Onebeacon Government Risks

OneBeacon Government Risks

800 IH-10 West

The Forum, Suite 1045

San Antonio, TX 78230

(303) 531-3816 • www.onebeacon.com/grs

RENEWAL APPLICATION

Please complete PART A and other PARTS as applicable

A New Business Application is required for any proposed coverage not currently insured by OneBeacon Government Risks

PART A / GENERAL INFORMATION
PART B / PROPERTY
Ø Attach Statement of Values
PART C / INLAND MARINE
Ø Attach Statement of Values
PART D / CRIME
PART E / AUTOMOBILE
Ø Attach Schedule of Covered Automobiles
PART F / GENERAL LIABILITY
PART G / DAM, RESERVOIR OR LEVEE SUPPLEMENT
PART H / PUBLIC OFFICIALS ERRORS AND OMISSIONS LIABILITY
PART I / LAW ENFORCEMENT LIABILITY
PART J / EXCESS LIABILITY

PART A GENERAL INFORMATION

1. ENTITY

Application Date:
Legal Name of Insured: / Webb County
Mailing Address: / 1110 Washington St.- Suite #204
Street Address: / Same as above
County: / Webb
Population / 250,304
Extended Named Insured(s):
FEIN: / 74-6001587 / Web-Site Address: / www.webbcountytx.gov
Primary Contact: / Cynthia Mares / Phone: / 956-523-4144
Proposed Effective Date: / 10/01/2009 / Proposal Due Date:

2. SUBMITTING AGENCY

Agency: / Wells Fargo Insurance Services USA, Inc.
Mailing Address: / 5151 Belt Line Road, Suite # 200, Dallas, Texas, 75254
Producer: / Robert S. Bookhammer III / e-mail: /
Phone: / (972) 588-6456 / Fax: / (972) 239-2919

3. COVERAGE REQUESTED

General Liability / Property / Equipment Breakdown
Public Officials Errors and Omission Liability / Equipment/Inland Marine
Law Enforcement Liability / Crime
Automobile Liability / Flood
Automobile Physical Damage / Earthquake
Excess Liability / Other:

4. OPERATING CONTROLS

1. / Yes / No / Are certificates of insurance required from your subcontractors?
If “Yes”, explain:
2. / Yes / No / Are you named as an additional insured on your subcontractors' liability policies?
3. / Yes / No / Does the entity have a formalized risk management procedure or program?
Do the formal procedures include the following:
Yes / No / Written Safety or Loss Prevention Manual
Yes / No / Employee training meeting
Yes / No / Property or equipment inspection and maintenance logs
Yes / No / Procedures to prevent & report sexual harassment
Yes / No / Accident investigation program
Describe any other formal or informal operating controls:

PART B PROPERTY RENEWAL APPLICATION

Please provide all values to be insured in an attachment

1. / Yes / No / Have the submitted property values increased for renewal?
2. / How are these renewal values determined?
Flat Percentage
Updated Appraisal
3. / Yes / No / Any loss payees or additional insured interests applicable at renewal to any properties?
If “Yes”, please list item # and interest:
4. / Yes / No / Any newly vacant property locations?
5. / Yes / No / Do you currently have any property in the “course of construction” or do you plan to have any new additions, renovations, or expansions?
If “Yes”, describe:
Cost of Construction:
6. / Yes / No / Have any occupancies changed for any currently insured locations?
If “Yes”, describe:

PART C INLAND MARINE RENEWAL APPLICATION

Please provide all values to be insured in an attachment

1. / What types of inland marine equipment are to be insured?
Contractor’s Equipment
Miscellaneous Tools and Equipment
Employee Tools
Leased, Rented or Borrowed Equipment
Other
2. / What Deductible is to apply to Contractor’s Type Equipment?
$250
$500
$1,000
$2,500
$5,000
Other / $10,000
3. / What Deductible is to apply to Miscellaneous Tools and Equipment?
$250
$500
$1,000
$2,500
$5,000
Other
4. / What Deductible is to apply to Employee Tools?
$250
$500
Other

PART D CRIME RENEWAL APPLICATION

1. / Yes / No / Are additional limits needed for any crime insuring agreement?
If “Yes”, please list insuring agreement and limit.
Insuring Agreement / Limit
2. / What Deductible is requested?
$500
$1,000
$2,500
$5,000
$10,000
Other
3. / What security provisions apply? / How Often?
Audit / Semi-Annually
Reconciliations / Monthly
Bank statements / Monthly
Countersignature
Other:

PART E AUTOMOBILE RENEWAL APPLICATION

Please provide an updated fleet schedule in an attachment

1. / Yes / No / Are all of the entity’s owned or leased vehicles to be insured under this policy?
If “No”, list vehicles insured elsewhere:
2. / Yes / No / Are Fire or Ambulance vehicles to be covered on an Agreed Amount basis for APD?
If “Yes”, note vehicle unit #s and requested values on submitted automobile schedule
3. / Yes / No / Any loss payees or additional insured interests applicable at renewal to any automobiles?
If “Yes”, please list auto # and interest:

PART F GENERAL LIABILITY RENEWAL APPLICATION

Indicate presence of each item by checking the appropriate box:

Operation / Exposure / Any Part of Operation
Subcontracted to
Others (Y/N)? / If Operated by proposed insured, provide the following additional information:
Yes / No
Aircraft, Airport and Related Facilities
Ambulance Services
Boat Docks or Marina
Bridges
Carnivals, Fairs, Parades
Cemetery Operations
Chemical Spraying – Pesticide/Herbicide
Dams, Reservoir or Levee / Updated Inspection Report(s)
Day Care, Day Camps, Day Nurseries / N
Electric Utility
Emergency Medical Services / N
Exhibit Hall or Meeting Area
Fire Department
Fireworks Exhibits
Garbage or Refuse Collection
Gas Utility
Golf Course / Y
Halfway Houses, Shelters, Group Homes
Health Care and Social Services
Hospital or Medical Clinic
Ice or Roller Rinks
Industrial Buildings for Redevelopment
Irrigation Ditches – Existence Hazard
Jails or Correctional Facilities / N
Lake or Reservoir
Landfills/Dumps/Refuse Sites/Incinerators / Y
Law Enforcement Activities / N
Liquor Sales
Nursing Homes
Parks and Playgrounds
Ports/Harbors/Terminal
Public Housing Authority
Rescue Squad
Sewage Collection Lines
Sewage Disposal Plant
School
Streets and Roads
Swimming Areas, Pool or Beach
Transit Operations
Vacant Land
Wastewater Operations
Watercraft > 100 Horsepower
Water Operations

NOTE: If any exposure is contracted, complete independent contractor listing in PART A.

PART F GENERAL LIABILITY RENEWAL APPLICATION Part F, Continued

1. / What deductible is requested? Note: Underwriters may require higher or lower deductibles than requested
If a deductible > $25,000 or self-insured retention is requested, mark as “other” and specify amount
$1,000
$2,500
$5,000
$10,000
$15,000
$25,000
Other
2. / How are deductibles to apply?
Loss Only
Loss and Loss Expense
3. / General Liability is rated on operating budget – how is the budget provided to OneBeacon?
Attached to this application
Link to website located here: www.webbcountytx.gov
4. / What is the payroll for water, sewer or irrigation operations? (Not required for city or county business)
Payroll includes remuneration paid to direct employees (except clerical office and executive officers), 100% of contract cost for leased employees, and 33% of total contract costs
5. / What expenditures are budgeted for “green initiatives”?
“Green initiatives” are expenditures associated with efforts to implement environmental sustainability.
Examples of eligible expenditures include community environmental sustainability education, recycling and composting programs, sustainability planning or similar operations undertaken to improve the physical environment.
6. / How many of each type of employee are to be included? Only required if Health Care Coverage is requested
# / Social Service Provider
# 5 / Jail Nurse
# / Nurse
# / Paramedic
# 2 / Emergency Medical Technician
# 50 / First Responder – Including Volunteers

PART G DAM, RESERVOIR OR LEVEE SUPPLEMENT

OneBeacon will specifically request if required for renewal

PART H PUBLIC OFFICIALS LIABILITY RENEWAL APPLICATION

Question # 2 is Not Required if provided under General Liability

2. / $ / What are the entity’s total budgeted expenditures?
$ / Are there budgeted items insured elsewhere?
$ / Are there any budgeted items for contracted operations?
$ / What are the “Green Initiative”* expenditures?
$ / What are the capital expenditures?
$ / What are the debt payments?
$ / Are any expenditures “pass through” fund transfers?
$ / *Green Initiatives are expenditures associated with efforts to implement environmental sustainability such as recycling or composting programs and community education.
3. / # / How many Board Members, Public Officials, Directors, or Officers?
# / How many Full-Time Paid Employees?
# / How many Part-Time Paid Employees?
# / How many Temporary or Seasonal Workers?
# / How many Volunteers? (do not include volunteer board members)
# / How long have the board members and management team served?
4. / % / What is the estimated employee turnover rate for the past year?
5. / # / How many involuntary employment terminations for the past year?
6. / # / Are any involuntary employment terminations planned for the upcoming year?
7. / Are there any outstanding disputes involving any of the following:
8. / Yes / No / Civil rights violations?
9. / Yes / No / Refusal of public service?
10. / Yes / No / Inadequacy of public service?
11. / Yes / No / Wrongful takings or condemnation proceedings?
12. / Yes / No / Approval of building plans or building specifications?

PART I LAW ENFORCEMENT LIABILITY RENEWAL APPLICATION

1. / What deductible is requested?
Note: Underwriters may require higher or lower deductibles than requested
If a deductible > $25,000 or self-insured retention is requested, mark as “other” and specify amount
Law Enforcement Wrongful Acts Coverage
$5,000 Loss and Loss Expense (Default amount)
$10,000 Loss and Loss Expense
$15,000 Loss and Loss Expense
$25,000 Loss and Loss Expense
Other
2. / What is the population served?
0 to 10,000
10,001 to 25,000
25,001 to 50,000
>50,000
3. / # / 173 / How many Full-Time Officers, armed and with full arrest authority?
# / 10 / How many Part-Time Officers, armed and with full arrest authority?
# / 93 / How many Full or Part-Time Officers, unarmed and with limited authority? 75 Full Time / 18 P/T
# / 49 / How many administrative employees? 29 Full Time / 20 Part Time
# / 6 / Number of Police Dogs?
# / 92,400 / Area in Square Feet of Holding or Detention Area?
4. / Yes / No / Is the law enforcement agency accredited by any professional organization or agency?
Texas Commission Law Enforcement Officers Standards & Education.
If Yes, by what agency? Texas Commissioner on Jail Standards.
5. / Are written policies established for the following?
Use of deadly force
Use of non-lethal force
Vehicle “hot pursuit”
Domestic violence
Handling of intoxicated persons
Outside employment (moonlighting)
Armed while off duty
Use of volunteers
6. / What type of detention facilities are operated?
Jail
Holding Facility
Juvenile Center
Other

PART J EXCESS LIABILITY RENEWAL APPLICATION

1. / Coverage is to apply over what underlying coverage?
General Liability
Law Enforcement Liability
Public Officials Errors and Omissions Liability
Commercial Automobile Liability
Employers Liability
2. / Excess Limit Requested:
Renewal Coverage will be issued as expiring unless otherwise requested
$1,000,000/$1,000,000 Aggregate
$2,000,000/$2,000,000 Aggregate
$3,000,000/$3,000,000 Aggregate
$4,000,000/$4,000,000 Aggregate
$5,000,000/$5,000,000 Aggregate
$6,000,000/$6,000,000 Aggregate
$7,000,000/$7,000,000 Aggregate
$8,000,000/$8,000,000 Aggregate
$9,000,000/$9,000,000 Aggregate
$10,000,000/$10,000,000 Aggregate
3. / Please provide updated Employers’ Liability carrier information:
Carrier:
Term:
Policy #:
Limits:

Minimum underlying limits required to schedule Employers’ Liability are $500,000 Each Accident/ $500,000 Disease per Employee/ $500,000 Disease Aggregate

4. / Excess Limits may be tailored to account requirements subject to OneBeacon underwriting approval:
Renewal Coverage will be issued as expiring unless otherwise requested
Yes No Are excess limits to apply above underlying Uninsured/Underinsured Motorists Limits?
Yes No Are excess limits to apply above underlying Pollution Coverage extensions?
Yes No Are excess limits to apply above underlying Failure to Supply Coverage?
Yes No Are excess limits to apply above underlying Sexual Abuse Coverage?

Arkansas Fraud Warning

Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information on an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

Colorado Fraud Warning

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.

Florida Fraud Warning

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.

Kentucky Fraud Warning

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.

Louisiana Fraud Warning

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.

Maine Fraud Warning

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 a denial of insurance benefits.