Okaloosa County BOCC — August 5, 2014 — Petroleum Storage Tank renewal documents — reading text

Krystal King From: Jo Amber DeZonno [jdezonno@policymanagers.com] Sent: Wednesday, July 23, 2014 1:18 PM To: Krystal King Subject: Okaloosa County Board of Commissioners - FPL 008084220 - 9/30/14 Attachments: 00317EE3.PDF Good Afternoon — Thank you for providing the documentation needed to invoice the above account. Our office has implemented an Auto- Renewal process and this policy written through Commerce & Industry Insurance fits these guidelines. ” Attached is the invoice for you to remit payment. As noted on the invoice, premium is due “prior to the expiration date to bind coverage. Upon receipt of the billed premium, our office will forward an electronic copy of the Policy & Certificate of Insurance. Please note: No Third Party checks will be accepted and the billed premium is due prior to the effective date. Checks should be made payable to: Policy Managers 317 Riveredge Blvd Suite 206 Cocoa, FL 32922 Should you have any questions, please feel free to contact our office. Thank you — JoAmber Dezonno Account Executive Policy Managers An Assured Partners, Inc. Member Firm 317 Riveredge Blvd, Suite 206 Cocoa, FI 32922 Ph: 321-213-6456 Direct *Fax: 321-433-1093 *Toll Free: 800-475-4055 Ext: 4051 JDezonno@policymanagers.com Success finds a way... failure finds an excuse AssuredPartners Storage Tank Third Party Liability & Corrective Action Insurance Important Reminder to PolicyManagers Clients: No Insurance can be bound by e-mail, and no changes in existing 1 Policy Managers’ A Division of Chamber Insurance Agency Services, LLC 317 Riveredge Boulevard, Sulte 206 ¢ Cocca, Florida 32922 # 800.475.4055 @ Fax: 321.433.1093 www.policymanagers.com Okaloosa County Board Of Commissioners 601 A North Pearl Street Ste 204 Crestview, FL 32536 DUE UPON RECEIPT. DETAGH THIS PORTION AND RETURN TO: POLICY MANAGERS® BILLED POLICY# COMPANY NAME POLICY TERM 7/23/14 008084220 Commerce And Industry Insurance Co. 9/30/14 9/30/15 INVOICE# DESCRIPTION PREMIUM DEPOSIT BALANCE 347480 Storage Tank Liability Ins. 10,313.00 .00 10,313.00 347480 FHCF Surcharge 134.09 .00 134.09 PLEASE REMIT PAYMENT 20 DAYS BEFORE THE EFFECTIVE DATE AMOLINE QUE Remit to: Policy Managers® ary. . A Division of Chamber Insurance Agency Services, LLC Visit our Web site at www.pollcymanagers.com 317 Riveredge Boulevard, Suite 206 ¢ Cocoa, FL 32922 Pol#: 008084220 Q#103048 14 Pol#: 008084220 Policy Managers® 317 Riveredge Boulevard, Suite 206 * Cocoa, Florida 32922 * 800.475.4055 * Fax: 321.433.1093 * www.policymanagers.com A Division of Chamber Insurance Agency Services, LLC 7/11/14 Okaloosa County Board Of Commissioners 601 A North Pearl Street Ste 204 Crestview, FL 32536 Re: AIG Environmental TankGuard® Program Applicant: Okaloosa County Board Of Effective Date: 9/30/14 Dear Sir (Madam) : Thank you for allowing Policy Managers® to provide terms for coverage under AIG Environmental TankGuard® Program. Having carefully reviewed your submission, we are pleased to offer the enclosed Premium Indication for a policy underwritten by Commerce and Industry Insurance Company. The enclosed Indication is based on the information contained in your submission, and may require that you submit certain additional informa- tion to us for approval prior to our binding coverage on your behalf. Moreover, this Indication could be subject to change or withdrawal, depending on the content of the information provided. We recommend that you immediately review this Indication in its entirety to determine whether any additional information is required. If so, we encourage you to submit it to us immediately. eky See ate SBwRS Orang Gena Gardner Assistant Vice President (321) 433-4049 ggardner@policymanagers.com Enclosures Commerce And Industry Insurance Company Q#103048 14 Indication - 14 AIG SUB.# 000000000 Pol#: 008084220 Prepared Especially For Okaloosa County Board Of The following is our premium indication for the storage tank system listed below. Coverage for Storage Tank Third Party Liability, Corrective Action and Clean-up Costs is offered using Commerce and Industry Insurance Company Form #81106(08/09) with the appropriate endorsements listed below. Coverage is offered on a Claims Made and Reported Basis. Policy Dates: From: 9/30/14 To: 9/30/15 Retroactive Date: See Schedule Commission Rate: Covered Storage Tank Systems Locations: See Schedule Attached Opt . Limits of Liability Deductible Annual State (Fa Incident/Agg. ) (Ea Incident) Premium Surcharges 001 1,000,000/ 2,000,000 10,000 10,223 132.86 * 1.23 ** All premiums are fully earned upon tank removal. There will be no credit for midterm removal. * State Surcharges are in addition to the annual premium and are assessed when covered locations are within the states of KY, WV, NJ, FL and/or OR. ** This is the additional State Surcharge premium if TRIA is accepted. Payment of surchages is expected along with the annual premium at binding of coverage. The premium amount(s) stated above does not include the premium for Terrorism Risk Insurance Act Coverage. Please see the attached Disclosure Statement regarding Terrorism Risk Insurance Act Coverage and the premium for such coverage. In the event that you choose to purchase TRIA Coverage along with one of the options above, the total premium shall be the premium shown above for the option chosen plus the TRIA Coverage premium shown on the attached Disclosure Statement for that option. Coverage Forms and Endorsements: - Storage Tank Policy 81106 (08/09) - Storage Tank Declarations Page 81206 (08/09) - Table of Contents 83115(10/03) - Site Schedule 81029(02/13) - Schedule of Coverage Storage Tank Systems 81017(10/02) - Separation of Insureds Endorsement 81026 (06/10) - Notice of Loss/Notice of Claim 91968(12/06) CI2940 - Gaining the Ultimate Value-Added Advantage Thgh AIG 111209(7/13) - Economic Sanctions Endorsement 89644 (06/13) - 76105(06/10) Florida Cancellation/Nonrenewal Endorsement - 83111(05/10) Florida Amendatory Endorsement - 74825(08/09) Florida Addendum To The Declarations - 90231(08/13) Florida Notice of Loss Control Services Q#103048 14 Pol#: 008084220 This indication is subject to the following, prior to binding: - Written request to bind - Signed TRIA Disclosure Statement (if Insured is rejecting coverage - If TRIA Coverage is rejected, then Certified Acts of Terrorism Exclusion Endorsement 81309(2/03) will be attached. - If TRIA Coverage is accepted, the Limitation of Loss for Certified Acts of Terrorism 81290(12/02) will be attached. NOTICE: PLEASE READ CAREFULLY THE ATTACHED POLICYHOLDER DISCLOSURE STATE- MENT UNDER TERRORISM RISK INSURANCE ACT OF 2002. THE INSURED REPRESENTS AND WARRANTS THAT AN OFFICER OF THE INSURED SHALL COMPLETE, SIGN AND RETURN SUCH DISCLOSURE STATEMENT TO THE COMPANY WITHIN 30 DAYS OF THE DATE OF BINDING THIS INDICATION, IF CERTIFIED ACTS OF TERRORISM COVERAGE UNDER TRIA OF 2002 IS REJECTED BY THE INSURED AND THAT THE INSURED OR ITS BROKER SHALL ADVISE THE COMPANY ELLECTRONICALLY THROUGH THE E-TANK SYSTEM OF SUCH REJECTION PRIOR TO BINDING. HOWEVER, IF SUCH COVERAGE IS ACCEPTED BY THE INSURED, THE BROKER MUST ADVISE THE COMPANY IN WRITING ELLECTRONICALLY THROUGH THE E-TANK SYSTEM PRIOR TO BINDING, THE COMPANY SHALL RELY UPON THIS REPRESENTATION AND WARRANTY IN THE ISSUANCE OF ANY BINDER ISSUED RELATED TO THIS INDICATION. All submitted information is subject to underwriter approval. Federal and/or state required Storage Tank Certificates of Financial responsibility. 40 CFR 280.97 or state equivalent will also be included when the policy is issued. This indication is valid for 30 days from the date of this letter if new business, or if a renewal, until the proposed policy inception date shown above. If you have any questions regarding this indication, please contact the program specialist shown below eky See ae: SEGRE Orang Gena Gardner Assistant Vice President (321) 433-4049 SCHEDULE OF COVERED STORAGE TANK SYSTEMS QO#103048 14 Pol#: 008084220 Location Address UST/ Capacity Install Retro AST Capacity Year Date Okaloosa Cnty-Road Dept 84 Ready Ave NW Fort Walton Beach, FL 32548 AST 12,000 2003 1/01/03 AST 12,000 2003 1/01/03 Okaloosa Cnty-Road Dept 1759 S Ferdon Blvd Crestview, FL 32536 AST 10,000 1995 1/01/95 AST 10,000 1995 1/01/95 AST 10,000 1996 1/01/96 AST 10,000 1996 1/01/96 Dept Of Buildings 1250 Eglin Pky Shalimar, FL 32579 AST 2,000 2006 8/24/10 Okaloosa Regional Airport Hwy 85 Eglin AFB, FL 32542 AST 1,070 2004 11/07/06 AST 1,070 2004 11/07/06 AST 20,000 2009 12/08/09 AST 20,000 2009 12/08/09 AST 20,000 2009 12/08/09 AST 20,000 2009 12/08/09 AST 25,000 2009 12/08/09 AST 25,000 2009 12/08/09 AST 1,500 2009 12/08/09 Okaloosa Cnty-Dept Of Corrections 1200 James Lee Blvd Crestview, FL 32539 AST 750 1992 1/01/92 Okaloosa County Conference Ctr 1250 Miracle Strip Pkwy Ft Walton Beach, FL 32548 AST 710 2003 1/01/03 Garniers Waste Water Treatm Fac 714 Essex Road Ft Walton, FL 32547 AST 500 2000 3/22/05 AST 10,000 1994 7/17/12 AST 1,000 2003 7/17/12 Golf Course Site 1955 Lewis Turner Blvd Ft Walton Beach, FL 32547 AST 500 1994 7/17/12 AST 500 1994 7/17/12 AST 500 1994 7/17/12 Fire Dept Site (Station 7) 1968 Lewis Turner Blvd Ft Walton Beach, FL 32547 AST 500 1994 7/17/12 Bob Skkes Airport Fire Pumping Fac 5759 John Givens Rd Crestview, FL 32539 AST 750 1998 7/09/13 Okaloosa Co Water & Sewer Admin 1808 Lewis Turner Bivd Ft Walton Beach, FL 32547 AST 2,000 2001 7/09/13 Island Main Pump Station 105 Santa Rosa Blvd Ft Walton Beach, FL 32548 AST 1,750 2013 7/09/13 Q#103048 14 POLICYHOLDER DISCLOSURE STATEMENT UNDER Pol#: 008084220 TERRORISM RISK INSURANCE ACT OF 2002 You are hereby notified that under the federal Terrorism Risk Insurance Act of 2002 (the “Act”) effective November 26, 2002, you now have a right to purchase insurance coverage for losses arising out of an Act of Terrorism, which is defined in the Act as an act certified by the Secretary of the Treasury (i) to be an act of terrorism, (ii) to be a violent act or an act that is dangerous to (A) human life; (B) property or (C) infrastructure, (iii) to have resulted in damage within the United States, or outside of the United States in case of an air carrier or vessel or the premises of a U.S. mission and (iv) to have been committed by an individual or individuals acting on behalf of any foreign person or foreign interest, as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. You should read the Act for a complete description of its coverage. The Secretary's decision to certify or not to certify an event as an Act of Terrorism and thus covered by this law is final and not subject to review. There is a $100 billion dollar annual cap on all losses resulting from Acts of Terrorism above which no coverage will be provided under this policy and under the Act unless Congress makes some other determination. For your information, coverage provided by this policy for losses caused by an Act of Terrorism may be partially reimbursed by the United States under a formula established by the Act. Under this formula the United States pays 90% of terrorism losses covered by this law exceeding a statutorily established deductible that must be met by the insurer, and which deductible is based on a percentage of the insurer's direct earned premiums for the year preceeding the Act of Terrorism. Unless you sign this form and return it to us rejecting Terrorism Coverage under the Federal Act, you will be covered for Terrorism as defined in the Act and your premium for that coverage is based upon which coverage option you choose (Coverage options setting forth limits, policy term, etc. are set forth in the attached letter of indication). Option 1 Terrorism Act Premium: $90 COMMERCE & INDUSTRY INS CO Return to: Policy Managers® NAMED