HomeMy WebLinkAboutRexburg Fall Fest CSQ501809105 GL Quote.pdfDate:
To:
From:
RE:
Quote number:
QUOTATION
We are pleased to present a quote for this risk. This quote is based on the information you submitted,
however the terms and conditions may differ from what was requested. Please review carefully.
Coverage to be provided by The Cincinnati Specialty Underwriters Insurance Company, an approved
non-admitted company.
08/23/2021
677 S Woodruff Ave
Idaho Falls ID 83401
Nick Gottschall
501809105
Archibald Insurance Center, Inc.
11-016
CSU Producer Resources, Inc.
A subsidiary of Cincinnati Financial Corporation
P.O. Box 145496, Cincinnati, OH 45250-5496
513-870-2000
Rexburg Life, LLC
Coverage:
Proposed Policy Period: From:
Quote Expiration:
To:
Description of Operations:Special Event
10/15/2021
09/15/2021 09/17/2021
Retroactive Date:NONE
Special Event Liability -
Limits of Insurance
Each Occurrence
Damage to Premises Rented to You
Medical Expense
Personal & Advertising Injury
General Aggregate other than Completed Operations
Products/Completed Operations Aggregate
Deductible Per Claim
Combined BI and PD
OCCURRENCE
$1,000,000
$100,000
$1,000
$1,000,000
$2,000,000
$2,000,000
$250
Payment Options:CSU offers both Agency Bill and Direct Bill payment methods. Listed below are the
payment methodsavailable to the insured.
CSIA 401 10 16 .Page of 1 4
Attached to Quote number:
Re:
Date of Quote:501809105 08/23/2021
Rexburg Life, LLC
Terrorism Risk Insurance Act
Other Taxes or Fees
Special Event/Flat Deposit Premium
Premium:
TOTAL
Agency Bill:
$
$
$
$
$
$
Broker Fee $
11.00
12.00
4.00
N/A
Surplus Lines Tax
750.00
812.00
35.00
Stamping Fee
Annual
$
$
$
$
$
$
$
Direct Bill:
Terrorism Risk Insurance Act
Other Taxes or Fees
TOTAL
Broker Fee
Special Event/Flat Deposit Premium 750.00
11.00
35.00
12.00
4.00
N/A
812.00
Surplus Lines Tax
Stamping Fee
Down-Payment*$ 812.00
*Down-Payment includes any fully earned or flat premiums,Broker Fee (where applicable),and all Surplus
Lines Tax and other state specific taxes or fees.Depending on the bind request date or length of the policy
term, the down-payment may include premiums from subsequent installments.
CSIA 401 10 16 .Page of 2 4
Attached to Quote number:
Re:
Date of Quote:501809105 08/23/2021
Rexburg Life, LLC
Provisions applicable to premium:
A.Premium is subject to annual audit:Yes No
B.Agency Bill Payment Terms:Premium is payable in full on the 15th of the month following the statement
month.If payment is not received by the15th of the month following the statement month,coverage will
be cancelled and may not be reinstated or may not be reinstated at the same terms and conditions.If
premium is financed and the finance company requests the company to cancelcoverage,the company
will honor that request.If the finance company subsequently requests the company to reinstate coverage,
the company,at its sole discretion, may not reinstate coverage or may reinstate coverage with a gap in
coverage terms or conditions.
C.Direct Bill Payment Terms:Payor is responsiblefor submitting the down-payment and any subsequent
installment reflected onthe billing invoice within 22 days from the invoice date.Subsequentinstallments
are subject t o change based on policychanges and/or billing charges.Please refer to BillingInvoice for
future installments.
D.Direct Bill Billing Charge:Thefollowing billing charges vary bystate and may apply up to $25 per
infraction:Non-Sufficient Funds (NSF)Charge,Rescission Charge,and/or Late Charge.Please refer to
the Disclosure of Direct Bill Charges form included with your invoicefor more information.
E.Minimum Earned Premium at Inception:%
Minimum earned premium is the minimum amount to be retained as premium if coverage is cancelled at
the insured’s request after coverage is bound with the company.
F.Minimum Premium is the lowest amount to be retained for the policy period.Minimum premium is equal
to % of the deposit premium.
G.Flat Premium:Any premium shown as a flat is fully earned and is notsubject to the minimum earned
premium.
H.Broker Fee:The broker fee is consideredaflat charge and fully earned and is not subject to the minimum
earned premium.
Forms and Endorsements:
Refer to Forms and Endorsements Schedule
Standard Terms and Conditions:
1.In compliance with TRIA,a signed disclosure statement and coverage selection form is requiredatthe
time coverage is bound.
2.Please advise if coverage is desired.Coverage is not bound until issuance of a policy number by the
company.
3.Commission:%
X
100
100
CSIA406
15
Additional Terms and Conditions and Remarks:
Authority to Issue Certificates of Insurance:
After coverage is bound with our prior approval, you may issue unmodified ACORD Certificates of
Insurance with an accurate representation of the coverage form and endorsements applicable to the
policy at the time you issue the Certificate. No modification to the ACORD Certificate of Insurance is
allowed without prior written approval from the company.
Certificates of Insurance do not amend, extend or alter policy coverage, terms or conditions in any
manner. Changes to the policy are permitted only with prior written approval by the company.
CSIA 401 10 16 .Page of 3 4
Attached to Quote number:
Re:
Date of Quote:501809105 08/23/2021
Rexburg Life, LLC
DISCLOSURE NOTICE OF TERRORISM INSURANCE
You are hereby notified that under the Terrorism Risk Insurance Act, as amended, that you have the right to
purchase insurance coverage for losses resulting from acts of terrorism, as defined in Section 102(1) of the
Act.
Certified Act of Terrorism
As defined in Section 102(1)of the Act, the term "act of terrorism" means any act that is certified by the Secre-
tary of the Treasury -in concurrence with the Secretary of State, andtheAttorney General of the United States
-to be an act of terrorism; to be a violent act or an act that is dangerous to human life,property, or infrastruc-
ture; to have resulted in damage within the United States,or outside the United States in the case of certain air
carriers or vessels or the premises of a United States mission; and to have been committed by an individual or
individuals 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.
Disclosure of Federal Participation in Payment of Terrorism Losses
You should know that where coverage is provided for losses resulting from certified acts of terrorism,such
losses may be partially reimbursed by the United States government under a formula established by federal
law.However, your policy may contain other exclusions which might affectyour coverage,such as an exclu-
sion for nuclear events. Under the formula, the United States government generally reimburses 85% of cov-
ered terrorism losses exceeding the statutorily established deductible paid by the insurance company provi d-
ing the coverage. The premium charged for this coverage is provided below and does not include anycharges
for the portion of loss that may be covered by the federal government under the Act.
You should also know that the Terrorism Risk Insurance Act,as amended, contains a $100 billion capthat lim-
its U.S. government reimbursement as well as insurers' liability for losses resulting from certified acts of terror-
ism when the amount of such losses in any one calendar year exceeds $100 billion. If the aggregate insured
losses for all insurersexceed $100 billion,your coverage may be reduced.
Disclosure of Premium
In accordance with the federal Terrorism Risk Insurance Act,we are required to provide you with a notice dis-
closing the portion of your premium, if any, attributable to coverage for acts of terrorism certified under that
Act.
The portion of your premium attributable to coverage for acts of terrorism certified under the Act is Excluded
plus applicable taxes and fees. This amount does not include any charges for the portion of losses covered by
the United States government.
REJECTION OF TERRORISM INSURANCE COVERAGE
You may choose to reject this offer of coverage for losses resulting from acts of terrorism as defined in the Act
by signing the statement below and returning it to your insurance producer.
Coverage Rejection -I hereby reject the offer to purchase coverage for certified acts of terrorism as defined
in the Act. I understand that I will have no coverage for losses resulting from such acts of terrorism.
Authorized Signature by Applicant Date
Print Name Named Insured
The Cincinnati Specialty Underwriters Insurance Company Policy Number
CSIA 401 10 16 .Page of 4 4
POLICY NUMBER:POLICY EFFECTIVE DATE:NAMED INSURED:FORMS APPLICABLEForms and Endorsements ScheduleCSIA 406 08 07PageofForms Applicable - Common FormsCSIA501 (07/14) Common Policy DeclarationsCSIA409 (01/08) Named Insured ScheduleCSIA410 (03/08) Notice to PolicyholdersCSIA417 (01/15) Cap On Losses From Certified Acts Of TerrorismCSIA448 (01/15) Policyholder Notice Terrorism Insurance CoverageCSIA403 (11/17) Special Provisions - PremiumCSIA404 (08/07) Service of SuitForms Applicable - Commercial General LiabilityCSGA501 (04/08) Commercial General Liability Coverage Part DeclarationsCSGA403 (10/07) Liability Premises ScheduleCSGA408 (04/08) Commercial General Liability Classification and Premium ScheduleCG0001TOC (04/13) Commercial General Liability Coverage Form Table of ContentsCG0001 (04/13) Commercial General Liability Coverage FormCSGA401TOC (02/13)Changes to Commercial General Liability Coverage Form Table of ContentsCSGA401 (02/13) Changes to Commercial General Liability Coverage FormCSGA4015 (12/11) Limitation of Coverage to Designated OperationsCSGA221 (06/18) Deductible Liability InsuranceCSGA3131 (09/12) Golf Carts and Golf Mobiles Exclusion - Special EventCSGA4069 (09/12) Limitations of Coverage - Contractors Vendors Exhibitors or Concessionaires - Special EventCSGA386 (12/11) Special Event Exclusion - Injury to Performer or CrewCSGA387 (12/11) Special Event Exclusion - Mechanical BullCSGA388 (12/11) Special Event Exclusion - Injury to Volunteer Workers 1 2Rexburg Life, LLC09/15/2021POLICY NUMBER:POLICY EFFECTIVE DATE:NAMED INSURED:FORMS APPLICABLEForms and Endorsements ScheduleCSIA 406 08 07Pageof 1 2Rexburg Life, LLC09/15/2021
POLICY NUMBER:POLICY EFFECTIVE DATE:NAMED INSURED:FORMS APPLICABLEForms and Endorsements ScheduleCSIA 406 08 07PageofForms Applicable - Commercial General LiabilityCSGA389 (12/11) Special Event Exclusion - Animal BiteCSGA391 (12/11) Special Event Exclusion - Abuse or MolestationCSGA392 (12/11) Special Event Exclusion - Amendment of Liquor LiabilityCSGA393 (05/20) Special Event Exclusion - Communicable Disease, Contagious Disease or Infectious DiseaseCSGA394 (03/16) Special Event Exclusion - Assault or BatteryCSGA396 (12/11) Special Event Exclusion - Amusement Ride or DeviceCSGA398 (12/11) Special Event Exclusion - Fireworks or PyrotechnicsCSGA399 (12/11) Special Event Exclusion - Silica or Silica-Related DustCSGA4023 (12/11) Special Event - Amendment of Insured Contract DefinitionCSGA395 (10/12) Special Event Exclusion - Participants and ContestantsCSGA390 (03/16) SPECIAL EVENT EXCLUSION - ALL-TERRAIN VEHICLES UTILITY TERRAIN VEHICLES SNOWMOBILES OR OTHER RECREATCSGA397 (04/19) Special Event Exclusion - Firearms or AmmunitionCSGA418 (06/08) Amendment of Pollutants DefinitionCSGA361 (06/08) Exclusion - Fungi or BacteriaCSGA439 (11/08) Amendment of Duties in the Event of Occurrence Offense Claim or Suit ConditionCG2147 (12/07) Employment-Related Practices ExclusionCG2149 (09/99) Total Pollution Exclusion EndorsementCSGA4019 (12/11) Additional Insured - Managers or Lessors of PremisesIL0017 (11/98) Common Policy ConditionsIL0021 (09/08) Nuclear Energy Liability Exclusion EndorsementCSLL348 (01/08) Limitation - No Stacking of Limits of InsuranceIL0003 (09/08) Calculation of Premium 2 2Rexburg Life, LLC09/15/2021
CSIA 434 02 13
The Cincinnati Specialty Underwriters Insurance Company
P.O. Box 145496
Cincinnati,OH 45250
AFFIDAVIT OF DILIGENT EFFORT (CSD 2001)
STATE OF POLICY #
COUNTY OF
I , whose Social Security Number is NOT APPLICABLE of
affirm that I have sought to obtain
(Agency Name)(Type of Coverage)
for
(Named Insured)
From:
1.(Authorized Insurer)(Telephone Number)
(Person Contacted) and the reason(s) for the declination by the
Insurer was (were) as follows:
2.(Authorized Insurer)(Telephone Number)
(Person Contacted) and the reason(s) for the declination by the
Insurer was (were) as follows:
3.(Authorized Insurer)(Telephone Number)
(Person Contacted) and the reason(s) for the declination by the
Insurer was (were) as follows:
It is further affirmed that the Insured was expressly advised in writing prior to placing the insurance that (1)the
surplus lines with whom coverage is being placed is not authorized to do business as an admitted carrier in
this State and (2); in the event of insolvency of the surplus lines insurer, the property and casualty guaranty
fund of the State will not pay losses under the surplus lines coverage form.
(Dated)(Signature of Producing Agent)
(Printed Name of Producing Agent)
ID
MADISON COUNTY
Archibald Insurance Center, Inc.General Liability
Rexburg Life, LLC
Commercial General Liability Premises Schedule
POLICY NUMBER:POLICY EFFECTIVE DATE:if Supplemental
Declarations Is Attached
NAMED INSURED:
LOC.ADDRESS
CSGA 403 10 07 Page of
X
1 23 S 1ST E
REXBURG ID 83440
1 1
Rexburg Life, LLC
09/15/2021
CommercialGeneralLiabilityClassificationandPremiumSchedulePOLICY NUMBER: POLICY EFFECTIVE DATE:NAMED INSURED: LOCCLASSIFICATIONCODEPREMIUMRATEDEPOSIT PREMIUMNO.NO.BASEA- AreaPremisesProducts/PremisesProducts/B- PayrollOperations andCompletedOperations andCompletedS- GrossSalesAll OtherOperationsAll OtherOperationsU-Units09/15/2021Rexburg Life, LLCSpecial Event - In Program120000U$750 InclCSGA408 04 08Page of 1 1