, SERVICE OR REPAIR WORK act Curt DATE BUSINESS ews-HUB Idaho cur STARTED (MM/DD/YYYY) OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK AUUI I IUNAL IN I tKtS I (Not all TIews apply to all Scenarios - provicie only the necessary ciata) Attacn A(;UKU 40 Tor more AOClltlonal Interests INTEREST ADDITIONAL AL BREACH OF WARRANTY CO-OWNER I EMPLOYEE AS LESSOR LEASEBACK OWNER LENDER'S LOSS PAYABLE X Specific Contract NAME AND ADDRESS RANK: I EVIDENCE: CERTIFICATE POLICY SEND BILL LIENHOLDER Arkansas & Missouri Railroad Company LOSS PAYEE �306 East Emma Springdale, AR 72764 MORTGAGEE OWNER REGISTRANT INTEREST IN ITEM NUMBER LOCATION: BUILDING: VEHICLE: BOAT: AIRPORT: AIRCRAFT: ITEM CLASS: ITEM: ITEM DESCRIPTION TRUSTEE REFERENCE / LOAN #: INTEREST END DATE: LIEN AMOUNT: PHONE (A/C, No, Ext): FAX (A/C, No): REASON FOR INTEREST: Contract E-MAIL ADDRESS: ACORD 125 (2016/03) Page 2 of 4 GENERAL INFORMATION AGENCY CUSTOMER ID: FAYETTE-01 DKING1 EXPLAIN ALL "YES" RESPONSES la. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ? PARENT COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 1 b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? SAFETY MANUAL SAFETY POSITION MONTHLY MEETINGS I OSHA 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? Y / N N INSUBSIDIARY Y N 4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON -RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR OPERATIONS? (Missouri A plicants - Do not answer this question) NON-PAYMENT AGENT NO LONGER REPRESENTS CARRIER u NON -RENEWAL UNDERWRITING CONDITION CORRECTED (Describe): N N 5. 6. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? N 7. DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON -RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). N 8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? N OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 9. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS? N OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS? OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 11. 12. 13. 14. 15. HAS BUSINESS BEEN PLACED IN A TRUST? NAME OF TRUST: ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES? (If "YES', attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If "YES', describe use) DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If "YES', describe use) N N N N N N REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PRIOR CARRIER INFORMATION YEAR I CATEGORY GENERAL LIABILITY CARRIER AUTOMOBILE PROPERTY OTHER: $ POLICY NUMBER PREMIUM $ $ $ EFFECTIVE DATE EXPIRATION DATE ACORD 125 (2016/03) Page 3 of 4 PRIOR CARRIER INFORMATION (continued) AGENCY CUSTOMER ID: FAYETTE-01 DKING1— YEAR CATEGORY GENERAL LIABILITY AUTOMOBILE PROPERTY OTHER: CARRIER POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE EXPIRATION DATE CARRIER POLICY NUMBER PREMIUM $ $ $ Is EFFECTIVE DATE EXPIRATION DATE LOSS HISTORY Check if none (Attach Loss Summary for Additional Loss Information) ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST YEARS _ TOTAL LOSSES: $ I ' SUBRO- CLAIM DATE OF LINE TYPE I DESCRIPTION OF OCCURRENCE OR CLAIM DATE OF CLAIM AMOUNT PAID AMOUNT RESERVED GATION OPEN OCCURRENCE i YIN YIN I I Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for your state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION VVITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES. YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE THESE RIGHTS MAY BE LIMITED IN SOME STATES PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or VW Specific ACORD 38s are available for applicants in these states) (Applicant's Initials): Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO: 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. Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any 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)* *Applies in FL Only Applicable in KS: Any person who, knowingly and with intent to defraud, presents, Causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written 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 fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: 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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. `Applies in NY Only. Applicable in ME, TN, VA and WA: 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 and denial of insurance benefits. *Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law Applicable in PR: 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 a 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 by a fine of 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. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER'S SIGNATURE / APPLICANTS SIGNATURE PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO (Required in Florida) DATE NATIONAL PRODUCER NUMBER 08/15/2023 ACORD 125 Page 4 of 4 / 1 ACORO`" AGENCY Hub International Mid -America POLICY NUMBER AGENCY CUSTOMER ID: FAYETTE-01 COMMERCIAL GENERAL LIABILITY SECTION CARRIER EFFECTIVE DATE APPLICANT / FIRST NAMED INSURED 07/15/2023 City of Fayetteville DKING1 DATE (MM/DD/YYYY) 07/05/2023 NAIC CODE N/A IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims -made policy. Read all provisions of the policy carefully. CCIVFRAnFR I IMITR X COMMERCIAL GENERAL LIABILITY CLAIMS MADE F] OCCURRENCE OWNER'S & CONTRACTOR'S PROTECTIVE GENERAL AGGREGATE LIMIT APPLIES PER: POLICY LOCATION PROJECT OTHER: PRODUCTS & COMPLETED OPERATIONS AGGREGATE $ 2,000,000 $ 2 000 OOO PREMIUMS PREMISES/OPERATIONS PRODUCTS DEDUCTIBLES PROPERTY DAMAGE $5,000 PER BODILY INJURY $ B CLAIM Ix PER $ X OCCURRENCE PERSONAL& ADVERTISING INJURY $ 1,000,000 EACH OCCURRENCE $ 1,000,000 OTHER DAMAGE TO RENTED PREMISES each occurrence $ 50,000 MEDICAL EXPENSE (Any oneperson) $ 5,000 TOTAL EMPLOYEE BENEFITS $ OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) APPLICABLE ONLY IN WISCONSIN: IF NON -OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY: 1. UM / UIM COVERAGE IS F_ IS NOT AVAILABLE. 2. MEDICAL PAYMENTS COVERAGE IS IS NOT AVAILABLE. RRMFni i1 F nF HA7AR11R LOC # HAZ # CLASSIFICATION CLASS PREMIUM CODE BASIS Railroad Street Crossing U Railroad Street Crossing U Railroad Street Crossing U Walking Trail F EXPOSURE TERR RATE PREM/OPS I PRODUCTS PREMIUM PREM/OPS PRODUCTS 1 1 1 2 1 1 3 1 1 4 1 2734 RATING AND PREMIUM BASIS (P) PAYROLL - PER $1,000/PAY (C) TOTAL COST - PER $1,000/COST (U) UNIT - PER UNIT (S) GROSS SALES - PER $1,000/SALES (A) AREA - PER 1,000/SQ FT (M) ADMISSIONS - PER 1,000/ADM (T) OTHER EXPLAIN ALL "YES" RESPONSES 1. PROPOSED RETROACTIVE DATE: 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF -INSURED FROM ANY PREVIOUS COVERAGE? 4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? EMPLOYEE BENEFITS LIABILITY 1. DEDUCTIBLE PER CLAIM: $ 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: 2. NUMBER OF EMPLOYEES: 4. RETROACTIVE DATE: ACORD 126 (2014/04) Attach to ACORD 125 © 1993-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER In. FAYETTE-01 DKING1 EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / N 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS? N 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? I N 3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING? N 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? I N 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? I N 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? I N DESCRIBE THE TYPE OF WORK SUBCONTRACTED 5 PAID TO SUB- CONTRACTORS: PRODUCTS / COMPLETED OPERATIONS PRODUCTS ANNUAL GROSS SALES # OF UNITS MARKET EX LIFE ED INTENDED USE PRINCIPAL COMPONENTS EXPLAIN ALL "YES" RESPONSES (For all pastor present products or operations) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC. Y / N 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? 2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES', attach ACORD 815) 3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED? 4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS? 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? 6. PRODUCTS RECALLED, DISCONTINUED, CHANGED? 7. PRODUCTS OF OTHERS SOLD OR RE -PACKAGED UNDER APPLICANT LABEL? 8. PRODUCTS UNDER LABEL OF OTHERS? 9. VENDORS COVERAGE REQUIRED? 10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS? ACORD 126 (2014/04) Page 2 of 4 AGENCY CUSTOMER ID: FAYETTE-01 DKING1 ADDITIONAL INTEREST / CERTIFICATE RECIPIENT ACORD 45 attached for additional names INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE INTEREST IN ITEM NUMBER ADDITIONAL INSURED LOCATION: BUILDING: EMPLOYEE AS LESSOR ITEM ITEM: CLASS: LIENHOLDER ITEM DESCRIPTION LOSS PAYEE MORTGAGEE REFERENCE / LOAN #: GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / N 1. 2. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? N N 3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) N 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS? N 5. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS? N EQUIPMENT TYPE OF EQUIPMENT INSTRUCTION GIVEN (YIN) SMALL TOOLS LARGE EQUIPMENT SMALL TOOLS LARGE EQUIPMENT 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? N 7. ANY PARKING FACILITIES OWNED/RENTED? N 8. IS A FEE CHARGED FOR PARKING? N 9. RECREATION FACILITIES PROVIDED? N 10. ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? (If "YES", answer the following): N # APTS TOTAL APT AREA Sq. Ft. DESCRIBE OTHER LODGING OPERATIONS 11. IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply) APPROVED FENCE LIMITED ACCESS DIVING BOARD SLIDE ABOVE GROUND IN GROUND LIFE GUARD N 12. ARE SOCIAL EVENTS SPONSORED? N 13. ARE ATHLETIC TEAMS SPONSORED? TYPE OF SPORT CONTACT AGE GROUP TYPE OF SPORT CONTACT AGE GROUP SPORT (Y/N) 13- 18 SPORT (Y/N) 13 - 18 12 &UNDER OVER 18 12 &UNDER OVER 18 EXTENT OF SPONSORSHIP: EXTENT OF SPONSORSHIP: N 14. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? N 15. ANY DEMOLITION EXPOSURE CONTEMPLATED? N ACORD 126 (2014/04) Page 3 of 4 Ar.FNrV rusTnMFR In• FAYETTE-01 DKING1 EXPLAIN ALL "YES" RESPONSES (For all past or present operations) 16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? 17. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? WORKERS COMPENSATION LEASE TO COVERAGE CARRIED (YMI � FROM 18. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? 19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? 20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS? 21 IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT? 22 DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Y/N N N N N N N N Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)* presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO: 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 Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any 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)*. *Applies in FL Only. Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written 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 fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: 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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only. Applicable in ME, TN, VA and WA: 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 and denial of insurance benefits. *Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law Applicable in PR: 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 a 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 by a fine of 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. — — THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER'S SIGNATURE APPLICANTS SIGNATURE PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO (Required in Florida) DATE NATIONAL PRODUCER NUMBER 08/15/2023 ACORD 126 (201ft4) / / Page 4 of 4 DKING1 ACORO COMMERCIAL INSURANCE APPLICATION DATE(MM/DD/YYYY) APPLICANT INFORMATION SECTION 07/05/2023 AGENCY CARRIER NAIC CODE Hub International Mid -America N/A 6100 S. Yale Avenue Suite 1900 COMPANY POLICY OR PROGRAM NAME PROGRAM CODE Tulsa, OK 74136 POLICY NUMBER CONTACT NAME: UNDERWRITER UNDERWRITER OFFICE PHONE 359-6000 A/C Ext(918) ( (918) 359-6001 A/C No X QUOTE ISSUE POLICY Ll RENEW E-MAIL ADDRESS: STATUS OF TRANSACTION te Give ae and/or ac d/ Dah Attach BOUND ( Copy): CODE: SUBCODE: CHANGE DATE TIME AM AGENCY CUSTOMER ID: FAYETTE-01 License # 100101891 CANCEL PM LINES OF BUSINESS INDICATE LINES OF BUSINESS PREMIUM PREMIUM PREMIUM BOILER & MACHINERY $ CYBER AND PRIVACY $ YACHT $ BUSINESS AUTO $ FIDUCIARY LIABILITY $ X Excess Liability $ BUSINESS OWNERS $ GARAGE AND DEALERS $ $ COMMERCIAL GENERAL LIABILITY $ LIQUOR LIABILITY $ $ COMMERCIAL INLAND MARINE $ MOTOR CARRIER $ $ COMMERCIAL PROPERTY I $ I TRUCKERS $ $ CRIME I $ I I UMBRELLA $ $ ATTACHMENTS ACCOUNTS RECEIVABLE / VALUABLE PAPERS GLASS AND SIGN SECTION STATEMENT / SCHEDULE OF VALUES ADDITIONAL INTEREST SCHEDULE HOTEL / MOTEL SUPPLEMENT STATE SUPPLEMENT (If applicable) ADDITIONAL PREMISES INFORMATION SCHEDULE INSTALLATION / BUILDERS RISK SECTION VACANT BUILDING SUPPLEMENT APARTMENT BUILDING SUPPLEMENT INTERNATIONAL LIABILITY EXPOSURE SUPPLEMENT VEHICLE SCHEDULE CONDO ASSN BYLAWS (for D&O Coverage only) INTERNATIONAL PROPERTY EXPOSURE SUPPLEMENT CONTRACTORS SUPPLEMENT LOSS SUMMARY COVERAGES SCHEDULE OPEN CARGO SECTION DEALERS SECTION PREMIUM PAYMENT SUPPLEMENT DRIVER INFORMATION SCHEDULE PROFESSIONAL LIABILITY SUPPLEMENT ELECTRONIC DATA PROCESSING SECTION RESTAURANT / TAVERN SUPPLEMENT 1911[aa1'IMo]NLTA Fit 0161 PROPOSED EFF DATE PROPOSED EXP DATE BILLING PLAN PAYMENT PLAN METHOD OF PAYMENT AUDIT DEPOSIT MINIMUM POLICY PREMIUM PREMIUM 07/15/2023 07/15/2024 k $ $ $ DIRECT AGENCY iirrLB,AkN I lNrUKIV1A 1 IUN NAME (First Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC # City of Fayetteville 9121 921120 113 W Mountain, Room 306 BUSINESS PHONE#: (479) 575-8289 Fayetteville, AR 72701 WEBSITE ADDRESS CORPORATION HLLC JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION INDIVIDUAL NO OF MEMBERS AND MANAGERS: PARTNERSHIP TRUST NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS CORPORATION JOINT VENTURE NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION INDIVIDUAL LLC NO OF MEMBERS AND MANAGERS:- H PARTNERSHIP TRUST NAME (Other Named Insured) AND MAILING ADDRESS (including ZIP+4) GL CODE SIC NAICS FEIN OR SOC SEC # BUSINESS PHONE #: WEBSITE ADDRESS NOT FOR PROFIT ORG SUBCHAPTER "S" CORPORATION CORPORATION HLLC JOINT VENTURE INDIVIDUAL NO. OF MEMBERS _ AND MANAGERS. PARTNERSHIP TRUST ACORD 125 (2016/03) Page 1 of 4 © 1993-2015 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD CONTACT INFORMATION AGENCY CUSTOMER ID: FAYETTE-01 DKING1 CONTACT TYPE: CONTACT TYPE: CONTACT NAME: CONTACT NAME: PHO ER# [I HOME ❑BUS ❑H CELL PONE# RY [I HOME [I BUS El CELL PRIMARY [I HOME u BUS El CELL PHONE# SECONDARY [I HOME [I Bus El CELL PRIMARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS: PRIMARY E-MAIL ADDRESS: SECONDARY E-MAIL ADDRESS: YKtMIJt, INI-UKMA I IUN Attacn AL;UKU 5ZJ Tor AtIaitional t'remiseS LOC # STREET CITY LIMITS INTEREST Futrall Drive and Gregg St, 1 X INSIDE OWNER BLD# ciTY:Fayetteville STATE: AR OUTSIDE TENANT 1 COUNTY: ZIP: DESCRIPTION OF OPERATIONS: STREET LOC # Shiloh Drive and Gregg St CITY LIMITS INTEREST 2 INSIDE OWNER BLD# ciTY:Fayetteville STATE: AR OUTSIDE TENANT 1 COUNTY: ZIP: DESCRIPTION OF OPERATIONS: STREET LOC # Razorback Road & W. 15th. St CITY LIMITS INTEREST 3 INSIDE OWNER BLD# ciTY:Fayetteville STATE: AR OUTSIDE TENANT 1 COUNTY: ZIP: DESCRIPTION OF OPERATIONS: LOC # STREET CITY LIMITS INTEREST Various -Walking Trail 4 X INSIDE OUTSIDE OWNER TENANT BLD# ciTY:Fayetteville STATE: AR 1 COUNTY: ZIP: DESCRIPTION OF OPERATIONS: IATURE OF BUSINESS APARTMENTS DESCRIPTION OF PRIMARY OPERATIONS Walking trail, railroad crossings RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES: DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS # FULL TIME EMPL # PART TIME EMPL ANNUAL REVENUES: $ OCCUPIED AREA: SQ FT OPEN TO PUBLIC AREA: SQ FT TOTAL BUILDING AREA: SQ FT ANY AREA LEASED TO OTHERS? Y / N # FULL TIME EMPL ANNUAL REVENUES: $ OCCUPIED AREA: SQ FT # PART TIME EMPL OPEN TO PUBLIC AREA: SQ FT TOTAL BUILDING AREA: SQ FT ANY AREA LEASED TO OTHERS? Y / N # FULL TIME EMPL # PART TIME EMPL ANNUAL REVENUES: $ OCCUPIED AREA: SQ FT OPEN TO PUBLIC AREA: SQ FT TOTAL BUILDING AREA: SQ FT ANY AREA LEASED TO OTHERS? Y / N # FULL TIME EMPL # PART TIME EMPL ANNUAL REVENUES: $ OCCUPIED AREA: SQ FT OPEN TO PUBLIC AREA: SQ FT TOTAL BUILDING AREA: SQ FT ANY AREA LEASED TO OTHERS? Y / N SERVICE u WHOLESALE INSTALLATION, SERVICE OR REPAIR WORK DATE BUSINESS Idaho cur STARTED (MM/DD/YYYY) OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK AUUI I IUNAL IN I tKtS I (Not all TIews apply to all Scenarios - provicie only the necessary ciata) Attacn A(;UKU 40 Tor more AOClltlonal Interests INTEREST ADDITIONAL AL BREACH OF WARRANTY CO-OWNER EMPLOYEE AS LESSOR LEASEBACK OWNER LENDER'S LOSS PAYABLE X Specific Contract NAME AND ADDRESS RANK: I EVIDENCE: CERTIFICATE POLICY SEND BILL LIENHOLDER Arkansas & Missouri Railroad Company LOSS PAYEE �306 East Emma Springdale, AR 72764 MORTGAGEE OWNER REGISTRANT INTEREST IN ITEM NUMBER LOCATION: BUILDING: VEHICLE: BOAT: AIRPORT: AIRCRAFT: ITEM CLASS: ITEM: ITEM DESCRIPTION TRUSTEE REFERENCE / LOAN #: INTEREST END DATE: LIEN AMOUNT: PHONE (A/C, No, Ext): FAX (A/C, No): REASON FOR INTEREST: Contract E-MAIL ADDRESS: ACORD 125 (2016/03) Page 2 of 4 GENERAL INFORMATION AGENCY CUSTOMER ID: FAYETTE-01 DKING1 EXPLAIN ALL "YES" RESPONSES la. IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ? PARENT COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 1 b. DOES THE APPLICANT HAVE ANY SUBSIDIARIES? COMPANY NAME RELATIONSHIP DESCRIPTION %OWNED 2. IS A FORMAL SAFETY PROGRAM IN OPERATION? SAFETY MANUAL SAFETY POSITION MONTHLY MEETINGS I OSHA 3. ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS? Y / N N INSUBSIDIARY Y N 4. ANY OTHER INSURANCE WITH THIS COMPANY? (List policy numbers) LINE OF BUSINESS POLICY NUMBER LINE OF BUSINESS POLICY NUMBER ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON -RENEWED DURING THE PRIOR THREE (3) YEARS FOR ANY PREMISES OR OPERATIONS? (Missouri A plicants - Do not answer this question) NON-PAYMENT AGENT NO LONGER REPRESENTS CARRIER u NON -RENEWAL UNDERWRITING CONDITION CORRECTED (Describe): N N 5. 6. 7. ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING? DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON -RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY? (In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment). N N 8. ANY UNCORRECTED FIRE AND/OR SAFETY CODE VIOLATIONS? N OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 9. HAS APPLICANT HAD A FORECLOSURE, REPOSSESSION, BANKRUPTCY OR FILED FOR BANKRUPTCY DURING THE LAST FIVE (5) YEARS? N OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 10. HAS APPLICANT HAD A JUDGEMENT OR LIEN DURING THE LAST FIVE (5) YEARS? OCCUR DATE EXPLANATION RESOLUTION RESOLVE DATE 11. 12. 13. 14. 15. HAS BUSINESS BEEN PLACED IN A TRUST? NAME OF TRUST: ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD / DISTRIBUTED IN FOREIGN COUNTRIES? (If "YES', attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure) DOES APPLICANT HAVE OTHER BUSINESS VENTURES FOR WHICH COVERAGE IS NOT REQUESTED? DOES APPLICANT OWN / LEASE / OPERATE ANY DRONES? (If "YES', describe use) DOES APPLICANT HIRE OTHERS TO OPERATE DRONES? (If "YES', describe use) N N N N N N REMARKS / PROCESSING INSTRUCTIONS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) PRIOR CARRIER INFORMATION YEAR I CATEGORY GENERAL LIABILITY CARRIER AUTOMOBILE PROPERTY OTHER: $ POLICY NUMBER PREMIUM $ $ $ EFFECTIVE DATE EXPIRATION DATE ACORD 125 (2016/03) Page 3 of 4 PRIOR CARRIER INFORMATION (continued) AGENCY CUSTOMER ID: FAYETTE-01 , DKING1 YEAR CATEGORY GENERAL LIABILITY CARRIER POLICY NUMBER PREMIUM $ AUTOMOBILE PROPERTY OTHER: $ $ y $ _EFFECTIVE DATE EXPIRATION DATE CARRIER _POLICY NUMBER PREMIUM $ $ $ $ EFFECTIVE DATE j EXPIRATION DATE L055 H15TORY LneCK IT none (Attacn LOSS Summary Tor Aaoltlonal LOSS lntorrnavon) ENTER ALL CLAIMS OR LOSSES (REGARDLESS OF FAULT AND WHETHER OR NOT INSURED) OR OCCURRENCES THAT MAY GIVE RISE TO CLAIMS FOR THE LAST YEARS I TOTAL LOSSES: $ SUBRO- CLAIM DATE OF LINE TYPE I DESCRIPTION OF OCCURRENCE OR CLAIM DATE OF CLAIM AMOUNT PAID AMOUNT RESERVED GYIN OPEN OCCURRENCE YIN YIN Copy of the Notice of Information Practices (Privacy) has been given to the applicant. (Not required in all states, contact your agent or broker for ,our state's requirements.) PERSONAL INFORMATION ABOUT YOU, INCLUDING INFORMATION FROM A CREDIT OR OTHER INVESTIGATIVE REPORT, MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE AND SUBSEQUENT AMENDMENTS AND RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION CREDIT SCORING INFORMATION MAY BE USED TO HELP DETERMINE EITHER YOUR ELIGIBILITY FOR INSURANCE OR THE PREMIUM YOU WILL BE CHARGED. WE MAY USE A THIRD PARTY IN CONNECTION WITH THE DEVELOPMENT OF YOUR SCORE YOU MAY HAVE THE RIGHT TO REVIEW YOUR PERSONAL INFORMATION IN OUR FILES AND REQUEST CORRECTION OF ANY INACCURACIES YOU MAY ALSO HAVE THE RIGHT TO REQUEST IN WRITING THAT WE CONSIDER EXTRAORDINARY LIFE CIRCUMSTANCES IN CONNECTION WITH THE DEVELOPMENT OF YOUR CREDIT SCORE THESE RIGHTS MAY BE LIMITED IN SOME STATES PLEASE CONTACT YOUR AGENT OR BROKER TO LEARN HOW THESE RIGHTS MAY APPLY IN YOUR STATE OR FOR -INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US FOR A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING PERSONAL INFORMATION. (Not applicable in AZ, CA, DE, KS, MA, MN, ND, NY, OR, VA, or WV. Specific ACORD 38s are available for applicants in these states ) (Applicant's Initials): Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)" presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)* presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. "Applies in MD Only. Applicable in CO: 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. Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any 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)". "Applies in FL Only. Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written 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 fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: 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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)" `Applies in NY Only. Applicable in ME, TN, VA and WA: 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 and denial of insurance benefits. 'Applies in ME Only Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: 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 a 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 by a fine of 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. THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER'S SIGNATURE APPLICANTS SIGNATURE PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO (Required in Florida) DATE NATIONAL PRODUCER NUMBER 08/ 15/2023 ACORD 125 (2016/03) Page 4 of 4 / 1 ACORO`" AGENCY Hub International Mid -America POLICY NUMBER AGENCY CUSTOMER ID: FAYETTE-01 COMMERCIAL GENERAL LIABILITY SECTION CARRIER EFFECTIVE DATE APPLICANT / FIRST NAMED INSURED 07/15/2023 City of Fayetteville DKING1 DATE (MM/DD/YYYY) 07/05/2023 NAIC CODE N/A IMPORTANT - If CLAIMS MADE is checked in the COVERAGE / LIMITS section below, this is an application for a claims -made policy. Read all provisions of the policy carefully. CCIVFRAnFR I IMITR X COMMERCIAL GENERAL LIABILITY CLAIMS MADE F] OCCURRENCE OWNER'S & CONTRACTOR'S PROTECTIVE GENERAL AGGREGATE LIMIT APPLIES PER: POLICY LOCATION PROJECT OTHER: PRODUCTS & COMPLETED OPERATIONS AGGREGATE $ 5,000,000 $ 5 000 OOO PREMIUMS PREMISES/OPERATIONS PRODUCTS DEDUCTIBLES d0ROPERTY DAMAGE $ ILY INJURY PER $ CLAIM PER $ OCCURRENCE PERSONAL & ADVERTISING INJURY $ EACH OCCURRENCE $ 5,000,000 OTHER DAMAGE TO RENTED PREMISES each occurrence $ MEDICAL EXPENSE (Any oneperson) $ TOTAL EMPLOYEE BENEFITS $ OTHER COVERAGES, RESTRICTIONS AND/OR ENDORSEMENTS (For hired/non-owned auto coverages attach the applicable state Business Auto Section, ACORD 137) APPLICABLE ONLY IN WISCONSIN: IF NON -OWNED ONLY AUTO COVERAGE IS TO BE PROVIDED UNDER THE POLICY: 1. UM / UIM COVERAGE IS F_ IS NOT AVAILABLE. 2. MEDICAL PAYMENTS COVERAGE IS IS NOT AVAILABLE. RRMFni i1 F nF HA7AR11R LOC # HAZ # CLASSIFICATION CLASS PREMIUM CODE BASIS Railroad Street Crossing U Railroad Street Crossing U Railroad Street Crossing U Walking Trail F EXPOSURE TERR RATE PREM/OPS I PRODUCTS PREMIUM PREM/OPS PRODUCTS 1 1 1 2 1 1 3 1 1 4 1 2734 RATING AND PREMIUM BASIS (P) PAYROLL - PER $1,000/PAY (C) TOTAL COST - PER $1,000/COST (U) UNIT - PER UNIT (S) GROSS SALES - PER $1,000/SALES (A) AREA - PER 1,000/SQ FT (M) ADMISSIONS - PER 1,000/ADM (T) OTHER EXPLAIN ALL "YES" RESPONSES 1. PROPOSED RETROACTIVE DATE: 2. ENTRY DATE INTO UNINTERRUPTED CLAIMS MADE COVERAGE: 3. HAS ANY PRODUCT, WORK, ACCIDENT, OR LOCATION BEEN EXCLUDED, UNINSURED OR SELF -INSURED FROM ANY PREVIOUS COVERAGE? 4. WAS TAIL COVERAGE PURCHASED UNDER ANY PREVIOUS POLICY? EMPLOYEE BENEFITS LIABILITY 1. DEDUCTIBLE PER CLAIM: $ 3. NUMBER OF EMPLOYEES COVERED BY EMPLOYEE BENEFITS PLANS: 2. NUMBER OF EMPLOYEES: 4. RETROACTIVE DATE: ACORD 126 (2014/04) Attach to ACORD 125 © 1993-2014 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD AGENCY CUSTOMER In. FAYETTE-01 DKING1 EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / N 1. DOES APPLICANT DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS? N 2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL? I N 3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING? N 4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS? I N 5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE? I N 6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? I N DESCRIBE THE TYPE OF WORK SUBCONTRACTED 5 PAID TO SUB- CONTRACTORS: PRODUCTS / COMPLETED OPERATIONS PRODUCTS ANNUAL GROSS SALES # OF UNITS MARKET EX LIFE ED INTENDED USE PRINCIPAL COMPONENTS EXPLAIN ALL "YES" RESPONSES (For all pastor present products or operations) PLEASE ATTACH LITERATURE, BROCHURES, LABELS, WARNINGS, ETC. Y / N 1. DOES APPLICANT INSTALL, SERVICE OR DEMONSTRATE PRODUCTS? 2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS? (If "YES', attach ACORD 815) 3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED? 4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS? 5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY? 6. PRODUCTS RECALLED, DISCONTINUED, CHANGED? 7. PRODUCTS OF OTHERS SOLD OR RE -PACKAGED UNDER APPLICANT LABEL? 8. PRODUCTS UNDER LABEL OF OTHERS? 9. VENDORS COVERAGE REQUIRED? 10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS? ACORD 126 (2014/04) Page 2 of 4 AGENCY CUSTOMER ID: FAYETTE-01 DKING1 ADDITIONAL INTEREST / CERTIFICATE RECIPIENT ACORD 45 attached for additional names INTEREST NAME AND ADDRESS RANK: EVIDENCE: CERTIFICATE INTEREST IN ITEM NUMBER ADDITIONAL INSURED LOCATION: BUILDING: EMPLOYEE AS LESSOR ITEM ITEM: CLASS: LIENHOLDER ITEM DESCRIPTION LOSS PAYEE MORTGAGEE REFERENCE / LOAN #: GENERAL INFORMATION EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / N 1. 2. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED? ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? N N 3. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) N 4. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST FIVE (5) YEARS? N 5. DO YOU RENT OR LOAN EQUIPMENT TO OTHERS? N EQUIPMENT TYPE OF EQUIPMENT INSTRUCTION GIVEN (YIN) SMALL TOOLS LARGE EQUIPMENT SMALL TOOLS LARGE EQUIPMENT 6. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? N 7. ANY PARKING FACILITIES OWNED/RENTED? N 8. IS A FEE CHARGED FOR PARKING? N 9. RECREATION FACILITIES PROVIDED? N 10. ARE THERE ANY LODGING OPERATIONS INCLUDING APARTMENTS? (If "YES", answer the following): N # APTS TOTAL APT AREA Sq. Ft. DESCRIBE OTHER LODGING OPERATIONS 11. IS THERE A SWIMMING POOL ON PREMISES? (Check all that apply) APPROVED FENCE LIMITED ACCESS DIVING BOARD SLIDE ABOVE GROUND IN GROUND LIFE GUARD N 12. ARE SOCIAL EVENTS SPONSORED? N 13. ARE ATHLETIC TEAMS SPONSORED? TYPE OF SPORT CONTACT AGE GROUP TYPE OF SPORT CONTACT AGE GROUP SPORT (Y/N) 13- 18 SPORT (Y/N) 13 - 18 12 &UNDER OVER 18 12 &UNDER OVER 18 EXTENT OF SPONSORSHIP: EXTENT OF SPONSORSHIP: N 14. ANY STRUCTURAL ALTERATIONS CONTEMPLATED? N 15. ANY DEMOLITION EXPOSURE CONTEMPLATED? N ACORD 126 (2014/04) Page 3 of 4 Ar.Flury rllsTnMFR In• FAYETTE-01 DKING1 EXPLAIN ALL "YES" RESPONSES (For all past or present operations) Y / 1 16. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES? N 17 DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS? N WORKERS WORKERS LEASE TO COMPENSATION _._.. LEASE FROM .COMPENSATION ^_ 18 IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES? -7 N 19. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED? N 20. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE (3) YEARS? N 21 IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT? N 22 DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES? N REMARKS (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully)` presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully)' presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. *Applies in MD Only. Applicable in CO: 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. Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any 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)'. `Applies in FL Only. Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written 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 fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. Applicable in KY, NY, OH and PA: 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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)'. 'Applies in NY Only. Applicable in ME, TN, VA and WA: 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 and denial of insurance benefits. "Applies in ME Only. Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law. Applicable in PR: 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 a 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 by a fine of 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) THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION_ HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE. PRODUCER'S SIGNATURE APPLICANTS SIGNATW PRODUCER'S NAME (Please Print) STATE PRODUCER LICENSE NO (Required in Florida) DATE NATIONAL PRODUCER NUMBER 08/15/2023 ACORD 126 (29'14104) // Page 4 of 4 DATE: 07/20/2023 From: Janie Williams Graham -Rogers 501 SE Frank Phillips Blvd Bartlesville, OK 74003 To: Eric Herget HUB International RE: City of Fayetteville Renewal of Policy #: NEW QUOTATION We are pleased to offer the following quotation. Please review this quotation carefully, as the terms and conditions offered may be different than requested. You must contact us in writing to bind coverage, as your office holds no binding authority. Policy Term: 07/21/2023 - 07/21/2023 Quotation Premium Quote Exp Date: 07/21/2023 12:01 AM Excluding TRIA Including TRIA Premium: $25,000.00 Premium: $25,000.00 Broker Fee $1,250.00 Broker Fee $1,250.00 TRIA: $500.00 AR SL Tax(4%) $1,050.00 AR SL Tax(4%) $1,070.00 Total: $27,300.00 Total: $27,820.00 Payment Terms: Premium Due Within 20 Days of Effective Date. Minimum Earned Percentage: 25.00 % Note: Fees are fully earned Policy Type: Occurrence Carrier(s): Landmark American Ins Co - Non -Admitted Please be sure to check the Carrier's current A.M. Best rating to satisfy you and your client's interests. Commercial Umbrella Limit $5,000,000 Endorsements/Exclusions: (Standard Company or ISO Exclusions are applicable including, but not limited to the following terms, conditions and exclusions. The state specific forms vary per state, and may not be listed on this proposal. It is your responsibility as agent of the insured to check coverage and terms.) See Attached Terms and Conditions: • No Flat Cancellation(s) Permitted • Should any loss occur between the date of this quotation/binder and the effective date, the company(ies) reserve the right to withdraw this quotation/binder. 07/20/23 Page 2 of 2 • Signed and dated Acord application due at binding (must be signed and dated by both the Agent and Insured). If there are terms/conditions that are inconsistent with the coverage bound, please note that your binder/policy prevails and any changes to terms/conditions, etc. must be made by endorsement request and are subject to carrier approval. • Terrorism Coverage is being offered for an additional premium. Please confirm your choice to purchase or decline terrorism coverage as outlined in this quote in writing at time of binding. • The taxes and fees shown above are based on this account's home state's taxes and rules. If the schedule is altered (mailing address change, amended TIV, adding or deleting properties) prior to binding, it may affect the determination of the home state is and thus the tax/fee percentages may change. • See Attached for Additional Terms/Conditions/Subjectives S� RSUI Group, Inc. RE: Lead Excess Quote Submission Number: 761545 Company: Landmark American Insurance Company - Non -Admitted (A.M. Best rating: A++ XIV and S&P rating: AA+) Coverage: Excess Liability Insured: City of Fayetteville Fayetteville, AR Policy Dates: July 21, 2023 - July 21, 2024 Form: Form 2007 Please contact the underwriter if you have any questions about the standard provisions of this form. Limit: $5,000,000 In Excess Of: General Liability : $1,000,000 Occurrence Limit $2,000,000 General Aggregate Limit $2,000,000 Completed Ops/Products Aggregate Limit $1,000,000 Personal & Advertising Injury Limit Form 2013 Defense Outside Limits 761545 A member ofAlleghany Insurance Holdings LLC Policy Attachments and Forms • Absolute Asbestos Exclusion RSG 36003 0904 • Absolute Automobile Exclusion RSG 36112 0821 • Arkansas Changes - Cancellation and Nonrenewal RSG 33028 1208 • Arkansas Surplus Lines Disclosure Notice RSG 99069 0106 • Communicable Disease, Epidemic, and Pandemic Exclusion RSG 36138 0920 • Exclusion - Fluorinated Compounds (PFAS) RSG 36149 0522 • Exclusion - Real and Personal Property - Care Custody and Control RSG 36016 0408 • Exclusion - Sublimited Underlying Coverage RSG 36093 0905 • Exclusion of Certified Acts of Terrorism and Other Nuclear, Bio, Chem or Radio Acts of Terrorism RSG 36045 0315 • Pollution Exclusion Endorsement - Total RSG 36030 0803 • Professional Services Exclusion RSG 36031 0205 • Service of Suit Clause RSG 34006 0407 • State Fraud Statement RSG 99022 1022 • Uninsured Underinsured Motorist Exclusion RSG 36037 0116 • War Liability Exclusion RSG 36044 0404 Lead Company Attachments and Forms • As per underlying quote submitted to carrier Premium Amount Flat Charge: $25,000.00 Terrorism Premium: $500.00 Gross Premium: $25,500.00 Comments: THE PREMIUM AMOUNT DOES NOT INCLUDE SURPLUS LINES TAX. YOUR OFFICE IS RESPONSIBLE FOR THE COLLECTION AND FILINGS. Based on the insured's operations we have identified the Home State as AR. Please read all terms and conditions shown above carefully as they may not conform to specifications shown on your submission. Please note: Certificates of Insurance do not amend, extend or alter coverage afforded by any Landmark American Insurance Company policy and are the responsibility of the insured to maintain for their records. We greatly appreciate your business. (qq jlj / A member of Alleghany Insurance Holdings LLC OFFER OF TERRORISM COVERAGE In accordance with the Terrorism Risk Insurance Act, we are required to offer the insured coverage for losses resulting from an act of terrorism, not otherwise excluded by this policy and as covered by the Terrorism Risk Insurance Act. All other policy provisions will apply to coverage for such act of terrorism. The insured must choose whether or not to pay the premium described below under DISCLOSURE OF PREMIUM for coverage for acts of terrorism that are certified by the Secretary of the Treasury as covered acts under the Terrorism Risk Insurance Act, or not to pay the premium, and reject this offer of coverage at the time of binding. In any case, if the insured rejects terrorism coverage in any scheduled underlying policy, this policy is written to exclude terrorism. If the premium shown in the DISCLOSURE OF PREMIUM is not collected and the insured does not reject coverage for terrorism this policy will be issued excluding acts of terrorism. DISCLOSURE OF PREMIUM If you accept this offer, the portion of your premium for the policy term attributable to coverage for all acts of terrorism covered under this policy including terrorist acts certified under the Act is $ 500.00 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% of that portion of the amount of such insured losses that exceed the applicable insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year, the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. CAP INSURER PARTICIPATION IN PAYMENT OF TERRORISM LOSSES If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year and the Insurer has met our Insurer deductible under the Terrorism Risk Insurance Act, the Insurer will not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of the Treasury. T 9009 DATE: 07/20/2023 FROM: Janie Williams Graham -Rogers 501 SE Frank Phillips Blvd Bartlesville, OK 74003 Agency Fax: (918)337-3627 TO: Eric Herget HUB International RE: City of Fayetteville Renewal of Policy #: NEW QUOTATION We are pleased to offer the following quotation. Please review this quotation carefully, as the terms and conditions offered may be different than requested. You must contact us in writing to bind coverage, as your office holds no binding authority. Policy Term: 07/20/2023 - 07/20/2024 Quotation Premium Quote Exp Date: 07/20/2023 12:01 AM Premium: $25,000.00 Broker Fee $1,250.00 AR SL Tax(4%) $1,050.00 Total: $27,300.00 Payment Terms: Premium Due Within 20 Days of Effective Date. Minimum Earned Percentage: 25.00 % Note: Fees are fully earned Policy Type: Occurrence Carrier(s): Landmark American Ins Co Non -Admitted Please be sure to check the Carrier's current A.M. Best rating to satisfy you and your client's interests. Locations: Per Schedule on file with the Company Commercial General Liabilitv General Aggregate: $2,000,000 Products/Completed Operations Aggregate: $2,000,000 Each Occurrence: $1,000,000 Personal and Advertising Injury: $1,000,000 Damages to Premises Rented To You: $50,000 Medical Payments (any one person): $5,000 Deductible (BI/PD) $5,000 Per Occurrence 07/20/23 Page 2 of 2 Endorsements/Exclusions: (Standard Company or ISO Exclusions are applicable including, but not limited to the following terms, conditions and exclusions. The state specific forms vary per state, and may not be listed on this proposal. It is your responsibility as agent of the insured to check coverage and terms.) See Attached Terms and Conditions: • No Flat Cancellation(s) Permitted • Should any loss occur between the date of this quotation/binder and the effective date, the company(ies) reserve the right to withdraw this quotation/binder. • Signed and dated Acord application due at binding (must be signed and dated by both the Agent and Insured). If there are terms/conditions that are inconsistent with the coverage bound, please note that your binder/policy prevails and any changes to terms/conditions, etc. must be made by endorsement request and are subject to carrier approval. • Terrorism coverage has been Accepted by the Insured. • The taxes and fees shown above are based on this account's home state's taxes and rules. If the schedule is altered (mailing address change, amended TIV, adding or deleting properties) prior to binding, it may affect the determination of the home state is and thus the tax/fee percentages may change. • See Attached for Additional Terms/Conditions/Subjectives RE: Primary Casualty Quote Submission Number: Company: Coverage: Insured: Policy Dates: RSUI Group, Inc. 761348 Landmark American Insurance Company - Non -Admitted (A.M. Best rating: A++ XIV and S&P rating: AA+) Commercial General Liability Including Products Liability City of Fayetteville Fayetteville, AR July 20, 2023 - July 20, 2024 Form And Coverages 2013 ISO - Occurrence With Defense Outside Limit - Commercial General Liability Including Products Liability. Please contact the underwriter if you have any questions about the standard provisions of this form. Each Occurrence: $1,000,000 General Aggregate: $2,000,000 Products/Comp. Oper. Aggregate: $2,000,000 Personal Injury and Advertising Limit: $1,000,000 Medical Payments: $5,000 Damage to Premises Rented: $50,000 Deductible Each Occurrence: $5,000 Aggregate: $0 Defense Outside Deductible Policy Attachments and Forms • Amendment of Insured Contract Definition CG 2426 0413 • Arkansas Changes - Cancellation and Nonrenewal IL 0231 1022 • Arkansas Changes - Transfer of Rights of Recovery Against Others to Us IL 0199 0702 761348 A member ofAlleghany Insurance Holdings LLC • Arkansas Surplus Lines Disclosure Notice RSG 99069 0106 • Commercial General Liability Coverage Form CG 0001 0413 • Common Policy Conditions IL 0017 1198 • Communicable Disease Exclusion CG 2132 0509 • Contractual Liability - Railroads CG 2417 1001 • Deductible Liability Insurance CG 0300 0196 • Exclusion - Absolute Asbestos RSG 16004 0903 • Exclusion - Assault And Battery RSG 16008 1208 • Exclusion - Cross Suits RSG 16014 0604 • Exclusion - Cyber Liability, Data Compromise or Breach, and Statutes Related to Data Security RSG 16123 0821 • Exclusion - Employment Related Practices CG 2147 1207 • Exclusion - Fluorinated Compounds RSG 16132 0522 • Exclusion - Lead RSG 16032 0903 • Exclusion - Sexual Abuse, Molestation, or Human Trafficking RSG 16133 0822 • Exclusion - Silica or Mixed Dust RSG 16080 0304 • Fungi or Bacteria Exclusion CG 2167 1204 • Limitation - Of Coverage To Designated Premises Project Or Operation CG 2144 0417 • Minimum Premium and Minimum Retained Premium RSG 14024 0112 • Non - Accumulation of Limits RSG 14046 0714 • Nuclear Energy Liability Exclusion Endorsement IL 0021 0702 • Primary and Noncontributory - Other Insurance Condition CG 2001 1219 • Service Of Suit RSG 94022 0407 • State Fraud Statement RSG 99022 1022 • Total Pollution Exclusion Endorsement CG 2149 0999 Premium Amount Flat Charge: $25,000.00 Minimum Premium: $25,000.00 Minimum Earned Premium: $6,250.00 Gross Premium: $25,000.00 Based on Estimate Of: $0.00 Comments: THE PREMIUM AMOUNT DOES NOT INCLUDE SURPLUS LINES TAX. YOUR OFFICE IS RESPONSIBLE FOR THE COLLECTION AND FILINGS. Based on the insured's operations we have identified the Home State as AR. Please read all terms and conditions shown above carefully as they may not conform to specifications shown on your submission. Please note: Certificates of Insurance do not amend, extend or alter coverage afforded by any Landmark American Insurance Company policy and are the responsibility of the insured to maintain for their records. We greatly appreciate your business. A member of Alleghany Insurance Holdings LLC / IDf, RSUI Group, Inc. S OFFER OF TERRORISM COVERAGE In accordance with the Terrorism Risk Insurance Act, we are required to offer the insured coverage for losses resulting from an act of terrorism, not otherwise excluded by this policy and as covered by the Terrorism Risk Insurance Act. All other policy provisions will apply to coverage for such act of terrorism. The insured must choose whether or not to pay the premium described below under DISCLOSURE OF PREMIUM for coverage for acts of terrorism that are certified by the Secretary of the Treasury as covered acts under the Terrorism Risk Insurance Act, or not to pay the premium, and reject this offer of coverage at the time of binding. In any case, if the insured rejects terrorism coverage in any scheduled underlying policy, this policy is written to exclude terrorism. If the premium shown in the DISCLOSURE OF PREMIUM is not collected and the insured does not reject coverage for terrorism this policy will be issued excluding acts of terrorism. DISCLOSURE OF PREMIUM If you accept this offer, the portion of your premium for the policy term attributable to coverage for all acts of terrorism covered under this policy including terrorist acts certified under the Act is $ 0 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% of that portion of the amount of such insured losses that exceeds the applicable Insurer retention. However, if aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year, the Treasury shall not make any payment for any portion of the amount of such losses that exceeds $100 billion. CAP INSURER PARTICIPATION IN PAYMENT OF TERRORISM LOSSES If aggregate insured losses attributable to terrorist acts certified under the Terrorism Risk Insurance Act exceed $100 billion in a calendar year and the Insurer has met our Insurer deductible under the Terrorism Risk Insurance Act, the Insurer will not be liable for the payment of any portion of the amount of such losses that exceeds $100 billion, and in such case insured losses up to that amount are subject to pro rata allocation in accordance with procedures established by the Secretary of Treasury. 761348 1 of 1 A member of Alleghany Insurance Holdings LLC