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Home My WebLink About000300.tiff Weld County, Colorado ,. -. N a Amy - :, z...�3*sz.,..3.':,.•aw .. y-;r)t t<,r,s.,. Ny6 t'6, . 33.s`-` FeF Y: -'---tea_ '"�d^3%ti^,.]TS3n..Y>`._-,- - ,p ttm:cs�•rePr.o-�... HiKC/F -r -. J;6"3l".0 - - �.. ..,,.._.. - eb ,..., .e 'Tav" . Client Authorization to Bind Coverage After careful consideration of Gallagher's proposal dated 12/6/2017 , we accept the following coverage(s). Please check the desired coverage(s) and note any coverage amendments below: LINE OF COVERAGE CARRIER Excess Workers Comp — One Year Accept Reject i Term I I Accept Reject ' Excess Workers Comp — Two Year Safety National Casualty Corp . Term p TRIA Cannot be rejected l TRIA Coverage , :_.....,.r.,..._,.rrr....r.rr.__,...__.� _ _..,. _ _rrrr,_rr__„___.� _, ....r:rrrrr_r..r:.._ ...._.... _r_..._ _.._ _.r_..._.r.._.r_..,._r....__....._._._....�. r.r.,.r._..�_._ _ __.............1 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: It is understood this proposal provides only a summary of the details; the policies will contain the actual coverages. We confirm the values, schedules, and other data contained in the proposal are from our records and acknowledge it is our responsibility to see that they are maintained accurately. We agree that your liability to us arising from your negligent acts or omissions, whether related to the insurance or surety placed pursuant to these binding instructions or not, shall not exceed $20 million , in the aggregate. Further, without limiting the foregoing , we agree that in the event you breach your obligations, you shall only be liable for actual damages we incur and that you shall not be liable for any indirect, consequential or punitive damages . By: Julie A . Cozad , Chair Print Name (Specify Title) Board of Weld County Commissioners Company ,_ i ;(' i :aturc. P i r r _.......), (` __ 1t ' DEC 2 8 2017 Date : t:,. . , t .r t . �. o . .:.-,.:• :, , ,, —V:11''''‘'''‘''"1"-.‘ .,.,,... .-. ; .r.. r ,.,:r — -v Ja,-... : 1 — .a.cam+. ^., .. .R .. ',I' _. Y ... '? ,. , . � M � v „ :41 t J r.. . .:....qrr. _ .. � ,... n . ,cn � , ,.'.. A nn �.,1. r , ,, v � M.Tt . ._ n' Y � '^, , '.Y,., . . .r. n .� " „ .. .w.4::::.u ,. .^4... ,-: v , .C4 .,, .. A \ rYL. .. xv. c r. .a \. / .._ \ rfSR .. M 1,... �. x , .n C „,.- , G:. - i r 1t1,11. ,-;;:,"4,4. n. , . , . P X, [d. .. w }X xe ... rda, :'v .. .. _., -r ...- ,. , ,,: . ' .,.,. s„a .. ", 1. ,0... .... Y w , . , . , ,( ,.Y. . C ... . . . . ro5 d .. , . r _ f r ,. R (.,.4"'. '.?'. ..,, . . , � . a , .-. ., ,.. �Fr ,. � ,. . .. ., , � w ,%1': . t. r,� r. \. . Ma V , w v , .. , - d.,. 1. . ,1 \ 1. 1 rr^' r J. 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S,' „ " ''"4 , , ,.. �. K[ M r_.. .ffi . M, s 4... .e.J M . .�+.n,JT�4Ll`x'v:x2.ra .4 ^:F.;9,. .:� 'rM'. I,W at , hn.r> , &Y�. Weld County, Colorado _ „4,,,s.,,,,,, u: r = _ nn-v,--- ___ Bindable Quotations & Compensation Disclosure Schedule Client Name : Weld County, Colorado WHOLESALER, MGA OR INTERMEDIARY . EST. ANNUAL COMM.% COMM.% AJG OWNED ? COVERAGE(S ) CARRIER NAME(S) PREMIUM OR FEE1 NAME OR FEE YES/NO Workers' Compensation Safety National Casualty $ 154, 902 15% ! N/A i N/A N/A SIR : $750 , 000 ( 1 Yr. Term ) Corporation Workers' Compensation I Safety National Casualty j $ 154, 902 15% N/A N/A __ N/A SIR : $750 , 000 (2 Yr. Term — annual Corporation 1 installments) L [ i _______... ._ _ _ ____ _________ _ Some carriers pay Gallagher supplemental or contingent commissions in addition to the policy commission . Contingent commissions are typically contingent upon performance factors such as growth , profit, volume or retention , while supplemental commissions are not. These supplemental or contingent commissions may range from less than 1 % up to 10% of the policy premium . Please refer to the Compensation Disclosure or contact your Gallagher representative for additional information . 1 The commission rate is a percentage of annual premium excluding taxes & fees . •# . .. . a, cen e � ,, .rte: CORE36O ,,, Gallagherc 0 R E 17BS©17\29618W- EkecSum - . Hello