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EIOR
Services'
Northwest Professional Center Renewal Application For
227 US Hwy 206, Suite 302 Business and Management (BAM
)
Tel : (973) 252-5141 / (800) 689-2550 Indemnity Insurance
Fax: (973) 252-5146 / (800) 689-2839 Non- Profit Organizations
www. ERiskServices. corn
email : application@ERiskServices . com
NOTICE: THE POLICY FOR WHICH APPLICATION IS MADE, SUBJECT TO ITS TERMS, APPLIES ONLY TO ANY
CLAIM MADE AGAINST ANY OF THE INSUREDS DURING THE POLICY PERIOD. THE LIMIT OF LIABILITY
AVAILABLE TO PAY DAMAGES OR SETTLEMENTS SHALL BE REDUCED AND MAY BE EXHAUSTED BY
AMOUNTS INCURRED AS COSTS, CHARGES AND EXPENSES (AS DEFINED IN THE COVERAGE SECTION FOR
WHICH APPLICATION IS MADE), AND COSTS, CHARGES AND EXPENSES SHALL BE APPLIED TO THE
RETENTIONS.
General instructions for completing this Application
1 . Please type or print in ink.
2. Please read carefully and answer all questions. If a question is not applicable, so state.
3. The Application must be signed by an executive officer.
4. This Application and all exhibits shall be held in confidence.
5. Please read the Policy for which application is made (the "Policy") prior to completing this Application.
6. The terms as used herein shall have the meanings as defined in the Policy.
1. General Information Expiring Policy: E K 13 4 3 910 9
I . Name of Organization: Weld County Housing Authority
Address: 1150 " O " Street
(Number) (Street)
Greeley CO 80631
(City) (State) (Zip Code)
2. Internal Revenue Service Code:
3. Nature of Operations: Housing Authority
4. Has the Organization been in operation longer than three (3) years? Li Yes __ No
5.
Is the Organization involved in any labor/union negotiations or collective bargaining activities? __ Yes P.11 No
( 10 - 09 ) Page 1 of 4
II. False Information
NOTICE TO ARKANSAS APPLICANTS: Any person who knowingly presents a false or fraudulent Claim for payment for
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.
NOTICE TO COLORADO APPLICANTS: 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.
NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: 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
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly, and with intent to injure, defraud, or deceive any
Insurer files a statement f Claim or an application containing any false, incomplete or misleading information is guilty of a
felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For you protection, Hawaii law requires you to be informed that presenting a
fraudulent Claim for payment of a Loss or benefit is a crime punishable by fines or imprisonment, or both.
NOTICE TO KENTUCKY APPLICANTS: 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.
NOTICE TO LOUISIANA APPLICANTS: 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.
NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an
insurance company for the purposes of defrauding the company. Penalties may include imprisonment, fines or a denial of
insurance benefits.
NOTICE TO MINNESOTA APPLICANTS: A person who submits an application or files a Claim with intent to defraud or
helps commit a fraud against an Insurer is guilty of a crime.
NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an
Application for an insurance policy is subject to criminal and civil penalties.
NOTICE TO NEW MEXICO APPLICANTS: 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.
NOTICE TO NEW YORK APPLICANTS : Any person who knowingly and with intent to defraud any insurance company or
other person files an application for commercial insurance or a statement of Claim for any commercial or personal insurance
benefits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact
material thereto, and any person who, in connection with such application or claim, knowingly makes or knowingly assists,
abets, solicits or conspires with another to make a false report of the theft, destruction, damage or conversion of any motor
vehicle to a law enforcement agency, the department of motor vehicles or an insurance company 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 value of the subject
motor vehicle or stated Claim for each violation.
NOTICE TO OHIO APPLICANTS: Any person who, with the 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.
( 10 - 09 ) Page 2 of 4
NOTICE TO OKLAHOMA APPLICANTS: 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.
NOTICE TO PENNSYLVANIA APPLICANTS: 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.
NOTICE TO TENNESSEE & VIRGINIA APPLICANTS: 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.
NOTICE TO WASHINGTON APPLICANTS : It is a crime to knowingly provide false, incomplete, or misleading
information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines, and
denial of insurance benefits.
III. Other Information
1 . The undersigned declares that to the best of his/her knowledge the statements herein are true. Signing of this
Application does not bind the undersigned to complete the insurance, but it is agreed that this Application shall be the
basis of the contract should a Policy be issued, and this Application will be attached to and become a part of such
Policy, if issued. Insurer hereby are authorized to make any investigation and inquiry in connection with this
Application as they may deem necessary.
2. It is warranted that the particulars and statements contained in the Application for the proposed Policy and any
materials submitted herewith (which shall be retained on files by Insurer and which shall be deemed attached hereto, as
if physically attached hereto), are the basis for the proposed Policy and are to be considered as incorporated into and
constituting a part of the proposed Policy.
3 . It is agreed that in the event there is any material change in the answers to the questions contained herein prior to the
effective date of the Policy, the applicant will notify Insurer and, at the sole discretion of Insurer, any outstanding
quotations may be modified or withdrawn.
4. It is agreed that in the event there is any misstatement or untruth in the answers to the questions contained herein,
Insurer have the right to exclude from coverage any claim based upon, arising out of or in connection with such
misstatement or untruth.
111 Signed: le Date: ,_ a C--"
(must be signed by an Executive Officer of the Parent Organization)
For purposes of creating a binding contract of insurance by this application or in determining the rights and obligations under
such contract in any court of law, the parties acknowledge that a signature reproduced by either facsimile or photocopy shall
have the same force and effect as an original signature and that the original and any such copies shall be deemed one and the
same document
Please fully complete and attach the Information for the Coverage
Section(s) desired.
( 10 - 09 ) Page 3 of 4
Employment Practices Coverage Section Information
Is the Organization see<ing Employment Practices coverage? If yes, please answer the following ; Yes al No
questions.
1 . Total number of Employees ( full-time and part-time)
MI0to5 S 51to75
6 t 10 76 to 100
MI 11 tc 15 101 to 200
CI I ( tc 25 MI 201 to 300
2( to 50 Exact number, if over 300
Note: When answering the above range of Employees, multiply the number of part-time Employees by a factor of . 5 and add
to number of ill-time Employees.
2. Does the Organization anticipate in the next 12 months, or has the Organization
transacted in he last 12 months, any consolidations or layoffs affecting 35% or more of
the Employees of the Organization? Yes :i No
3 . Describe the internal controls the Organization maintains for Employment Practices.
a) Does the Organization publish and distribute an employee handbook to every
Employee? Yes No
b) Are -he-e written procedures for handling Employee complaints of
discrimination or sexual harassment? >:i Yes II No
c) Are -he-_-e written procedures for handling Employee grievances or complaints? Yes 5 No
Insured Person and Organization Coverage Section Information
Is the Organization seeing Insured Person and Organization coverage? If yes, please answer
the following questions. 11 Yes t:! No
1 . Describe the fallowing financial information of the Organization for the most recent fiscal year-end.
a) Total Asset; SO to 2, 000, 000 11 $ 15, 000, 001 to 20, 000, 000
►i1 S2, 000, 001 to 5, 000, 000 5 over $20, 000, 000
S5, 000, 001 to 7, 500, 000
II S7, 500, 001 to 10, 000, 000 Exact amount, if over $20, 000, 000
MI $ 10, 000, 001 to 15, 000, 000
b) Does the Organization have a negative fund balance? Yes Pai No
If yes, please provide complete financial statements
2. Number of for-profit Subsidiaries the Organization owns: ®0 I I Exact number if more than 1
3 . Are the annua_ revenues for the Subsidiaries referenced above greater than S250, 000? 111 Yes i No
If yes, please Jrcvide complete financial details.
4. Does the Organization render any professional services for others for a fee or
compensation? If yes, please provide details on a separate page. S Yes C4 No
Fiduciary Coverage Section Information
Is the Organization seeking Fiduciary coverage? If yes, please answer the following questions. Yes P No
1 . Does the Organization maintain any employee benefit or pension plan for its
Employees under the Employee Retirement Income Securities Act of 1974? MI Yes ►II No
2. Are the total plan assets for the plans referenced above greater than S1 , 000, 000? ►Ci Yes S No
If yes, please provide complete details regarding the plans.
( 10 - 09 ) Page 4 of 4
BASIC
FINANCIAL
jjti
STATEMENTS
COUNTY OF WELD
STATE OF COLORADO
Statement of Net Position
December 31 , 2021
Primary Government Component Units
Business-
Governmental Type Housing E911
Activities Activities Total Authority Authority
ASSETS
Cash and investments $ 501 ,460,796 $ 722, 131 $ 502, 182,927 $ 2,653, 125 $ 2,486,891
Property taxes receivable 190,026,845 - 190,026,845 - -
Receivables (net of allowance) 8,985,716 - 8,985,716 191 ,684 999,663
Notes Receivable 32,472,337 - 32,472,337 - -
Due from other gcve-nments 4, 133,463 - 4, 133,463 - -
Internal balances 7,726 (7,726) - - -
Inventories 1 ,661 ,847 - 1 ,661 ,847 - -
Other assets 1 ,567,620 - 1 ,567,620 - -
Net Pension Asset 35,301 ,212 - 35,301 ,212 - -
Restricted Cash ard Equivalents 885,416 - 885,416 8,082 -
Capital assets not being depreciated 79,254,323 - 79,254,323 - -
Capital assets net of depreciation 438,335,767 3,473,602 441 ,809,369 19,236 -
Total assets 1 ,294,093,068 4, 188,007 1 ,298,281 ,075 2,872, 127 3,486,554
DEFERRED OUTFLOWS OF RESOURCES
Pension Plans 52,775,208 - 52,775,208 - -
Other Post Employment Benefits 79,722 - 79,722 -
Total Deferred Outflows of Resources 52,854,930 - 52,854,930 - -
LIABILITIES
Accounts payable and other current liabilities 17,539,857 - 17,539,857 15,773 -
Accrued liabilities 12, 155,830 - 12, 155,830 - -
Unearned Revenue 7,450, 104 277,090 7,727, 194 - -
Other liabilities 248 - 248 - -
Long-term liabilities:
Due within one year:
Compensated absences 378,994 - 378,994 9, 125 -
Due in more that oiie year:
Compensated absences 6,256,545 - 6,256,545 10,078 -
Net Pension Liability 4,690, 143 - 4,690, 143 - -
Net Other Post Employment Benefits Liability 665, 158 - 665, 158 - -
Total liabilities 49, 136,879 277,090 49,413,969 34,976 -
DEFERRED INFLOWS OF RESOURCES
Property Taxes 190,358,556 - 190,358,556 - -
Pension Plans 12,880,288 - 12,880,288 - -
Other Post Employment Benefits 214, 199 - 214, 199 - -
Total Deferred Inflows of Resources 203,453,043 - 203,453,043 - -
NET POSITION
Invested in capital assets 517,590,090 3,473,602 521 ,063,692 19,236 -
Restricted for:
Programs 20,852,276 - 20,852,276 - -
Emergencies 10,000,000 - 10,000,000 - -
Claims 4,734,405 - 4,734,405 - -
Public Works 183,672,661 - 183,672,661 - -
Other purposes 61 ,896,700 - 61 ,896,700 - -
Unrestricted 295,611 ,944 437,315 296,049,259 2,817,915 3,486,554
Total net position $ 1 ,094,358,076 $ 1910,917 $ 1 ,098,268,993 $ 2,837, 151 $ 3,486,554
See accompanying notes to the basic financial statements
27
COUNTY OF WELD
STATE OF COLORADO
Reconciliation of Total Governmental Fund Balances To Statement of Net Position
December 31,2021
Total governmental fund balances $ 451,030,537
Amounts reported for governmental activities in the Statement of activities are different because
Capital Assets used in governmental activities are not financial resources and therefore are not reported in
the funds 484,406,845
Long-term liabilities,including compensated absences,are not due and payable in the current period and
therefore are not reported in the funds
Pension Asset 35,301,212
Compensated Absences (6,635,539)
Pension Liability (4,690,143)
Net Other Post Employment Benefits Liability (665,158)
Deferred Inflows Pension Plans 52,775,208
Deferred Inflows Other Post Employment Benefits 79,722
Deferred Outflows Pension Plans (12,880,288)
Deferred Outflows Other Post Employment Benefits (214,199)
Accounts and notes receivables that do not provide current financial resources,are offset by deferred
inflows in the funds 35,113,476
Internal service funds are used by management to charge the costs of insurance and other services to
individual funds The assets and liabilities of the internal service funds are included in governmental
activities in the statement of net position 60,728,677
Internal Services used by Enterprise Fund 7,726
Net position of governmental activities $1,094,358,076
See accompanying notes to the basic financial statements
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