HomeMy WebLinkAbout20241950.tiffRESOLUTION
RE: APPROVE RENEWAL APPLICATION FOR PUBLIC ENTITY AND EMPLOYMENT
PRACTICES LIABILITY INSURANCE, AND AUTHORIZE CHAIR TO SIGN - KINSALE
INSURANCE COMPANY, C/O ARTHUR J. GALLAGHER RISK MANAGEMENT
SERVICES, LLC
WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to
Colorado statute and the Weld County Home Rule Charter, is vested with the authority of
administering the affairs of Weld County, Colorado, and
WHEREAS, the Board, ex -officio Housing Authority Board, has been presented with a
Renewal Application for Public Entity and Employment Practices Liability Insurance from the
County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld
County, on behalf of the Weld County Housing Authority, to Kinsale Insurance Company, c/o
Arthur J. Gallagher Risk Management Services, LLC, commencing August 2, 2024, and ending
August 1, 2025, with further terms and conditions being as stated in said renewal application, and
WHEREAS, after review, the Board deems it advisable to approve said renewal
application, a copy of which is attached hereto and incorporated herein by reference.
NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of
Weld County, Colorado, ex -officio Housing Authority Board, that the Renewal Application for
Public Entity and Employment Practices Liability Insurance from the County of Weld, State of
Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the
Weld County Housing Authority, to Kinsale Insurance Company, c/o Arthur J. Gallagher Risk
Management Services, LLC, be, and hereby is, approved.
BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized
to sign said renewal application.
cc :PE(Mit/rcL' FI(c1), HA(&,)
off/2.3/24
2024-1950
HA0031
PE0036
RENEWAL APPLICATION FOR PUBLIC ENTITY AND EMPLOYMENT
INSURANCE - KINSALE INSURANCE COMPANY, C/O ARTHUR
MANAGEMENT SERVICES, LLC
PAGE 2
The above and foregoing Resolution was, on motion duly made
by the following vote on the 22nd day of July, A.D., 2024.
ATTEST:
Weld County Clerk to the Board
APP
at kit ck
Deputy Clerk to the Board
ey
�Date of signature: z a I Z
PRACTICES LIABILITY
J. GALLAGHER RISK
and seconded, adopted
BOARD OF COUNTY COMMISSIONERS
WELD COUN . • LOR
Kevin D. Ross, Chair
Perry L. B(Ick, Pro-Tem
Mik Free
tt K. James
on Saine
2024-1950
HA0031
PE0036
Confikack- tl $ (
BOARD OF COUNTY COMMISSIONERS
PASS -AROUND REVIEW
PASS -AROUND TITLE: Housing Authority Insurance Renewal
DEPARTMENT: Human Resources DATE: 7/2/24
PERSON REQUESTING: Michelle Reimer, Kelly Leffler
Brief description of the problem/issue:
Attached you will find the Kinsale Insurance Housing Authority Liability Renewal Application for the 24-25
renewal. This would be the 2n° year for insurance through Kinsale, and it is recommended by the broker, AJG,
to keep the coverage through Kinsale. Once the application has been submitted, the application will go through
underwriting and we will receive the renewal premium invoice. Last year's premium was $10,579.13 and we do
not anticipate a high increase.
What options exist for the Board?
Binding with the broker's recommendation or not binding and risking an uninsured loss.
Recommendation:
Signing the application and bind with Kinsale per AJG's recommendation.
Support Recommendation Sc edule
Place on BOCC Agenda Work Session Other/Comments:
Perry L. Buck, Pro-Tem
Mike Freeman
Scott K. James
Kevin D. Ross , Chair
Lori Seine
t64-
.05
2024-1950
-7/22
PG003(0
HHd031
,„04k KINSALE®
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
PUBLIC ENTITY AND EMPLOYMENT PRACTICES LIABILITY RENEWAL APPLICATION
APPLICANT'S INFORMATION
1. Current Kinsale Policy Number: EKI3439109
2. Legal name of the Public Entity who is the primary applicant and will be the first named insured listed on the policy:
Weld County Housing Authority
3. Please list all other entities / organizations that you are requesting to be a named insured on the policy (a request does
not guarantee that all such entities will be quoted / covered):
NA
4. Principal Address: 1150 "O" Street
City: Greeley
Public Entity's Website: www. www.weld.00v
State: CO Zip: 80631
5. Do you have a Full Time Risk Manager? ® Yes ❑ No
If "yes" — how many years has the Risk Manager been in this position? years
Name of Risk Manager: Kelly Leffler Phone Number: (970-400-4220
6. Type of Public Entity: ❑ Town ❑ City ® County ❑ State
® Special District or Commission (Please Indicate):
❑ Airport ❑ Parks Department ❑ Transit Authority
❑ Development/Finance Authority ❑ Port Authority ❑ Utility (Gas/Electric/Cable)
® Housing Authority ❑ Sports/Convention Center ❑ Water/Sewer
❑ Other:
7. Populations Trends: Please provide Population information:
CURRENT YEAR
Population of Municipality: 359,442
Seasonal increase in population? ❑ Yes % ® No
B. Are the Public Entity's board, council or commission members appointed or elected? ® Appointed ❑ Elected
a. If APPOINTED, by whom? Board of County Commissioners
b. If ELECTED, are they elected via: ❑ Single Member District ❑ At Large ❑ Combination of Both
Page
1
of 8
GENERAL INFORMATION
Please provide the following information. If "yes to any question below, or if the applicant has budget deficits in the past
three years, please explain on a separate attachment. NA
1. a) Indicate fiscal year end date: 2022
b) Please provide a budget figure for the most recent fiscal year.
CURRENT YEAR
Revenue $ $4,113,854.00
Ex enditure $ $4,083,564.00
Surplus/Deficit ❑ O $
Outstanding Bond I ue $
Budget Surplus (Deficit)
c) Has any State or Federal funding (aid) been eliminated in the past year?
d) Does the Public Entity anticipate any special project which will result in a
sub tantial budget increa e or decrease in the next 3 years?
e) Has the Public Entity been in default on principal or interest on any bond?
Ekes ® No
❑ Yes ® No
❑ Yes ® No
If you selected "yes" to either C, D, or E, please provide a narrative explanation including dates and amounts involved.
2. Latest bond rating (Standard & Poor's or Moody's): NA Previous Rating: NA
3. Please attach a copy of your most recent comprehensive annual financial report.
OPERATIONS
Please respond to the following inquiries and use a separate attachment for details requiring further explanation.
1. Does the public entity administer any of the following operations?
Authorities
❑ Airport Authority
® Housing Authority
❑ Port Authority
❑ Transit Authority
Utilities
❑ Electric Utility
❑ Gas Utility
❑ Water / Sewer Utility
Zonintt/Safety
❑ Building Inspection
❑ License Issuance
El Permit Issuance
❑ Police Department
❑ Tax Assessment / Collection
❑ Zoning
Other
El Daycare
❑ Ho ital / Nursing Home
El Landfill
El Other Not Listed
2. If "yes" to question 1 above, were any of these services/operations new during the past 12 months, or will be
introduced during the next 12 months? ❑ Yes ® No
By attachment to this application, please explain any "yes" response including which services/operations are new, the
associated budget and staff count, and risk management controls in place.
EMPLOYEES
1. Number of Employees - Full Time: 17
Part Time: 2
2. Number of Volunteers: 0 How many hours per week do volunteers work on average?
age 2 of 8
f1
3 lea e e cribe the ervice performe by Volunteer for, or on behalf of, your Entity:
4 Salary ange
(including bonuses, dividends, and commissions)
$50,000 or less:
$50,001 to $100,000:
$100,001 and over:
TOTAL:
Number of Full Time Employees Number of Part Time Employees
4 0
13
0
0
0
0 0
Number of employee in each category:
3 Accountant 0 Engineer 0 olice
0 Architect 0 Fire/ e cue 0 oa / Utilitie
0 Attorney 5 General Office 9 Other: Inspectors, Maintenance
5 Di any of the following take place in the pa t 12 months?
a) Strike, slowdown, or other staffing disruption?
b) Disputes involving integration, egregation, discrimination, or violations of civil
rights (with staff or with students)?
c) Has any employee been uspende , i mi se , demote , transferred, or ha a
tenure contract non -renewed?
Please explain all "yes" answer to 5 A -C:
❑ Yes ® No
❑Ye ®No
❑Ye No
6 Doe the Applicant u e ea onal or temporary employees? ❑ Ye ® No
If "yes" - when an how many?
7 Doe the Applicant u e lea e worker ? ❑ Ye M No
If "yes" — how many have been retaine by the Applicant in the pa t 12 month ?
Doe the Applicant u e in epen ent contractors? ® Ye ❑ No
If "yes" — how many work solely for the Applicant? 0 as needed. subcontractors are primarily used for plumbing &
general maintenance
9 For which of the following ervice oe the ublic Entity u e ubcontractor (check all that apply)
❑ A mini trative /Secretarial ❑ Cu to ial ❑ Me ical ❑ Tran portation
❑ Accounting / Financial ❑ Food ❑ Specialized Education ® Other
lea a explain in etail:
10. Do you require all subcontractor or in ependent contractor to provi a evidence of ® Ye ❑ No
carrying liability insurance?
If "yes" - are you a e a an a itional in ured to these policie ? ® Ye ❑ No
11 How many employee are covere by collective bargaining or other union agreement ? 0
12. In the past 12 months, how many employees have left your employ? 3
Of the above, how many were terminated involuntarily? 2 terminations were due to substance abuse issues with
age 3 of 8 one and poor work performance on the other
. a the Applicant establi hed or changed any written policies/procedure governing teacher & other personnel
i the past 12 months? If "yes" to any response, please attach a arrative explanation detailing the changes.
Background check ❑ Ye ® No
Demotion ❑ Ye ® No
Di mi al ❑ Ye MI No
Drug Te ting ❑ Ye ® No
iring ❑ Ye ® No
romotion ❑ Ye ® No
Sexual ara ment ❑ Ye M No
Su pen ion ❑ Ye ® No
Tran fer ❑ Ye ® No
2. Do you conduct background check on all:
Applicant ? M Ye ❑ No
New ire ? M Ye ❑ No
Volunteer ? M Ye ❑ No
3. lea e check the appropriate areas for the type of checks performed:
Type Employees Volunteers
Academic Credential ❑ ❑
Credit ❑ ❑
Criminal Checks —All States ® ❑
Criminal Check — Federal ® ❑
Criminal Check — ome State ® ❑
Driving Record ❑ ❑
Licen e ❑ ❑
er onal Reference ® ❑
nor Employer ® ❑
Random Drug Te t (po t hire) ❑ ❑
Other: ❑ ❑
4. Have the Applica is supervisi g personnel or other employees attended trai i g a d
education program / eminar on exual hara sment and other types of di crimination
within the la t 2 month ?
If "yes" — who has attended? All Employees
If "yes" — who conduct the e ion ?
5. Doe the Applicant have it employment policies/procedures reviewed by labor or
employment coun el?
If "yes" — identify the firm and date of last review:
6. Doe the Applicant have a uman Re ource or er onnel Department?
If "no" — who handles this function? Shawn Walcot
7. Doe the Applicant have an employee handbook?
age 4 of 8
®Ye I=I No
®Ye 0 N
/ / 01/01/2018
❑Ye ®No
®Ye El No
es" — does the Applicant distribute to all employees? ® Yes ❑ No
es" — do all emplo ees sign for its receipt? ❑ Yes ❑ No
es" — does it expressl state that it is not a contract and that emplo ment is at will"? ❑ Yes ❑ No
. Does the Applicant have written procedures for handling employee complaints of
discrimination and/or sexual harassment?
9. Does the Applicant require all terminations to be reviewed by:
The person in charge of human resources?
Outside Counsel?
10. Does the Applicant maintain a personnel file for each emplo ee?
®Yes ❑ No
❑Yes No
❑Yes ®No
® Yes ❑ No
OTHER MATERIAL INFORMATION
1. After inquiry with each person as appropriate, does anyone have any other Material ❑ Yes ® No
Facts to disclose? (If "yes"— please provide such Material Facts on a separate sheet.)
A Material Fact is one likely to influence assessment of this risk, the premium charged or the terms and
conditions imposed by Underwriters. If you ore in any doubt as to whether a fact would be considered material,
you should disclose it. All of the information requested in this proposal is material.
INSURANCE AND LOSS HISTORY
1. Does the Applicant currentl carr General Liabilit Insurance?
❑ Yes ® No
2. Other than routine visits, has the entity had any on -site monitoring visits by a State or ® Yes No
Federal Agency within the last 12 months?
If "yes" — please explain: CHAFA
3. Is the Applicant operating under any court orders?
es" — please explain:
❑ Yes ® No
4. After inquir with each person as appropriate, in the last 12 months, have an ublic ❑ Yes ® No
Entit Liabilit claims, or an wrongful termination discrimination, sexual harassment
claims, or an other wrongful emplo ment practices liabilit claim or suit (including third -
part claims) ever been made against the Entity, or any predecessor Entit , or an current
or former member of the Entit , or predecessor Entit (whether insured or uninsured)?
If "yes" — how many?
Please complete a separate Supplemental Claim Form for each claim or suit and include
a currently valued loss run for each claim.
5. In the last 12 months, have an of the following taken place:
a. Grand Jur investigations into activities of an entity or emplo ee?
es" — please provide details
age 5of8
❑ Yes ® No
dictme t of a y e tity or employee? ❑ Yes ® No
If "y s" — please provide details
6. After i quiry with each perso as appropriate, do you, or any of your oard mem ers, ❑ Yes ® No
trustees, or employees k ow of a y circumsta ces, acts, errors, omissio s, or a y
allegatio s or co to do sofa y i cide t that could result i a u lic E tity Lia ility claim,
or a y employme t related claim, i cludi g third party claims (whether i sured or
u i sured)?
If "yes" — how many?
Please complete a separate Supplemental Claim Form for each potential claim and
provide as much detail as possible.
7. Of the total umber of EEOC/State agency charges filed agai st a y Applica t over the last 12 months, indicate
the number of primary allegations as follows:
Location l Radnl j Age
No. Discrimination L Discrimination
With respect to litigated cases (i cludi g wro gful termi atio suits u der state law other tha a ti-
discrimi atio law) a d EEOC/State agency charges over the last 12 mo the for which settleme t was or may e
paid, please provide the followi g i formatio , which must e curre tly valued:
Date
Occurrence Claimant C
Religious Other Etude
Discrimination Discrimination
Damages
Allegation I Paid
FRAUD WARNING
Violation of
Equal Pay Act I Other Gender j Americans w/
Violation A Discrimination f Disabilities Act
Damages ° Legal Expenses Legal Expenses
Reserved Paid I Reserved —
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILUNOI5, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some states, 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
age 6 of 8
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 insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your 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 conceming 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 purpose of
defrauding the company. Penalties may include imprisonment, fines, or denial of insurance benefits.
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 an 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 shall also be subject to a civil penalty not to exceed $5,000 and the stated value
of the claim for each such violation.
NOTICE TOOHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a 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 a 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 the person to criminal and civil penalties.
NOTICE TO TENNESSEE 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 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.
The Applicant acknowledges that the answers prwided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of arty material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Page 71of 8
mp etion of this form does not bind co erase. Applicant's acceptance of the company's quotation is required prior to binding coverage and p icy
issuance.
All wrkten statements and materials fumished to the company In conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my
Professional Liability Application. I understand that an incorrect or incomplete statement could void my
protection.
Applicant Name (Print) Kevin D. Ross
Applicant's Signature: 7c.__
erk to the Bo
Agent/Broker Name: Gallagher
age /8of8
Title: Chair, Weld County Board of Commissioners
JUL 2 2 2024
Form W-9
(Rev. October 2018)
Departnert of the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and Certification
► Go to www.irs.gov/FormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
ai c
O i
M �
c e
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
ARTHUR J. GALLAGHER & CO.
ARTHUR J. GALLAGHER RISK MANAGEMENT SERVICES, LLC (FEIN: 36-2102482)
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the
following seven boxes.
❑ Individual/sole proprietor or X C Corporation ❑ s Corporation O Partnership ❑ Trust/estate
single -member LLC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
Note: Check the appropriate box in the line above for the tax classification of the single -member owner. Do not check
LLC if the LLC is classified as a single -member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single -member LLC that
is disregarded from the owner should check the appropriate box for the tax classification of its owner
❑ Other (see instructions) ►
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any) 5
Exemption from FATCA reporting
code (if any) E
Whiles to accounts maintained outside the U.S.)
iddress (number, street, and apt. or suite no.) See instructions.
0 GOLF ROAD
ity, state, and ZIP code
LLING MEADOWS, IL 60008
st account number (s) here (optional)
Taxpayer Identification Number (TIN)
Requester's name and address (optional)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and
Number To Give the Requester for guidelines on whose number to enter.
Social security number
I I -
or
1 1
Employer identification number
3
6
21115
1
61113
rEfali Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting fora number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
Sign signature of Here U.S. person► \�/ ••^
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information retum with the IRS must obtain your comet taxpayer
identification number (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), to report on an information return the amount paid to you, or other
amount reportable on an information return. Examples of information
returns include, but are not limited to, the following.
• Form 1099-INT (interest earned or paid)
Date► 01/10/2024
• Form 1099-DIV (dividends, including those from stocks or mutual
funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you area U.S. person (including a resident
alien), to provide your correct TIN.
ff you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X
02/22/2023 7:02:32 AM -0600 IRS PAGE 4 OF 9
Department of the Treasury
Internal Revenue Service
Cincinnati3OH 45999
In reply refer to: 0235222594
Feb 16, 2023 LTR 147C
36-2102482
ARTHUR J GALLAGHER RISK MANAGEMENT SERVICES LLC
2850 GOLF RD STE 1000
ROLLING MDWS, IL 60008
Taxpayer Identification Number: 36-2102482
Form(s):
Sear Taxpayer:
Thank you for your request dated February 9th, 2023.
Your Employer Identification Number (EIN) is 36-2102482. Please keep this letter in your
permanent records. Enter your name and your EIN on all business federal tax forms and
on related correspondence.
If you have any questions regarding this letter, please call Tiffany Banks at 859-320-3405
between the hours of 6:30 AM and 4:00 PM EST. If you prefer, you may write to us at the
address shown at the top of the first page of this letter. When you write, please include a
telephone number where you may be reached and the best time to call.
Sincerely,
/s/Tiffany Banks
1000195652
Tax Examining Technician
Cr Gallagher
AJG Risk Management Services LLC W-9 Reporting
Effective January 1, 2023, Arthur J. Gallagher Risk Management Services, Inc. converted to an LLC ("AJG RMS LLC").
From that moment, for U.S. federal tax purposes, AJG RMS LLC is viewed as an entity that is disregarded as an
entity separate from its owner (known as a "disregarded entity").
IMPORTANT: This conversion did not change the federal tax EIN for AJG RMS (Risk Management Services) LLC.
Please see the attached 147C confirmation letter from the IRS (Internal Revenue Service) concerning what the
EIN is for AJG RMS LLC. That is, AJG RMS LLC is still a separate legal entity with its own EIN for commercial
purposes, but it is no longer a separate taxpayer for income tax purposes.
As a result, the IRS rules for W-9 reporting require that AJG RMS LLC must be reflected on a W-9 of Arthur J.
Gallagher & Co, rather than on its own W-9, and the Tax ID displayed on Part I of the W-9 must be the regarded
taxpayer, i.e., AJG & Co. This concept also applies to certain other income tax related reporting purposes, such as
reporting of forms 1099. (see Treas. Reg. Section 301.6109-1(h)(2)(i). Rev. Rul. 2001-61). However, recognizing
that many carriers are in the habit of looking to a W-9 for EINs, Arthur J Gallagher Risk Management Services, LLC's
EIN (36-2102482) has been added on line 2 for informational purposes.
Said differently, given that AJG RMS is now a deemed division of AJG & Co solely for U.S. income tax purposes, the
IRS W-9 requirements no longer allow for a separate W-9 for AJG RMS LLC and the structure of the form does not
provide a natural place to put the EIN of disregarded entities.
Please refer to the relevant IRS instructions on Form W-9, below, supporting our W-9 presentation as described
above
e. Disregarded entity. For U.S. federal tax purposes, an entity that is
disregarded as an entity separate from its owner is treated as a
"disregarded entity." See Regulations section 301.7701-2(c)(2)(iii). Enter
the owner's name on line 1. The name of the entity entered on line 1
should never be a disregarded entity. The name on line 1 should be the
name shown on the income tax return on which the income should be
reported. For example, if a foreign LLC that is treated as a disregarded
entity for U.S. federal tax purposes has a single owner that is a U.S.
person. the U.S. owner's name is required to be provided on line 1. If
the direct owner of the entity is also a disregarded entity, enter the first
owner that is not disregarded for federal tax purposes. Enter the
disregarded entity's name on line 2, "Business name/disregarded entity
name." If the owner of the disregarded entity is a foreign person. the
owner must complete an appropriate Form W-8 instead of a Form W-9.
This is the case even if the foreign person has a U.S. TIN.
This reporting has been confirmed with outside Tax Counsel and Gallagher has been assured that this presentation
is not only required but is also common and consistent with how other US companies report disregarded entities
for income tax purposes. Given the Form W-9 requires a corporate officer to sign it under the penalties of perjury,
it is important that Gallagher complete this form following the IRS instructions.
Gallagher acknowledges that the W-9 requirements have caused some confusion amongst parties that have
historically relied on the W-9 of AJG RMS for certain non -income tax reporting purposes. To mitigate this
confusion, Gallagher has started posting both the W-9 and the 147C confirmation letter, along with this
explanation, on its W-9 website.
Houstan Ara • on
From:
Sent:
To:
a
Subject:
Attachments:
Kelly Leffler
Wednesday, July 10, 2024 11:53 AM
Houstan Aragon; Brandy Peterson
FW: Housing Authority Renewal
AJG 2024 W9.pdf
Sounds like Gallagher is who will be billing us.... See below
From: Nathan Kathol <Nathan_Kathol@ajg.com>
Sent: Wednesday, July 10, 2024 11:05 AM
To: Kelly Leffler <kleffler@weld.gov>
Cc: Riley Worthington <Riley_Worthington@ajg.com>
Subject: RE: Housing Authority Renewal
This email originated from outside of Weld County Government. Do not click links or open attachments unless you recognize the
sender and know the content is safe.
Hi Kelly,
We typically don't give out W9's on the carriers as we process the policy through our office (you will receive an invoice
from my office at the time of binding with payment being made directly to Gallagher). Hence, would Gallagher's W9
work (see attached)?
Thanks!
Nathan Kathol, CLCS
Client Service Executive
Public Sector I Higher Education
Gallagher
Insurance Risk Management t Consulting
P: 303-889-2532 1800.333.3231 Ext 2532 I M: 720-237-4503
Nathan Kathol@ajg.com
www.ajg.com
6300 S Syracuse Way, Suite 700 I Centennial, CO 80111
Please note: The discussion set forth above is only an insurance/risk management perspective and is NOT legal advice. We do not provide legal advice,
as we are not qualified to do so. I highly recommend that you seek the advice of legal counsel in order to become fully apprised of the legal implications
related to these issues.
A licensed Gallagher representative must provide the appropriate insurance carrier with written instructions in order to bind insurance
coverage. Therefore, client instructions via email are not sufficient to bind coverage unless and until you have received explicit written confirmation from
an authorized Gallagher representative
From: Kelly Leffler <kleffler@weld.gov>
Sent: Wednesday, July 10, 2024 10:50 AM
To: Nathan Kathol <Nathan Kathol@ajg.com>
1
Contract Form
Entity Information
Entity Name* Entity ID*
ARTHUR.] GALLAGHER RISK @00000344
MANAGEMENT SERVICES, INC
Q New Entity?
Contract Name* Contract ID
KINSALE INSURANCE HOUSING AUTHORITY LIABILITY 8496
Contract Status
CTB REVIEW
Contract Lead *
BPETERSON
Contract Lead Email
bpeterson@weld.gov
Contract Description *
2ND YEAR RENEWAL APPLICATION FOR KINSALE INSURANCE HOUSING AUTHORITY
Contract Description 2
Contract Type *
APPLICATION
Amount*
$10,579.13
Renewable
YES
Automatic Renewal
Grant
IGA
Department
HUMAN RESOURCES
Department Email
CM-
HumanResources@weldgo
v.com
Department Head Email
CM-HumanResources-
DeptHead@weldgov.com
County Attorney
GENERAL COUNTY
ATTORNEY EMAIL
County Attorney Email
CM-
COUNTYATTORNEY@WEL
DGOV.COM
If this is a renewal enter previous Contract ID
If this is part of a MSA enter MSA Contract ID
Parent Contract ID
Requires Board Approval
YES
Department Project #
Requested BOCC Agenda Due Date
Date* 07/13/2024
07/17/2024
Will a work session with BOCC be required?*
HAD
Does Contract require Purchasing Dept. to be
included?
NO
Note: the Previous Contract Number and Master Services Agreement Number should be left blank if those contracts
are not in OnBase
Contract Dates
Effective Date
Termination Notice Period
Contact Information
Contact Info
Review Date
06/02/2025
Renewal Date
07/01/2025
Committed Delivery Date Expiration Date
Contact Name Contact Type Contact Email Contact Phone 1 Contact Phone 2
Purchasing
Purchasing Approver Purchasing Approved Date
Approval Process
Department Head
JILL SCOTT
DH Approved Date
07/17/2024
Final Approval
BOCC Approved
BOCC Signed Date
BOCC Agenda Date
07/22/2024
Finance Approver
CHERYL PATTELLI
Legal Counsel
BYRON HOWELL
Finance Approved Date Legal Counsel Approved Date
07/18/2024 07/18/2024
Tyler Ref*
AG 072224
Originator
BPETERSON
Hello