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Res 21-16 Awarding Property/Casualty Services to Box Insurance for FY 21-22
WESTLAKE ACADEMY RESOLUTION NO.21-16 A RESOLUTION OF THE WESTLAKE ACADEMY BOARD OF TRUSTEES AWARDING THE BID FOR PROPERTY/CASUALTY INSURANCE PRODUCTS AND SERVICES TO BOX INSURANCE AGENCY FOR FY 2021-2022. WHEREAS, Westlake Academy desires to maintain a comprehensive risk management program for the protection of its property, students, employees, elected officials, and stakeholders; and, WHEREAS, the leaders of Westlake Academy desire to exercise exceptional levels of stewardship with all financial resources; and, WHEREAS, the Board of Trustees finds that the passage of this resolution is in the best interest of the citizens of Westlake as well as the students, their parents, and faculty of Westlake Academy. NOW, THEREFORE, BE IT RESOLVED BY THE BOARD OF TRUSTEES OF WESTLAKE ACADEMY: SECTION 1: that the Board of Trustees of Westlake Academy does hereby award the recommended bid for property/casualty insurance products and services to Box Insurance Agency for FY 21-22, attached hereto as Exhibit "A"; and further authorize the Superintendent or designee to execute this agreement. SECTION 2: that, all matters stated in the recitals hereinabove are found to be true and correct and are incorporated herein by reference as if copied in their entirety. SECTION 3: If any portion of this resolution shall, for any reason, be declared invalid by any court of competent jurisdiction, such invalidity shall not affect the remaining provisions hereof and the Council hereby determines that it would have adopted this resolution without the invalid provision. SECTION 4: That this resolution shall become effective from and after its date of passage. Resolution WA 21-16 Page 1 of 3 Exhibit "A" Recommended Bid — Box Insurance Coverage Commercial Property- Crum Forster General Liability — Utica Business Auto — Utica Umbrella ($5,000,000) — Utica Crime - Travelers Workers Compensation - Travelers International Travel — CHUBB Student Accident Policy — AJF/Philadelp Cyber Liability Total Expiring Premium $ 91,995 $ 14,461 $5,029 (4 Autos) $ 7,138 $ 2,850 $ 25,924 $ 2,000 hia $ 5,943 $400 $155,845.00 Renewal Premium $ 103,995 $ 15,347 $ 5,029 (4 Autos) $ 7,505 $ 2,850 $ 18,492 $ 2,000 $ 5,943 $400 $161,926.00 Resolution WA 21-16 Page 3 of 3 PASSED AND APPROVED ON THIS 9TH DAY OF AUGUST 2021. ATTEST: 4641� Todd Wood, Board Secretary APPROVED AS TO FORM: C� Janet S. B bert or L. Stanton Lowry, School Mtorney J A r La ra Wheat, President hX4 " ) Ca 4, Amanda DeGan, Superintendent Resolution WA 21-16 Page 2 of 3 AN INSURANCE PROPOSAL PREPARED FOR: Westlake Academy 1500 Solana Blvd Building 7, #7200 Westlake, TX 76262 PRESENTED BY: Dustin Parker & Adam Syswerda BOX INSURANCE AGENCY 1200 S. MAIN STREET, STE. 1600 Grapevine, TX 76051 August 31, 2021 DISCLAIMER - The abbreviated outlines of coverages used throughout this proposal are not intended to express any legal opinion as to the nature of coverage. They are only visuals to a basic understanding of coverages. Please read your policy for specific details of coverages. This proposal does not constitute a binder of insurance. Coverage may be bound based on the terms outlined and chosen by signing and dating on the last page of this proposal. 0 9101909. BOX INSURANCE - AC � G E''<C Y 2021-2022 Westlake Academy Proposal Submittal Format 1. Box Services 2. Index 3. Questionnaire 4. Property 5. General Liability: (Education Liability Package Included) 6. Auto 7. Umbrella 8. Crime 9. Workers Compensation 10. International Travel 11. Student Accident 12. Cyber Liability 13. Premium Summary 14. Required Documents a. Agent Current License b. Copy of E&O Certificate of Insurance c. Completed and Signed Felony Conviction Notice Form d. Completed and Signed Non -Collusion Certification Form e. Completed and Signed Conflict of Interest Questionnaire f. Completed and Signed W-9 Form g. Completed and Signed Form 2270 1200 S. Main Street, Suite 1600 1 Grapevine, TX 76051 1 Phone: 817-865-1801 1 www.boxinsurance.com WESTLAKE ACADEMY REQUEST FOR PROPOSAL PROPOSAL FOR: Property, Liability, Umbrella, Workers Compensation, Auto, and Student Accident Insurance POSTED DATE: July 9, 2021 EFFECTIVE DATES: September 1, 2021 to August 31, 2022 PROPOSAL DUE DATE: August 2, 2021 PROPOSAL DUE TIME: 12:00 p.m. CST CONTACT: Sandy Garza, Purchasing Agent E-mail: sgarzaAwestlake-tx.org Electronic proposals subject to the Terms and Conditions of this REQUEST FOR PROPOSAL and other provisions, must be received by the Purchasing Agent at sgarza(a,west1ake-tx.or1! before the closing time and date shown above. The Town will retain late bids; however, they will not be opened nor considered in the evaluation of the bid. Bids may be withdrawn at any time prior to this deadline. Bids may not be altered, amended, or withdrawn after the official opening without the recommendation and approval of the Purchasing Agent. The undersigned agrees if the bid is accepted, to furnish any and all items upon which prices are offered, at the price(s) and upon the terms and conditions contained in the specifications. The period for acceptance of this proposal shall be 60 calendar days. THE UNDERSIGNED, BY SIGNING BELOW, YOU SIGNIFY THAT YOU HAVE READ THE ENTIRE DOCUMENT AND AGREE TO THE TERMS AND CONDITIONS THEREIN. BY SIGNING BELOW, YOU ALSO CERTIFY THAT IF A TEXAS ADDRESS IS SHOWN AS THE ADDRESS OF THE PROPOSING VENDOR, THE VENDOR QUALIFIES AS A TEXAS "RESIDENT BIDDER" AS DEFINED IN RULE 1 TAC 111.2. Company Name and Address: Company's Authorized Agent Box Bonding LLC, Dba Name and Title (Typed or Printed): Box Insurance Agency Adam Syswerda, Vice President Signature 1200 S. Main St. Suite 1600 Grapevine, TX 76051 Federal ID Number (TIN) or SSN and Name 75-2835423 Telephone No. 817-865-1806 Date: August 2, 2021 Fax No.: 817-424-1404 Email address: adam@boxinsurance.com Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 1 of 39 Request for Proposal — Westlake Academy Property, Liability, Umbrella, Workers Compensation, and Student Accident Insurance Table of Contents...............................................................2 Acknowledgement of Receipt....................................................3 Questionnaire....................................................................4 General Requirements and Instructions.......................................5 Policy Requirements and Limits...............................................8 Property Insurance, Fire and Extended Equipment Coverage .........8 General Liability, EPLI, EBLI, ELLI, D&0 Insurance ...............10 Automobile and Physical Damage Insurance ...........................12 Umbrella Liability Insurance.............................................14 Crime Insurance.............................................................16 Workers Compensation Insurance.........................................18 International Travel Insurance.............................................20 Student Accident Insurance..................................................22 Cyber Liability Insurance.................................................24 Proposal Submittal Format....................................................26 Exhibit "A" - Property Schedule.............................................27 Felony Conviction Notice Form..............................................28 Non -Collusion Statement......................................................29 Conflict of Interest Questionnaire...........................................30 W-9 Form.......................................................................32 Form2270.......................................................................38 LossRuns........................................................................39 Westlake Academy - FY21122 Comprehensive Insurance RFP Page 2 of39 ACKNOWLEDGEMENT OF RECEIPT THIS FORM MUST BE COMPLETED AND RETURNED PRIOR TO THE SUBMISSION OF ANY BID FOR THIS REQUEST FOR PROPOSAL. Please fill in the requested information below as acknowledgement that you have received the Request for Proposal noted above. If your firm is interested in participating, please complete pages three and four (3 and 4) and return by email by July 30, 2021 to: Sandy Garza Westlake Academy sgarza@westlake-tx.org Name of Firm: Box Bonding Agency, LLC dba Box Insurance Agency Address: 1200 S. Main St. Suite 1600 City/State/Zip: Grapevine Texas 76051 Phone: ( 817 ) 865-1806 Fax: ( ) E- Mail:adam a(-boxinsurance.com Name: (Print) Adam Syswerda Title: Vice President Signature: Date:7/14/21 X Yes, our company does have an interest in responding. No, our company does not have an interest in responding. Westlake Academy - FY21122 Comprehensive Insurance RFP Page 3 of39 QUESTIONNAIRE 1. Who will have primary responsibility for Westlake Academy's account? Paul Fredette a. Number of years in the insurance business: 25 b. Insurance background: President of 3 different agencies, Practice leader at Marsh & McLennan c. Number of schools or public entities serviced: 7 2. Who will be the back-up person for Westlake Academy's account? Adam Syswerda a. Number of years in the insurance business: _8 b. Insurance background: Vice President, Box Insurance Agency c. Number of schools or public entities serviced: 7 3. Westlake Academy will expect the following annual reports from its agents: a) Summary of premiums and losses by coverage. b) Forecast of insurance market status prior to renewal. c) Insurance policy abstracts (summaries). d) Prior to future renewals, report containing suggested coverage or rating enhancements for the upcoming year. e) Following future renewals, a report detailing all material policy changes. f) Risk management services. 4. Please attach a copy of the following documents: a) A copy of the current license. b) A certificate for agent's error and omission coverage insured for at least $1 million limit. Westlake Academy - FY21/22 Comprehensive Insurance RFP Page 4 of 39 General Requirements and Instructions A. Information 1. The information contained in these specifications is confidential and is to be used only in connection with preparing a proposal for the following insurance services or insurance coverages: Commercial Property - Fire & Extended Coverage Commercial General Liability School Professional Liability Auto Liability & Physical Damage Workers' Compensation Commercial Umbrella Liability Crime International Travel Liability Student Accident Liability Cyber Liability 2, The effective dates of the policy period for all proposals will be from September 1, 2021 through August 31, 2022. 3. Westlake Academy reserves the right to accept or reject all or any part of the proposals, waive minor technicalities, and award the proposal to best serve the interest of the Academy. The Academy also reserves the right to waive or dispense with any of the formalities contained herein. 3. Proposals are to be submitted on the basis of the specifications contained herein. Alternate proposals will also be considered, provided the alternatives are clearly explained. All deviations from the specifications must be clearly identified and explained. 4. The information contained in these specifications is to be basis for proposal responses. After receipt of proposal, additional information needed may be requested via e-mail at: sgarza@westlake-tx.org, 5. The information contained herein is believed to be accurate and up-to-date but is not intended to be an express or implied warranty. 6. No telephone, or fax, or e-mailed proposals will be accepted, Proposals may only be accepted if delivered by email to sgarzagwestlake-tx.org, 7. Vendors are cordially invited view the opening of received proposals but are not required to attend. A link will be posted on the Town of Westlake Bidding page no later than July 9, 2021. Advertisements will be posted for two (2) weeks in the Town's newspaper of record (Fort Worth Star -Telegram) on July 11, 2021 and July 18, 2021. B. LEGAL 1. All parties submitting proposals are expected to comply with federal, state and local insurance laws and regulations relative to the preparation and submissions of insurance proposals. Specifically, the services to be provided are expected to be in compliance with the Americans with Disabilities Act (ADA), insurance laws and insurance regulations. All proposals that are submitted will be presumed to be in compliance with all applicable laws. C. COMMUNICATION 1. Proposals should reference `RFP 21-001 - Westlake Academy Property & Liability Insurance". Proposers should direct any inquiries or questions to: Sandy Garza Westlake Academy sgarza@westlake-tx.org 2. Proposers must provide proposals by the deadline to: Sandy Garza Westlake Academy 1500 Solana Boulevard, Bldg. 7, Ste. 7200 - Westlake, Texas 76262 Westlake Academy - FY21122 Comprehensive Insurance RFP Page 5 of 39 D. COMMUNICATION WITH TOWN OF WESTLAKEIWESTLAKE ACADEMY MEMBERS Companies submitting proposals shall not discuss this RFP with employees of the Town of Westlake, Westlake Academy or members of the Town Council/Board of Trustees. If discussion is necessary, your company will be notified in writing. Failure to abide by this requirement may result in automatic disqualification. E. TIME FRAME 1. The RFP package will be available for download from our website at http://www.westiake-tx.org. Vendors WILL NOT be notified of additional information/addenda postings. It is the vendor's responsibility to view the web page regularly, or prior to submitting a proposal response, to ensure that no addenda or additional information have been issued for the solicitation. 2. Proposals: must be delivered electronically via email to sgarza@westlake-tx.orq, or a printed copy of proposal to 1500 Solana Boulevard, Bldg. 7, Ste. 7200 • Westlake, Texas 76262 by the deadline no later than 12:00 p.m., Monday, August 2, 2021. 3. The parties submitting the selected proposals will be notified by August 9, 2021 of the Academy's decision. 4. The effective date for proposals is September 1, 2021. 5. Policies or coverage documents are to be provided to the Academy by October 1, 2021. The Academy reserves the right to not pay any premium until valid policies or coverage documents are received. F. PROPOSALS 1. Proposals must be clearly explained and identified. All costs, including optional programs, must be clearly separated and summarized, Exceptions to or deviations from the specifications must be explicitly identified. 2. Each party submitting a proposal is asked to screen their designated proposals for correctness and compliance with the specifications. 3. The contents of the proposals shall be kept confidential during the process of review. G. DISQUALIFICATION AND REJECTION OF PROPOSALS 1. Failure to comply with the requirements or the procedures set forth herein, or to satisfy the insurance and servicing criteria as set forth in the specifications, may result in disqualification. It is not intended that these exceptions to the specifications will, in and of themselves, result in disqualification. H. SELECTION OF VENDOR 1. Westlake Academy reserves the right to reject any or all of the proposals, in whole or in part; to waive any informality in any proposal, and to accept the proposal which, in its discretion, is in the best interest of the Academy. An Academy insurance consultant may review proposals for completeness and for compliance with bid specifications. Proposals will be carefully evaluated for cost effectiveness, for coverage provisions, and for compliance with the coverage and servicing criteria contained in the specifications and in accordance with Texas Education Code 44.031 and any other pertinent laws. 2. The contract will be awarded to the responsible vendor who submits a superior but economical proposal based on the relative importance of the following selection criteria: Selection Criteria Maximum Points Coverage 35 Cost 35 Professional Qualifications 15 Service 15 Total 100 Westlake Academy - FY21/22 Comprehensive Insurance RFP Page 6 of 39 I. TERMS OF AGREEMENTS 1. Westlake Academy desires to receive proposals for a one (1) year period, beginning on September 1, 2021 through August 31, 2022. 2. Westlake Academy reserves the right to terminate the agreement at the expiration of the budget period, during the term of the agreement or at the end of the anniversary date with a sixty (60) day notice. The agreement will be for current revenues only in accordance with Local Government Code Section 271.903 to terminate the agreement. 3. The agreement is to contain a cancellation provision that provides for a sixty (60) day notice of cancellation (except for non-payment) and sixty (60) days a for non -renewal or material change. J. QUALIFICATION OF INSURERS 1, Insurance companies must have a general policyholder's rating of A- VII or better as published by A.M. Best Company in the latest edition of its Key Rating Guide. Insurers shall be duly licensed and comply with all applicable insurance laws and requirements of the Texas State Board of Insurance. 2. Proposals will be accepted for intergovernmental risk sharing pools organized in accordance with article 4413(32c), Texas Interlocal Cooperation Act. Self -insured pools must include a current audited financial statement (Balance Sheet and Statement of Operations, including the auditor's opinion, and Reinsurance Provisions.) K. AGENT MINIMUM QUALIFICATIONS All agents submitting proposals for this insurance must meet the following minimum qualifications: 1. The agency must be licensed in Texas. 2. The agency must have insurance for agent's errors and omissions liability with a limit of at least $1 million per occurrence. A certificate of the agent's E&O insurance must be included with the proposal. 3. The agency must have been in business for at least five (5) years. 4. The agency must assign a minimum of one qualified account representative. This representative must have a minimum of three (3) years of experience in commercial property and liability insurance lines or hold the C.P.C.U. or A.R.M. designation. L. AUTHORIZED SIGNATURE 1. All proposal forms must be signed by persons who have legal authority to bind the insurer and administrator to the services that are proposed. M. Policy Requirements and Limits 1. All proposals must adhere to the specifications and limits as defined on the following pages for each insurance product. Any deviation or additional coverage(s) should be clearly explained. If the quote contains higher limits than specified, it should be listed separately as an alternate quote. Westlake Academy - FY 21/22 Comprehensive Insurance RFP Page 7 of 39 PROPERTY, FIRE, AND EXTENDED EQUIPMENT INSURANCE A. BACKGROUND INFORMATION 1. Please contact Purchasing Agent at sgarza@westlake-tx.org for loss runs. 2. Schedule of Buildings and Contents limits are located on page 25 as Exhibit "A". 3. Summarized property schedule with estimated replacement cost (limits), including desired deductibles and coinsurance as of September 1, 2021 is as follows: Description Limit Deductible Coinsurance Building Physical Property $ 46,505,600 $ 5,000 100% Building Personal Property $ 4,860,000 $ 5,000 100% Business Income and Extra Expense: $ 484,000 Total Property Limits $ 51,848,600 Note: Blanket Coverage at full replacement cost is required for all property quotes. B. Insurance coverage is to include the following: 1. Blanket coverage on all buildings, contents and auxiliary structures including on -site improvements. 2. Basis of Recovery is to be full replacement cost. 3. Automatic coverage on newly acquired property is to be included. 4. Coverage is to include extra expense and loss of revenue related to loss. 5. Coverage is to be for all risk, including theft of contents. 6. Quotes should include deductibles of $5,000 with 100% coinsurance. Deductibles for wind, hail, earthquake, and floods should be $50,000 or less with 100% coinsurance, if available. In the event a $50,000 wind/hail deductible (or lower) is not available, the lowest deductible available should be quoted as a percentage. 7. Wind and hail deductibles may be accompanied by a "buy -down" reinsurance policy. This policy should be shown separately from the primary policy, including premiums. 8. Include a listing of endorsements, extensions, and exclusions. C. Quoted Coverage Provisions 1. Description Limit Deductible Coinsurance Building Physical Property $ 46,505,600 $10,000 Agreed Value Building Personal Property $ 4,860,000 $10,000 Agreed Value Business Income and Extra Expense: $ 485,000 24 hours Agreed Value 2. Is automatic coverage for newly acquired property provided: ® Yes ❑ No If yes, please attach description. 3. Does coverage include equipment breakdown? it Yes ❑ No If yes, please attach description. 4. Is there additional deductible or exclusion for wind, hail or earthquake? IJ Yes ❑ No If yes, please attach description and/or provide additional proposal to cover this risk. D. Quotation 1. Property, Fire, and Extended Equipment Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ 103,995 2. Alternate Property, Fire, and Extended Equipment Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 8 of 39 E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: The North River Insurance Company A. M. Best Rating/Size: A XIV Insurance Company: ® Yes ❑ No Risk Pool: ❑ Yes ❑ No For Alternate Quote(s): Name of Company: _ A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Wind/Hail Deductible is the greater of $100,000 or 2% Flood Limit is $5,000,000 with a $50,000 deductible Earthquake Limit is $5,000,000 with a $50,000 deductible Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 9 of 39 GENERAL LIABILITY INSURANCE A. BACKGROUND INFORMATION 1. All coverage in Section "B" must be included. Please contact Purchasing Agent at sgarzaC@westlake-tx.orq for loss runs. 2. Estimated student count is 880. Grades K-8: 555 Grades 9-12: 325 3. Estimated number of full-time equivalent employees is 108. Total employees (including substitute teachers) is approximately 165. 4. Sports programs include: Football, basketball, volleyball, baseball, softball, track, cross country track, tennis, golf, softball, cheerleading, and soccer. B. Insurance coverage should include the following: 1. Incidental medical malpractice coverage for registered nurses administering first aid, dispensing prescribed medications, and maintaining students' health immunization records. 2. Coverage for the negligent act, error or omission of the Academy and/or its employees relative to the administration of employment practices and employee benefit programs. 3. Coverage is to include premises liability. 4. Persons to be covered are to include the Academy, school board members, employees, student teachers, school volunteers, or any authorized agent as designated by the Academy. 5 If coinsurance is quoted as an alternative to deductible, please list this figure separately. 6. Include a listing of coverage extensions, endorsements and exclusions. 7. If EPLI, EBLI, ELLI, and D&O coverage is not automatically included, please provide separate quote(s). These are required components of the liability coverage policy. Per Occurrence Aggregate Deductible General Liability $ 1,000,000 $ 2,000,000 $0 Products/Completed Operations $ 1,000,000 $ 2,000,000 $0 Personal & Advertising Injury $ 1,000,000 $ 1,000,000 $0 Damage to Rented Premises. $ 1,000,000 $ 1,000,000 $0 Medical Expenses $ 10,000 $0 Employee Benefits Liability $ 1,000,000 $ 3,000,000 $1,000 Abuse & Misconduct Liability** $ 1,000,000 $ 1,000,000 $0 Educators Legal Liability* ** $ 1,000,000 $ 2,000,000 $10,000 Professional Liability — D&O* ** $ 1,000,000 $ 2,000,000 $10,000 Employment Practices Liability* ** $ 1,000,000 $ 1,000,000 $10,000 * Retention shown as Deductible ** Retroactive Date 8/31/11 C. Quoted Coverage Provisions 1. Coverage Detail Per Occurrence Aggregate Deductible General Liability $nnn.nnn $ $0 Products/Completed Operations $1,000,000 $ 2,000000-- ,$0 Personal & Advertising Injury $1,000,000 $ 1 nnn.noo $0 Damage to Rented Premises $1,000,000 $ 1 oon n00 To Medical Expenses $in,nno $n Employee Benefits Liability $1,000,000 $ 3,000,000 $1,non Abuse & Misconduct Liability $1,000,000 $ 1,000,000 $0 Professional Liability — D&O $1,000,000 $ 2,000,000 $10,000 Educators Legal Liability $1,000,000 $ 2,000,000 $10,000 Employment Practices Liability $1,000,000 $ 1,000,000 $10,000 Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 10 of 39 2. Please respond to the following questions as they relate to the Professional Legal Liability coverage proposed. Please specify if there are any SUB -LIMITS, otherwise it will be assumed full policy limits are available: a. Who are the "covered persons" or "named insureds?" b. Is Prior Acts coverage provided? If so, what is the retroactive date? c. Is corporal punishment/student discipline covered? d. Describe the terms available for "Extended Reporting/Discovery Period" coverage available when either the insured or insurer cancels or non -renews? How long is the reporting period and what is the cost? e. Does the policy cover non -pecuniary relief? If so, are there any sub -limits for either defense costs or damages? If sub -limits apply, please stipulate. f. Are board members/employees covered as they serve on other boards within the course and scope of their employment (i.e., would coverage extend to a superintendent as he/she served on a Special Education Cooperative)? g. Are claims alleging discrimination covered (e.g., 1983 Civil Rights violation)? If so, what is the Limit of Liability? h. Is sexual misconduct (i.e., harassment), sexual abuse and molestation covered? If so, are there sub -limits? i. Does the coverage pay on behalf of or indemnify? j. Are defense costs within limits or in addition to? k. Please explain the notice of claim provision and what constitutes a "demand." D. Quotation (Must include all coverages and limits from Section A) 1. General Liability, EPLI, EBLI, ELLI and D&O Quote — (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ 15,497 2. Alternate General Liability, EPLI, EBLI, EELI, and D&O Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ Dl. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: Utica National Insurance A XIII A. M. Best Rating/Size: Insurance Company: ® Yes ❑ No For Alternate Quote(s): Name of Company: A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Risk Pool: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 11 of 39 Automobile & Physical Damage Insurance A. BACKGROUND INFORMATION 1. Please contact Purchasing Agent at sgarza(cDwestlake-tx.orq for loss runs. 2. Current list of vehicles: 2006 Chevrolet Girardin Bus —18 passengers 2010 Chevrolet Spartans Bus — 20 passengers 2018 Blue Bird Bus — 77 passengers 2020 Blue Bird Bus — 77 passengers 4. All drivers have proper class endorsements and driving histories are reviewed annually. B. Insurance coverage is to include the following: 1. Liability Limits & Coverage Desired: Auto Liability must be as follows: Limit Per Deductible Bodily Injury & Property Damage $ 1,000,000 Accident $ 1,000 Personal Injury Protection $ 2,500 Person $ 0 Uninsured Motorist $ 1,000,000 Accident $ 0 Underinsured Motorist $ 1,000,000 Accident $ 0 Physical Damage Coverage Comprehensive ACV/Repair Loss $ 1,000 Vandalism ACV/Repair Loss $ 0 Collision $ 1,000,000 Accident $ 1,000 2. Basis of Recovery is to be full repair cost or actual cash value, where applicable. 3. Hired auto and non -owned auto is to be included. 4. Include a listing of additional coverages, extensions, and exclusions. C. Quoted Coverage Provisions 1. Coverage Detail Bodily Injury & Property Damage Personal Injury Protection Uninsured Motorist Underinsured Motorist Medical Expenses Physical Damage Coverage Comprehensive Physical Damage Vandalism Collision Per Occurrence $ 1,000,000 $ 2,500 $ 1,000,000 $ 1,000,000 ACV/Repair ACV/Repair $ 1, 000, 000 Aggregate Deductible Accident $ 1.000 pPrson Acrident $ 0 Accident $ 0 Loss $ 1,000 0 Accident $ 1,000 2. Does coverage include automatic coverage for substitute or newly acquired vehicles? ®Yes ❑ No If yes, please describe: D. Quotation 1. Automobile Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ 5,394 2. Alternate Automobile Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 12 of 39 E. INSURANCE COMPANY/RISK POOL INFORMATION Utica National Name of Company: A. M. Best Rating/Size: A XIII Insurance Company: ® Yes ❑ No Risk Pool: ❑ Yes ❑ No For Alternate Quote(s): Name of Company: _ A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 13 of 39 Umbrella/Excess Liability Insurance A. BACKGROUND INFORMATION 1. No claims since inception of coverage in 2003. 2. Coverage is to be in excess of all Liability limits. B. Insurance coverage is to include the following: 1. Liability Limits & Coverage: Limit Per General Liability $ 5,000,000 Occurrence Personal & Advertising Injury $ 5,000,000 Person/Org Wrongful Acts — Claims Made Basis $1,000,000 Occurrence Aggregate Limit Self -Insured Retention - $10,000 2. Include a listing of additional coverages and coverage extensions. 3. Include a listing of exclusions. C. Quoted Coverage Provisions 1. Coverage Detail Limit General Liability $ s non no Personal & Advertising Injury $ 5 000 00 Wrongful Acts — Claims Made Basis $1,000.000 Aggregate Limit Self -Insured Retention 2. Is prior acts coverage provided? ❑ Yes ❑ No If yes, please give effective date(s) and explanation. Aggregate $ 5,000,000 $ 5,000,000 $ 1,000,000 $ 5,000,000 Per Aggregate C rmirrPnr:P nnn,nnn Person/Org. $JrL 000 Occurrence $ 1,000,000 $ 5,000,000 D. Quotation 1. Umbrella Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ 7,505 2. Alternate Umbrella Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: Utica National Insurance Company A. M. Best Rating/Size: A XIII Insurance Company: ® Yes ❑ No Risk Pool: ❑ Yes ❑ No Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 14 of 39 For Alternate Quote(s): Name of Company: A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 15 of 39 Crime Insurance A. BACKGROUND INFORMATION 1. No claims since inception of coverage in 2003. 2. Copy of current policy declaration schedule is attached. B. Insurance coverage is to include the following: 1. Crime Limits & Coverage Desired: Sinale Loss Limit Retention Employee Theft $ 250,000 $ 2,500 ERISA Fidelity $ 250,000 $ 0 Forgery or Alteration $ 250,000 $ 2,500 On Premises $ 250,000 $ 2,500 In Transit $ 250,000 $ 2,500 Money Orders/Counterfeit $ 250,000 $ 2,500 Computer Fraud $ 250,000 $ 2,500 Program/Restoration Expense $ 100,000 $ 2,500 Funds Transfer Fraud $ 250,000 $ 2,500 Claim Expense $ 5,000 $ 0 2. Include a listing of additional coverages and coverage extensions. 3. Include a listing of exclusions. C. Quoted Coverage Provisions Coverage Detail Single Loss Limit Retention Employee Theft $250,000 $ 2,500 ERISA Fidelity $250,000 $ 0 Forgery or Alteration $250,000 $ 2 500 On Premises $ 250,000 $ 2.500 In Transit $ 250,000 $ 2.500 Money Orders/Counterfeit $ 250,000 $ 2,500 Computer Fraud $ 250,000 $ 2,500 Program/Restoration Expense $ 100,000 $ 2,500 Funds Transfer Fraud $ 250,000 $ 2,500 Claim Expense $ 5,000 $ 0 D. Quotation Crime Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ 2,850 2. Alternate Crime Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $, E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: Travelers Casualty and Surety Company of America A XV A. M. Best Rating/Size: Insurance Company: KI Yes ❑ No Risk Pool: ❑ Yes ❑ No Westlake Academy - FY 21122 Comprehensive Insurance RFP Page 16 of 39 For Alternate Quote(s): Name of Company: A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 17 of 39 Workers Compensation Insurance A. BACKGROUND INFORMATION 1. Please contact Purchasing Agent at sgarza@westlake-tx.org for loss runs. 2. Experience Modifier is currently 0.67. 3. Estimated FY 21-22 payroll schedule is below. 4. Estimated number of regular employees is 108 (excluding substitute teachers & part-time coaches.) B. Insurance coverage is to include the following: 1. Workers Compensation Limits & Coverage Desired: Limit Per Bodily Injury by Accident $ 1,000,000 Accident Bodily Injury by Disease $ 1,000,000 Policy Limit Bodily Injury by Disease $ 1,000,000 Employee 2. Estimated FY 21-22 payroll is as follows Payroll Code Annual Amount Employees 8868 $ 5,800,000 97 (does not include substitute teachers) 8810 $ 328,000 6 9101 $ 280,400 5 Total Estimated Payroll: $6,408,400 108 3. Please include "Others States Coverage" where applicable, as an additional endorsement. 4. Please include "Terrorism Risk" as an additional endorsement. 5. Include a listing of additional coverage, extensions, and exclusions. 6. Include a Blanket Waiver of Subrogation. C. Quoted Coverage Provisions 1. Does coverage utilize a specific provider network? ❑ Yes ❑ No If yes, please provide details. Cl. Quotation 1. Workers Compensation Insurance Quote (Attach complete coverage information) Annual Premium (09/01/2021 to 08/31/2022): $ 18,492 2. Alternate Workers Compensation Insurance Quote (Attach complete coverage information) Annual Premium (09/01/2021 to 08/31/2022): $ CIL INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: Accident Fund Insurance Company A. M. Best Rating/Size: A XIII Insurance Company: ® Yes ❑ No Risk Pool: ❑ Yes ❑ No Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 18 of 39 For Alternate Quote(s): Name of Company: A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Enrolled In Accident Fund's national dividend plan Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 19 of 39 International Travel Liability Insurance A. BACKGROUND INFORMATION 1. No claims since inception of coverage in 2015. 2. Coverage is for employees engaged in overseas travel, and no countries excluded. 3. Coverage should include Medical Assistance, Personal Assistance, and Travel Assistance for employees and students, based on 50 participants per year. B. Desired Insurance coverage is to include the following: 1. Benefits Medical Expense Limit Dental Treatment Room and Board ICU Room and Board Charges Treatment of Pregnancy Preexisting Conditions Chiropractic Care Emergency Medical Evacuation Repatriation of Remains Chaperone Replacement Accidental Death & Dismemberment Accidental Death & Dismemberment Kidnap/Ransom Aggregate Limit Limit Per Aggregate $ 50,000 Person $ 50,000 $ 250 Tooth $ 500 Average semi -private room rate Twice the semi -private room rate Treated as any other medical condition Treated as any other medical condition $ 35 Visit $ 350 100% Expenses 100% Expenses $ 2,000 $ 10,000 Student $ 50,000 Faculty $ 100,000 Event $ 100,000 $ 250,000 Benefit Max 2. All coverage is $0 deductible with 100% coinsurance. 3. Include a listing of additional coverages, coverage extensions, and AD&D schedule. 4. Include a listing of exclusions. C. Quoted Coverage Provisions 1. Coverage Detail Medical Expense Limit Dental Treatment Room and Board ICU Room and Board Charges Treatment of Pregnancy Preexisting Conditions Chiropractic Care Emergency Medical Evacuation Repatriation of Remains Chaperone Replacement Accidental Death & Dismemberment Accidental Death & Dismemberment Kidnap/Ransom Aggregate Limit Limit Per Aggregate $ 50,000 Person $ 50,000 q 1)r,n Tnnth 4t inn Average Semi Private Room rate Twice the semi -private room rate Treated as any other medical condition Treated as any other medical condition $ 35 Visit $ 350 100% Expenses 100% Expenses $ 2,000 $ 10,000 Student $ 50,000 Faculty $ 100,000 Event $ 100,000 $ 250,000 Benefit Max 2. Does coverage include evacuation/repatriation? KI Yes ❑ No Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 20 of 39 D. Quotation 1. International Travel Insurance Quote (Attach complete coverage information) Annual Premium (09/01/2020 to 08/31/2021): $ $2,000 2. Alternate International Travel Insurance Quote (Attach complete coverage information) Annual Premium (09/01/2020 to 08/31/2021): $ E. INSURANCE COMPANY/RISK POOL INFORMATION CHUBB Name of Company: A. M. Best Rating/Size: AXV Insurance Company: U Yes ❑ No For Alternate Quote(s): Name of Company: A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Risk Pool: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 21 of 39 Student Accident Insurance A. BACKGROUND INFORMATION 1. Coverage is for all K-12 students participating in school sponsored activities, including sports. Liability waivers are obtained on all participants in sports programs. 2. Estimated Student Enrollment Count: 885 Grades K-8: 560 Grades 9-12: 325 3. Estimated Sports Participation is as follows: Football (grades 9-10): 35 Football (grades 11-12): 26 All other sports (grades 9-10): 170 All other sports (grades 11-12): 180 4. Batting cages or trampolines are not within the scope of the program. B. Insurance coverage is to include the following: 1. Liability Limits & Coverage: Accident Medical Expense Accidental Death Benefit Accidental Dismemberment AD&D Aggregate Limit Limit Deductible $ 25,000 $ 0 $ 15,000 $ 0 $ 50,000 $ 0 $ 500,000 2. Include a table of benefit amounts & percentages for covered medical expenses. 3. Include a listing of additional coverages, coverage extensions, exclusions, and AD&D schedule. C. Quoted Coverage Provisions 1. Coverage Detail: Accident Medical Expense Accidental Death Benefit Accidental Dismemberment AD&D Aggregate Limit Limit Deductible $ 25,000 $ 0 $ 15,000 $ 0 $ 50,000 $ 0 $ 500,000 2. Is arranged transportation included, prior, during, and after sponsored events?: ® Yes ❑ No If yes, please give effective date(s) and explanation. D. Quotation 1. Student Accident Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ 5,943 2. Alternate Student Accident Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ Westlake Academy — FY21122 Comprehensive Insurance RFP Page 22 of 39 E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: Philadelphia Insurance Company A. M. Best Rating/Size: A XV Insurance Company: © Yes ❑ No Risk Pool: ❑ Yes ❑ No For Alternate Quote(s): Name of Company: A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 23 of 38 Cyber Risk Liability (optional) A. BACKGROUND INFORMATION 1. Coverage is intended to supplement Cyber Liability Coverage(s) that are contained within other policies quoted, or offer additional coverage excluded within those policies. 2. This should be offered as a stand-alone policy which may be accepted or rejected by Westlake Academy, without affecting the pricing of other policies. 3. Coverage should include the following or the most equivalent limits and deductible available: B. Insurance coverage is to include the following: 1. Liability Limits & Coverage: Liability Coverages Networks and information security Communications and media Regulatory defense expenses 1s' Party coverage Crisis Management event expenses Security Breach remediation and notification expenses E-commerce extortion Business interruption and additional Expenses Limit Deductible $ 1,000,000 $10,000 $ 1,000,000 $10,000 $ 500,000 $10,000 $ 500,000 $10,000 $ 500,000 $10,000 $ 500,000 $10,000 $ 500,000 24 Hours 2. Include coverage descriptions of each insuring agreement 3. Include a listing of additional coverages, coverage extensions, and exclusions. C. Quoted Coverage Provisions 1. Coverage Detail: Liability Coverages Networks and information security Communications and media Regulatory defense expenses 1 It Party coverage Crisis Management event expenses Security Breach remediation and notification expenses E-commerce extortion Business interruption and additional expenses D. Quotation Limit Deductible $ 1,000,000 $10,000 $ 1,000,000 $10,000 $ 500,000 $10,000 $ 500,000 $10,000 $ 500,000 $10,000 $ 500,000 $10,000 $ 500,000 24 Hours 1. Cyber liability Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ Included in General Liability Pricing 2. Alternate Cyber liability Insurance Quote (Attach complete coverage information) Annual Premium (Period 09/01/2021 to 08/31/2022): $ Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 24 of 39 E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: Utica National Insurance A XIII A. M. Best Rating/Size: Insurance Company: ® Yes ❑ No Risk Pool: ❑ Yes ❑ No For Alternate Quote(s): Name of Company: A. M. Best Rating/Size: Insurance Company: ❑ Yes ❑ No Risk Pool: ❑ Yes ❑ No F. LIST ANY DEVIATIONS OR ADDITIONAL INFORMATION: Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 25 of 39 PROPOSAL SUBMITTAL FORMAT Quotations should be clearly labeled, using the format below. Proposals using an alternate format should have all quotes clearly labeled by policy type, and include policy limits, details, and cost. All submissions must include the completed forms below. 1 — Completed Questionnaire 2 - Property Insurance, Fire and Extended Equipment Coverage Quote 3 - General Liability Quote (including D&O, EPLI, EBLI and ELLI coverage) 4 - Automobile Liability & Physical Damage Quote 5 - Umbrella Liability Insurance Quote 6 - Crime Insurance Quote 7 — Workers Compensation Insurance Quote 8 — International Travel Insurance Quote 9 — Student Accident Insurance Quote 10 — Cyber Liability & Cyber Security Insurance Quote 11 - Agent's Current License, Copy of E&O Insurance Certificate 12 - Completed and signed Felony Conviction Notice Form 13 - Completed and signed Non -Collusion Certification Form 14 - Completed and signed Conflict of Interest Questionnaire Form 15 - Completed and signed W-9 Form 16 - Completed and signed Form 2270 Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 26 of 39 Exhibit "A" - Property Schedule 1. All buildings are located on 2600 JT Ottinger Road, Westlake TX, 76262. Blanket coverage is required for buildings and contents. Building Sq. Footage Valuation Roof Type #1 15,600 12,775,000 100% concrete tile #2: 20,000 9,120,800 100% concrete tile #3 11,200 5,500,000 100% concrete tile #4: 8,400 5,908,000 80% concrete tile, 20% flat membrane #5: 1,500 60,000 Portable #6: 1,500 60,000 Portable #7: 1,500 60,000 Portable #8: 10,853 3,036,800 75% seam metal, 25% flat membrane #9: 9,698 3,675,000 25% concrete tile, 75% flat membrane #10: 19,820 6,130,000 75% seam metal, 25% flat membrane #11: 1,500 60,000 Portable #12: 1,500 60,000 Portable #13: 1,500 60,000 Portable Property (Blanket) Limits: $46,505,600 2. Contents: $4,860,000 3. Business Income and Extra Expense: $485,000 4. Total Property Limits $51,849,600 Westlake Academy — FY 21122 Comprehensive Insurance RFP Page 27 of 39 Compliance Express TM Page 1 of 1 OF M General Lines Agency Life, Accident, Health and HMO, Property and Casualty BOX INSURANCE AGENCY INC 1200 SOUTH MAIN ST STE 1600 GRAPEVINE, TX 76051 is authorized to transact business as described above License No: 8774 Issue Date: 03-07-2000 Expiration Date: 03-07-2022 TEXAS <,r' �, � A. �• L7t:1'ARl;ti1f:K'1O!• I\SUK;l\Cli z x THIS IS TO CERTIFY THAT i BOX INSURANCE AGENCY INC 1200 SOUTH MAIN ST STE 1600, GRAPEVINE, TX 76051 LICENSE NUMBER: 8774 Generated by Sircon 207284647 IS HEREBY AUTHORIZED TO TRANSACT BUSINESS IN ACCORDANCE TO THE LICENSE DESCRIPTION SHOWN BELOW: General Lines Agency Life, Accident, Health and HMO, Property and Casualty Issue Date: 03-07-2000 Expiration Date: 03-07-2022 Generated by Sircon 207284647 https://www.sircon.com/ComplianceExpress/ServiceR equest/licPrnt.do?method=collectPay... `- �� CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 02-25-2021 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER CONTACT Professional Insurance Agents of Texas NAME: PHONE FAX C/o Cindy Cicack,16515 Pilgrims Circle Spring, TX 77379 (A/C. No. Ext): (A/C, No): E-MAIL ADDRESS: INSURER(S) AFFORDING COVERAGE NAIC# INSURER A: Utica Mutual Insurance Company INSURED INSURER B: Box Bonding Agency LLC dba Box Insurance Agency INSURER C: INSURER D: 1200 S. Main Street, Suite 1600 INSURER E: Grapevine,TX 76051 INSURER F: GOVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUBR POLICY EFF POLICY EXP LIMITS . __ I ...__ .._._ POLICY NUMBER ❑ CLAIMS MADE ❑ OCCUR GEN'LAGGREGATE LIMIT APPLIES PER : ❑ POLICY ❑ PROJECT ❑ LOC ❑ Other: EACH OCCURRENCE MED EXP (Any one person) $ DAMAGE TO RENTED PRE ISES fEa occurrence) $ PERSONAL BADV INJURY $ General Aggregate $ PRODUCTS - COMP/OP AGG $ S AUTOMOBILE LIABILITY ❑ ANY AUTO ❑ ALL OWNED ❑ SCHEDULED AUTOS AUTOS ❑ HIRED AUTOS ❑ NON -OWNED AUTOS COMBINED SINGLE LIMIT (Ea accident) $ BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ ❑ UMBRELLA LIAB ❑ OCCUR ❑ EXCESS LAB ❑ CLAIMS -MADE ❑ DED ❑ RETENTION $ EACH OCCURRENCE $ AGGREGATE $ $ WORKERS COMPENSATION AND EMPLOYERS' LIABILITY ANY PROPRIETOR/PARTNER/ Y/N EXECUTIVE OFFICER/ MEMBER ❑ EXCLUDED? (Mandatory In NH) If yes, describe under DESCRIPTION OF OPERATIONS below N/A ❑ PER STATUTE ❑ OTH- ER E.L. EACH ACCIDENT $ E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ A OTHER EACH LOSS $10,000,000 AGENTS 8 BROKERS 5330160EO 02-18-2021 02-18-2022 AGGREGATE $11,000,000 ERRORS & OMISSIONS DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101, Additional Remarks Schedule, if more space is required) DEDUCT]BLE:$25,000.00 EACH LOSS: $75,000.00 AGGREGATE: (LOSS AND LITIGATION) Named Insureds also include the following- Box Professional Liability Insurance Agency LLC Box Home and Auto LLC, Box Insurance Agency Inc, Box Bonding Agency LLC CERTIFICATE HOLDER CANCELLATION Box Bonding Agency LLC SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION dba Box Insurance Agency DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. 1200 S. Main Street, Suite 1600 Grapevine TX 76051 )A', c A"Y' ©1988 - 2015 ACORD CORPORATION. All ACORD 25 (2016/03) The ACORD name and logo are registered marks of ACORD Town of Westlake Westlake Academy Human Resources Department FELONY CONVICTION NOTICE State of Texas Legislative Senate Bill No. 1, Section 44.034, Notification of Criminal History, Subsection (a), states "a person or business entity that enters into a contract with a school district must give advance notice to the district if the person or an owner or operator of the business entity has been convicted of a felony. The notice must include a general description of the conduct resulting in the conviction of a felony. Subsection (b) states "a school district may terminate a contract with a person or business entity if the district determines that the person or business entity failed to give notice as required by Subsection (a) or misrepresented the conduct resulting in the conviction. The district must compensate the person or business entity for the services performed before the termination of contract." THIS NOTICE IS NOT REQUIRED OF A PUBLICLY -HELD CORPORATION I, the undersigned agent for the firm named below, certify that the information concerning notification of felony has been reviewed by me and the following information furnished is true to the best of my knowledge. VENDOR'S NAME: Box Bonding Agency, LLC, DBA Box Insurance Agency AUTHORIZED COMPANY OFFICIAL'S NAME (PRINTED) Adam Syswerda Please check all that apply: ❑ My firm is publicly -held corporation, therefore, this reporting requirement is not applicable. My firm is neither owned nor operated by anyone who has been convicted of a felony: ❑ My firm is owned or operated by the following individual(s) who has/have been convicted of a felony: Name: Details of Conviction(s): 0)�� Contractor/Company Official Signature 8/7/2020 Date 1500 Solana Blvd, Bldg. 7, Suite #7200 • Westlake, Texas 76262 Metro: 817-490-5711 • Fax: 817-430-1812 • www.westlakeacademy.org Town of Westlake Westlake Academy Human Resources Department NON -COLLUSION STATEMENT The undersigned Proposer, by signing and executing this proposal, certifies and represents to the Town of Westlake and Westlake Academy that Proposer has not offered, conferred or agreed to confer any pecuniary benefit, as defined by Section 1.07 (a)(6) of the Texas Penal Code, or any other thing of value, as consideration for the receipt of information or any special treatment or advantage relating to this proposal; the Proposer also certifies and represents that Proposer has not offered, conferred or agreed to confer any pecuniary benefit or other things of value as consideration for the recipient's decision, opinion, recommendation, vote or other exercise of discretion concerning this proposal; the Proposer certifies and represents that Proposer has neither coerced nor attempted to influence the exercise of discretion by any officer, trustee, agent or employee of the Town of Westlake and Westlake Academy concerning this proposal on the basis of any consideration not authorized by law; the Proposer also certifies and represents that Proposer has not received any information not available to other proposers so as to give the undersigned a preferential advantage with respect to this proposal; the Proposer further certifies and represents that Proposer has not violated any state, federal or local law, regulation or ordinance relating to bribery, improper influence, collusion or the like and that Proposer will not in the future, offer, confer, or agree to confer any pecuniary benefit or other thing of value of any officer, trustee, agent or employee of the Town of Westlake and Westlake Academy in return for the person having exercised the person's official discretion, power or duty with respect to this proposal; the Proposer certifies and represents that it has not now and will not in the future offer, confer, or agree to confer a pecuniary benefit or other thing of value to any office, trustee, agent or employee of the Town of Westlake and Westlake Academy in connection with information regarding this proposal, the submission of this proposal, the award of this proposal or the performance, delivery or sale pursuant to this proposal. Firm Name: Box Bonding Agency, LLC, DBA Box Insurance Agency Address: 1200 S. Main St. Suite 1600 City/State/Zip: Grapevine, TX 76051 Phone: 817-865-1806 Fax: 817-424-1404 Name of Representative(s): Signature of Representative(s): Date: 8/7/2020 Adam Syswerda 1500 Solana Blvd., Bldg 7, Suite #7200 • Westlake, Texas 76262 Metro: 817-490-5711 • Fax: 817-430-1812 • www.westlakeacademy.org CONFLICT OF INTEREST QUESTIONNAIRE FORM CIQ For vendor doing business with local governmental entity This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. OFFICE USE ONLY This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who Date Received has a business relationship as defined by Section 176.001(1-a) with a local governmental entity and the vendor meets requirements under Section 176.006(a). By law this questionnaire must be filed with the records administrator of the local governmental entity not later than the 7th business day after the date the vendor becomes aware of facts that require the statement to be filed. See Section 176.006(a-1), Local Government Code. A vendor commits an offense if the vendor knowingly violates Section 176.006, Local Government Code. An offense under this section is a misdemeanor. Name of vendor who has a business relationship with local governmental entity. Box Bonding LLC, DBA Box Insurance Agency 2 ® Check this box if you are filing an update to a previously filed questionnaire. (The law requires that you file an updated completed questionnaire with the appropriate filing authority not later than the 7th business day after the date on which you became aware that the originally filed questionnaire was incomplete or inaccurate.) 3 Name of local government officer about whom the information is being disclosed. Name of Officer 4 Describe each employment or other business relationship with the local government officer, or a family member of the officer, as described by Section 176.003(a)(2)(A). Also describe any family relationship with the local government officer. Complete subparts A and B for each employment or business relationship described. Attach additional pages to this Form CIO as necessary. A. Is the local government officer or a family member of the officer receiving or likely to receive taxable income, other than investment income, from the vendor? Yes Fx I No B. Is the vendor receiving or likely to receive taxable income, other than investment income, from or at the direction of the local government officer or a family member of the officer AND the taxable income is not received from the local governmental entity? F]Yes X�No 5 Describe each employment or business relationship that the vendor named in Section 1 maintains with a corporation or other business entity with respect to which the local government officer serves as an officer or director, or holds an ownership interest of one percent or more. 6 ❑ Check this box if the vendor has given the local government officer or a family member of the officer one or more gifts as described in Section 176.003(a)(2)(B), excluding gifts described in Section 176.003(a-1). 7 8/7/2020 Signature of vendor doind business with the governmental entity Date Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity A complete copy of Chapter 176 of the Local Government Code may be found at http://www.statutes.legis.state.tx.us/ Docs/LG/htm/LG.176.htm. For easy reference, below are some of the sections cited on this form. Local Government Code § 176.001(1-a): "Business relationship" means a connection between two or more parties based on commercial activity of one of the parties. The term does not include a connection based on: (A) a transaction that is subject to rate or fee regulation by a federal, state, or local governmental entity or an agency of a federal, state, or local governmental entity; (B) a transaction conducted at a price and subject to terms available to the public; or (C) a purchase or lease of goods or services from a person that is chartered by a state or federal agency and that is subject to regular examination by, and reporting to, that agency. Local Government Code § 176.003(a)(2)(A) and (B): (a) A local government officer shall file a conflicts disclosure statement with respect to a vendor if: (2) the vendor: (A) has an employment or other business relationship with the local government officer or a family member of the officer that results in the officer or family member receiving taxable income, other than investment income, that exceeds $2,500 during the 12-month period preceding the date that the officer becomes aware that (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor; (B) has given to the local government officer or a family member of the officer one or more gifts that have an aggregate value of more than $100 in the 12-month period preceding the date the officer becomes aware that: (i) a contract between the local governmental entity and vendor has been executed; or (ii) the local governmental entity is considering entering into a contract with the vendor. Local Government Code § 176.006(a) and (a-1) (a) Avendor shall file a completed conflict of interest questionnaire if the vendor has a business relationship with a local governmental entity and: (1) has an employment or other business relationship with a local government officer of that local governmental entity, or a family member of the officer, described by Section 176.003(a)(2)(A); (2) has given a local government officer of that local governmental entity, or a family member of the officer, one or more gifts with the aggregate value specified by Section 176.003(a)(2)(B), excluding any gift described by Section 176.003(a-1); or (3) has a family relationship with a local government officer of that local governmental entity. (a-1) The completed conflict of interest questionnaire must be filed with the appropriate records administrator not later than the seventh business day after the later of: (1) the date that the vendor: (A) begins discussions or negotiations to enter into a contract with the local governmental entity; or (B) submits to the local governmental entity an application, response to a request for proposals or bids, correspondence, or another writing related to a potential contract with the local governmental entity; or (2) the date the vendor becomes aware: (A) of an employment or other business relationship with a local government officer, or a family member of the officer, described by Subsection (a); (B) that the vendor has given one or more gifts described by Subsection (a); or (C) of a family relationship with a local government officer. Form provided by Texas Ethics Commission www.ethics.state.tx.us Revised 11/30/2015 Form W--9 Request for Taxpayer Give Form to the NQenmentof er Identification Number and Certification requester. Do not Cepat Cepanmer,toflheTrzasury hgTre) Irternel Rev9ni>s 9eiviw send to the IRS. Name (as shown on your income tax return) N Business name/disregarded entity name, if different from above pN, Box Insurance Agency, Inc. = Check appropriate Wox for federal tar, classification: =o 0 ❑indivldaaUsolepropristor C Corporation ❑ „a Ccrporation ❑ Partner5tLp Q Trust/estate El o ` Z Limited lability company. Ester the tax classification (C=C corporates, S-S corporation, P-partre ship) ► Exempt payee tl o other (sea instructions) ► ,2a Address (number, street, autd apt. or sulte noJ Mequester's name and address (optional) S 1200 S. Main St, Ste.1600 m Chy, state, and ZIP code in Grapevine, TX 76051 Listeceount numbers) here (ootionaU Taxpayer identification Number (TW Enter your TIN in the appropriate box, Tho TIN provided must match the name given on the "Name" line ]Social security number I to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a (!j!T'i—j resident alien, sole proprietor, or disregarded entity, see the Part I Instructions on page 3. For "they _ 1 l i I i entities, It Is your employer Identification number (EIN). If you do not have a number, see How to get a 77N on page 3. Note. If the account is In more than one name, see the chart on page 4 for guidelines on whose I Employer identittC9tlon number number to enter, fTl Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or i am waiting for a number to be issued to me), and 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. 1 am a U.S. citizen or other U.S. person (defined below). 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 ail 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 More trids, you are not required to sign the certfficarion, but you must provide your correct TIN, See the instructions on page 4. Sign Signature of ` n Here U.S. person / Date> 10 Genera! Instructions [ Note. If a requester gives you a form otherthan Form W-9 to request your TiN, you must use the requester's form if h Is substantially similar Section references are to the Internal Revenue Code unless otherwise to this Form W-9. noted. Definition of a U.S, person, For federal tax purposes, you are Purpose of Form considered a U.S, person if you are: A person who Is required to fife an information return with the IRS must obtain your correct taxpayer Identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage Interest you paid, acqulsition or abandonment of secured property, cancellation of debt, or contributions you made to an iRA. Use Form W-9 only d you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving Is correct for you are waiting for a number to be issued), 2. Certify that you are not sub)eci to backup withholding, or ■ An individual who is a U.S. citizen or U.S, resident alien, • A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business In the United States are generally required to pay a withholding tax on any foreign partners' share of income from such business. Further, in certain cases where a Form W-9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a 3. Claim exemption from backup withholding if you are a U.S. exempt partner in a partnership conducting a trade or business in the United payee. If applicable, you are also certifying that as a U.S. person, your States, provide Form W-9 to the partnership to establish your U.S. allocable share of any partnership Income from a U.S. trade or business status and avoid withholding on your share of partnership income. is not subject to trie withholding tax on foreign partners' share of effectively connected income. Cat. No. 10231X Form W-9 (Rev. 12-2011) VERIFICATION REQUIRED BY TEXAS GOVERNMENT CODE CHAPTER 2270 By signing below, the signatory hereby verifies that the firm it represents: 1. Does not boycott Israel; and, 2. Will not boycott Israel during the term of the contract. SIGNED BY: Print Name & Title: Adam Sysorda, Vice President Firm Name: Box Insurance Agency 7/29/2021 Date Signed: NOTARIZATION THE STATE OFF ) COUNTY OF BEFORE ME, the undersigned notary public on this day personally appeared ala ama 51 + on behalf of ��.5 �d r (Company), who, being duly sworn, stated under oath that he/she has read the foregoing verification re fired by Texas Government Code Section 2270.002 and said statements contained therein are true and correct. g q BSCRIBEDbefore me on the of , 2021. NOTARY PUBLIC STATE OF TEXASa�� MY COMM. EXP. 02/14/25 NOTARY PUBLIC I4AND NOTARY ID 174695-3 FOR THE STATE OF ��,�� s The following definitions apply to Texas Government Code Section 2270.001: (1) 'Boycott Israel" means refusing to deal with, terminating business activities with, or otherwise taking any action that is intended to penalize, inflict economic harm on, or limit commercial relations specifically with Israel, or with a person or entity doing business in Israel or in an Israeli -controlled territory, but does not include an action made for ordinary business purposes; and (2) "Company" means a for -profit sole proprietorship, organization, association, corporation, partnership, joint venture, limited partnership, limited liability partnership, or limited liability company, including a wholly owned subsidiary, majority -owned subsidiary, parent company, or affiliate of those entities or business associations that exists to make a profit. State law requires any firm entering into an agreement or contract with the Authority to complete the foregoing verification. TEx. GOv'T CODE § 2270.002. Page 38 of 39 Westlake Academy Presented by: Underwriter Andy Clark CRUM&FORSTER `` A FAIRPAX c()MPArvl' pna�sl str�ern CBEST A. M. Best Rated A (Excellent) Confidentiality notice: The information contained in this Quote Proposal is confidential and may be privileged and protected from disclosure. If the reader of this Quote Proposal is not the intended recipient, or an employee or agent responsible for delivering this message to the intended recipient, you are hereby notified that it is strictly prohibited (a) to disseminate, distribute or copy this communication or any of the information contained in it, or (b) to take any action based on the information in it. If you have received this communication in error, please notify us immediately by replying to this message and deleting it from your computer. Electronic policy delivery notice This quote is conditioned upon the Insured's consent to receive electronic copies of policies, change endorsements, notices, and related materials (other than those that are subject to statuses or regulations specifically prescribing methods of delivery other than electronic delivery). By accepting this quote on behalf of the applicant/insured you acknowledge that you have received authority from the applicant/insured to accept this condition. CRUM&FORSTER Commercial Output Prograrn (Coverage Deductible I Valuation I Limit BL Irr.; 10.000 Rep acerren-Cott 46,505.600 BLsine:: Permonal Pronerf MOM Repacerren_Co:z 4.560,OW Inco-ne- Earning., Rests, Elva E. erze: 72 H3:r: 4:4;000 Ordirora Payroli Urr:tatior. ?0 Da}a l.'i�c^.armllia: 2°.' suhicci to 100.0w M.n_ Tenronsm Rejected Equipmmt Breakdown Coverage Type DeductNe, Limit Pr operci M004 51,365, 6D0 Incorne - Earni ng. and 'Extra Expenae 24 Ho_rz 454; DDO Spoilage 80,000 250,DOO 3r.;6-dow.n, Mzn!;ync:ior. ar FC.'ILFG (fqu.-pM Pr7r Irc,'. in ti. Cor,rm-ri.natirn i`E4u o.rr4m &a•axaomrl, rr�{i l.�r^.•C.n.' Car. Inc,' POW.?r L�'S7Gt7!'L n �`LOL' C l^o I Drc ]i:tlOW,n I err. i.lCi. Peive! U'.ruot'O.n (Ornor CC212C5 L T lacz � !r_i Ex pec fw,; E aersez 250..DD0 Hazardousiubatances 250.DDO Data Re: oration .SD.DOO Statement of Values Location Building I address Building Business Personal Property Income 1. 1 2600 Ottinger Road, Westlake, TX 76262 12,775,000 1,665rOCIO 334,000 1 2 2600 Ottinger Road, Westlake, TX 76262 9,120'r9co lSZO.D00 15,000 1 3 26W Ottinger Road, Westlake, TX 76262 5,500`CCO 520,DD0 15,000 L A 2600 Ottinger Road, Westlake, TX 76262 5,90S;CCIO 400,DD0 15,000 1 5 2600 Ottinger Road, Westlake, Tx 76262 60,000 10row 10,000 1 6 260D Ottinger Road, Westlake, TX 76262 60,000 10,000 10,000 1 7 2600 Ottinger Road, Westlake, TX 76262 64,." 10'e"I 10,000 L B 2600 Ottinger Road, Westlake, TX 76262 5,036,WD 365.,DOO 15,000 1 9 2600 Ottinger Road, Westlake, TX 76262 3,675,000 435,D00 15,001} I 10 260D Ottinger Road, Westlake, Tx 76262 6r13OrC-Cd7 5?5,DO0 15,000 t 11 26M Ottinger Road, Westlake, TX 76262 60r0DD 10rcloo 10,000 1 12 2600 Ottinger Road, Westlake, TX 76262 60pori 1D,C{{i 10,000 1 13 2600 Ottinger Road, Westlake, TX 76262 60,C-Di 10,0w 10,OD0 CRUM&FORSTER- Statement of Values Location I Building jAddress Building Business Personal Property Income 1 1 2600 Ottinger Road, Westlake, TX 76262 12,285,000 1,600,000 334,000 1 2 2600 Ottinger Road, Westlake, TX 76262 8,770,000 791,000 15,000 1 3 2600 Ottinger Road, Westlake, TX 76262 4,491,000 500,000 15,000 1 4 2600 Ottinger Road, Westlake, TX 76262 5,681,000 380,000 15,000 1 5 2600 Ottinger Road, Westlake, TX 76262 45,000 10,000 10,000 1 6 2600 Ottinger Road, Westlake, TX 76262 45,000 10,000 10,000 1 7 2600 Ottinger Road, Westlake, TX 76262 45,000 10,000 10,000 1 8 2600 Ottinger Road, Westlake, TX 76262 2,920,000 350,000 15,000 1 9 2600 Ottinger Road, Westlake, TX 76262 3,533,000 440,000 15,000 1 10 2600 Ottinger Road, Westlake, TX 76262 5,895,000 550,000 15,000 1 11 2600 Ottinger Road, Westlake, TX 76262 45,000 10,000 10,000 1 12 2600 Ottinger Road, Westlake, TX 76262 45,000 10,000 10,000 1 13 2600 Ottinger Road, Westlake, TX 76262 45,000 10,000 10,000 Note: Blanket Building and Business Personal Property Limits Applicable C-F CRU M & FORSTER' =AIRFAX C:JF-_V:Y Coverage Extensions Description JLimit Consequential Loss Damage From Theft Debris Removal (Additional Expense) Emergency Removal Emergency Removal Expense Fraud and Deceit Off Premises Utility Service Interruption Overhead Transmission Lines Subject to Applicable Covered Property Limit Subject to Applicable Covered Property Limit 50,000 365 Days 5,000 5,000 50,000 Included Supplemental Coverages Description JLimit Brands or Labels Expense Expediting Expenses Fire Department Service Charges Inventory and Appraisal Expense Ordinance or Law (Undamaged Parts of a Bldg) Ordinance or Law (Increased Cost to Repair/Cost to Demolish and Clear Site) Personal Effects Pollutant Cleanup and Removal Recharge of Fire Extinguishing Equipment Rewards Sewer Backup and Water Below the Surface Trees, Shrubs and Plants Underground Pipes, Pilings, Bridges and Roadways 50,000 50,000 25,000 50,000 Subject to Applicable Covered Property Limit Supplemental Marine Coverages Description Limit Accounts Receivable Fine Arts Off Premises Computers Property on Exhibition Property in Transit Sales Representatives Samples Software Storage Electrical or Magnetic Disturbance of Computers Power Supply Disturbance of Computers Valuable Papers 100,000 15,000 50,000 50,000 10,000 25,000 50,000 250,000 50,000 100,000 25,000 50,000 50,000 50,000 50,000 Subject to Applicable Covered Property Limit Subject to Applicable Covered Property Limit 100,000 CRU M & FORSTER A FAIRFAX COMPANY Coverage Options Description JILimit Newly Built or Acquired Buildings Personal Property - Acquired Locations Locations 'You' Elect Not to Describe Income Coverage Extensions Description jPeriod Interruption by Civil Authority Period of Loss Extension Income Supplemental Coverages Description JILimit 1,000,000 250,000 50,000 30 Days 90 Days Dependent Locations 100,000 Pollutants Cleanup and Removal 10,000 Property in Transit, On Exhibition, or Custody of Sales Representatives 50,000 Off Premises Utility Service Interruption 10,000 Off Premises Utility Service Interruption - Waiting Period 72 Hours Overhead Transmission Lines Included Contract Penalty Limit Any One Occurrence 25,000 Limit Any 12 Month Period 25,000 Income Coverage Options Description Limit Newly Built or Acquired Locations 100,000 C.F. CRUM&FORSTER7 EST. 1822 A FAIRFAX COMPANY SCHEDULE OF FORMS Title JForm Number JEdition U.S. Treasury Department's Office of Foreign Assets Control (OFAC) Advisory Notice to Policyholders IL P 001 0104 Policyholder Disclosure Notice of Terrorism Insurance Coverage CL 10 45 0115 Commercial Output Program Policy Declarations CO 05 001 0918 Schedule of Forms and Endorsements CO 06 001 0918 Certified Act of Terrorism Exclusion CL 06 10 0115 Virus or Bacteria Exclusion CL 07 00 1006 Schedule of Locations CO 06 002 0918 Common Policy Conditions CL 0100 0399 Amendatory Endorsement Texas CL 02 73 0719 Equipment Breakdown Coverage Part CO 00 001 0119 Amendatory Endorsement -Texas CO 01010 0119 Equipment Breakdown Schedule CO 06 010 0119 Commercial Output Program - Property Coverage Part CO 10 00 1002 Commercial Output Program - Income Coverage Part CO 10 01 0402 Spoilage Coverage Part - Scheduled Coverage CO 10 04 0402 Schedule of Coverages - Commercial Output Program CO 10 50 0305 Location Schedule CO 10 52 0402 Ordinary Payroll Limitation Schedule CO 1067 0402 Spoilage Schedule CO 10 74 0402 Scheduled Locations - Spoilage Coverage CO 10 75 0402 Scheduled Locations Endorsement CO 12 27 0502 Ordinary Payroll Limitation CO 12 42 0402 Waiting Period - Income Coverage CO 12 81 0402 Windstorm or Hail Deductibles (Percentage Deductible Subject to a Minimum Dollar Deductible) CO 03 001 0819 Flood Endorsement (Designated Zones) CO 04 018 0819 Earthquake Endorsement - Designated Zones CO 04 019 0918 Flood Schedule (Designated Zones) CO 06 008 0918 Earthquake Schedule (Designated Zones) CO 06 009 0918 Windstorm or Hail Schedule CO 06 012 0819 Windstorm Meaning and Clarification Endorsement CO 24 029 1119 Account Name: WESTLAKE ACADEMY Policy Period: 08/31/2021 to 08/31/2022 Quote Number: 5471537 Commercial General Liability Limits General Aggregate $2,000,00 Product/Completed Operations Aggregate $2,000,00 Per Occurrence $1,000,00 Personal & Advertising Injury $1,000,00 Damage to Premises Rented to You $1,000,00 Medical Expenses (Excludes Student Medical Expenses) $10,00 Deductible or Self Insured Retention Non Defense including court costs Outside the limits Athletic Participants Coverage Included Incidental Malpractice Liability Included Prejudgment and postjudgment interest Outside the limits Rating Classification(s): Description Rating Basis Exposure Schools - Private - Elementary, Kinder- Garten Or Junior Per Pupil 567 Schools - Private - High - Not -For -Profit Only Per Pupil 339 Museums - Not -For- Profit Only - Products - Completed Per Thousand Sq. Ft. 8400 Endorsements *Any Exclusions/Limitations listed are in addition to those in the coverage forms. 8C2636 Employment Related Practices- Liability Coverage Form 8D2636 Employment Related Practices- Liability Insurance Declaration 8E2813 Texas Employment Related Practices 8C1014 Employee Benefit Programs Liability Coverage Form 8E3529 Texas Amendatory Endorsement 8D1014 Employee Benefit Programs Liability Coverage Part Dec 8C1213 Sdell Coverage Form 8D1213 School District And Educators Legal Liability Insurance Declarations 8C3326TX Abuse or Molestation Liability Coverage Form 8D3326 Abuse or Molesation Liability Coverage Part (Claims -Made Basis) 8E3548TX General Liability Extension Endorsement 8D4117 Cyber Suite Declarations 8C4117 Cyber Suite Coverage Form 8E3350TX Exclusion - Fungi or Bacteria IL0985 Disclosure Pursuant to Terrorism Risk Insurance 81-938 Utica Lloyds of Texas CG2646 Texas Abuse or Molestation Exclusion 8E3345TX Fungi or Bacteria Exclusion 8E3149 Extended Reporting Period for Limted Erp Coverage 81-1788 Important Notice- TX Disclosure Form CG2167 Fungi or Bacteria Exclusion 8E1782 Exclusion - Lead Liability Exclusions 8E4174 Educational Institutions Limited Unmanned Aircraft Coverage 8E3042TX Educational Institution Coverage Endorsement 8E3204 Employment - Related Practices Exclusion 8E1611 TX Changes -Amendatory Endorsement 8E3350TX Exclusion - Fungi or Bacteria Account Name: WESTLAKE ACADEMY Policy Period: 08/31/2021 to 08/31/2022 Quote Number: 5471537 Endorsements *Any Exclusions/Limitations listed are in addition to those in the coverage forms. (continued) CG2639 Texas Changes - Employment Related Pracitces Exclusion 8E4182 Your Investigation And Public Relations Expenses 8E3674 Exclusion - Recording And Distribution of Material or Info In Violation of Law 8E3857 Knowledge of Wrongful Acts 8E3350TX Exclusion - Fungi or Bacteria 8E4303 Epidemic or Pandemic Exclusion Additional Considerations: *8E4303 (EPIDEMIC OR PANDEMIC EXCLUSION) IS BEING ADDED TO THE RENEWAL Educational Institutions Limited Unmanned Aircraft Coverage 8E4174 Adds Bodily Injury and Property Damage liability coverage for drones used in connection with the named insured's operations. Unscheduled Unmanned Aircraft $250,000 Account Name: WESTLAKE ACADEMY Policy Period: 08/31/2021 to 08/31/2022 Quote Number:5471537 Claims -Made Liability Coverages: School District and Educators Legal Liability Coverage: Limits $1,000,000 Each "Loss" $2,000,000 Annual Aggregate Retention $10,000 Each Loss Retained Amount Retroactive Date 8/31 /2011 Coinsurance None Defense Outside the limits Optional Extended Reporting Period Premium 145% of inception premium Who is insured? • Educational Institution • School Board, School Committee, Board of Trustees, or similar governing body • Elected or appointed members of the School Board, School Committee, Board of Trustees, School Directors, Board of Governors, etc. • Employees • Student Teachers • School Volunteers • Student serving school sponsored internship Payment of Damages Pay on behalf of Typical allegations brought under this coverage Failure to educate • Budget dispute claims Definition of suit includes Arbitration • Other alternative dispute resolution proceedings Limited Coverage for Salary or Benefits Claims $2,500 Each Loss Limit $100,000 Annual Policy Year Limit Cost of appeal bonds or bonds to release attachments Included Loss of Earnings due to assisting with investigation/defense $250 per day of claim All costs taxed against insured in suit Included Prejudgment and Postjudgment interest Included Cyber Suite Coverage: Aggregate Limit $1,000,000 Deductible $10,000 Retroactive Date None Exclusion(s) and Endorsement(s) in addition to those in the School District and Educators Legal Liability Coverage Form: 8E3204 I Employment Related Practices Exclusion Included Abuse or Molestation Liability (including Sexual Misconduct or Sexual Molestation): Limits $1,000,000 Each "Loss" Limit $1,000,000 Annual Aggregate Limit Retroactive Date 8/31/2011 Defense Applies outside the limits Optional Extended Reporting Period Premium 145% Account Name: WESTLAKE ACADEMY Policy Period: 08/31/2021 to 08/31/2022 Quote Number:5471537 Abuse or Molestation Liability (including Sexual Misconduct or Sexual Molestation) (continued): Who is insured includes • Named Insured • Directors, Officers or Trustees • Teachers • Board of trustees, governors or education • Same positions as above on Affiliates • Volunteer Worker Payment of Damages Pay on behalf of Definition of suit includes • Arbitration • Other alternative dispute resolution proceedings Cost of appeal bonds Included Loss of Earnings due to assisting with investigation/defense $250 per day of claim All costs taxed against insured in suit Included Prejudgment and Postjudgment interest Included Employee Benefit Programs Liability Coverage: Limits $1,000,000 Each Loss Limit $3,000,000 Annual Aggregate Limit Retention $1,000 Per Loss Retroactive Date 8/31 /2011 Defense Applies outside the limits Optional Extended Reporting Period Premium 145% of premium Employment -Related Practices Liability: Limits $1,000,000 Each Claim Limit $1,000,000 Policy Aggregate Limit Retention Amount Each Claim $10,000 Retroactive Date 8/31/2011 Coinsurance 0% Subject to a Maximum of Each Claim Defense Inside the limits Optional Extended Reporting Period Premium 109% if 12 months extended reporting is chosen 137% if 24 months extended reporting is chosen 165% if 36 months extended reporting is chosen Cost of appeal bonds or bonds to release attachments Included Payment of Damages Pay on behalf of Loss of Earnings due to assisting with investigation/defense of claim $250 per day All costs taxed against insured in suit Included Salary Remuneration Sublimit does not apply Definition of claim includes • Arbitration • Other alternative dispute resolution proceedings Who is insured • Named Insured • Current or Former Directors • Current or Former Employees • Current or Former Leased Employees Access to Risk Management Library via web Included Account Name: Policy Period: 08/31/2021 to 08/31/2022 Quote Number: Policy Coverage Symbol Limit Liability Combined Single Limit 1 $1,000,000 Personal Injury Protecton (PIP) 5 $2,500 Medical Payments Coverage Not Selected Uninsured/Underinsured Motorists 7 $1,000,000 Comprehensive Deductible - See Vehicles 7 Collision Deductible - See Vehicles 7 Hired Auto Liability Combined Single Limit Combined Single Limit Comprehensive Coverage Not Selected Specified Causes of Loss Coverage Not Selected Collision Coverage Not Selected Non -Owned Auto Liability Combined Single Limit $1,000,000 Drive Other Car Liability Combined Single Limit Coverage Not Selected Medical Payments Coverage Not Selected Uninsured/Underinsured Motorists Coverage Not Selected Comprehensive Coverage Not Selected Collision Coverage Not Selected Account Name: Policy Period: 08/31/2021 to 08/31/2022 Quote Number: Commercial Automobile Auto Endorsements / Enhancements 8E2419 04/17 Commercial Automobile Extension Endorsement CA2264 07/08 Texas Personal Injury Protection Endorsement 81_1303 06/15 Texas Policyholder Complaint Procedures IL0021 04/98 Nuclear Energy Liability Exclusion Endorsement CA0001 03/10 Business Auto Coverage Form CA0196 03/12 Texas Changes IL0017 11/98 Common Policy Conditions CA2394 03/06 Silica or Silica -Related Dust Exclusion for Covered Autos Exposure CA0243 03/01 Texas Changes -Cancellation And Nonrenewal 8L2182 05/16 Texas Uninsured/Underinsured Motorist Coverage Selection/Rejection CA2109 05/13 Texas Uninsured/Underinsured Motorist 8L938 04/05 Utica Lloyds of Texas 8L1339TX 09/19 Attention Texas Policyholders Premium $250.00 Included Included Included Included Included Included Included Included Included Included Included Included Account Name: Policy Period: 08/31/2021 to 08/31/2022 Quote Number: Commercial Automobile State: TX Vehicle Schedule A list of vehicles and the coverages that apply to each: Make, Model, Other Than Vehicle Vehicle ID Number Personal Injury Medical Collision Collision # Year (VIN) Liability Protection (PIP) Payments Deductible Deductible Towinq Premium 1 2006 HEVROLET GIRARDIN X X Comprehensive $1,000 $1,096.0 1GBJG31U661239854 $1,000 2 2010 HEVROLET STARTRANS X X Comprehensive $1,000 $1,096.0 1GB6G3AG5A1111517 $1,000 3 2018 3LUEBIRD BUS X X Comprehensive $1,000 $1,274.0 1 BAKGCEA4J F346083 $1,000 4 2020BLUEBIRD 77P BUS X X Comprehensive $1,00 $1,533.0 1 BAKGCEA8LF366551 $1,000 If physical damage coverage is selected, valuation applies on an actual cash value basis unless otherwise indicated. Account Name: WESTLAKE ACADEMY Policy Period: 08/31/2021 to 08/31/2022 Quote Number: 5465991 Limits of Insurance: Each Occurrence: $5,000,000 Aggregate Limit: $5,000,000 Self -Insured Retention: $10,000 Schedule of Applicable Underlying Insurance: Commercial General Liability Automobile Liability Employers Liability Abuse or Molestation Liability School District/Educators Legal Liability Employee Benefits Liability Employment Related Practices Liability Additional Considerations: "8UMC188 (EPIDEMIC OR PANDEMIC EXCLUSION) IS BEING ADDED TO THE RENEWAL 42 Utica National Insurance Group Coverages EDUCATIONAL INSTITUTIONS Educational Institution Coverage Endorsement (Excluding Student Medical Expense) General Liability Additional Insureds Aircraft • Hired, Chartered, or loaned to an insured with a paid crew that is not owned by the insured if no other insurance • "Insured Contract" coverage for use of aircraft that are not used for rides to and from school Bail Bonds "Bodily Injury" • Arising from providing or failing to provide professional health care services — includes employees, volunteers and auxiliary instructors • Includes shock, mental anguish or mental injury • To co -employees, co -volunteers & co -instructors Damage to Premises Rented to You — Includes Fire, Lightning, Explosion Extended Bodily Injury includes use of reasonable force to: • Protect persons or property • Restrain or remove a pupil whose behavior is disruptive despite request to refrain from such behavior Knowledge of occurrence — limits notification requirements to certain specified individuals Loss of Earnings due to assisting with investigation/defense of claim Medical Payments extended to cover volunteers iti L1SSS • By Contract, Agreement or Permit — Primary if required • Engineers, Architects or Surveyors • Lessor of Leased Equipment " Managers/Lessors of Premises • Owner of Leased Land * Vendors of your products Included if no other insurance Included Up to $2,500 Included Included $25,000 Per Occurrence $25,000 General Aggregate Greater of $500,000 or Amount Listed in Declarations Included Included Included Up to $500 a day Included 7-A-469 Ed. 02-2018 Page 1 of 2 Coverages (continued) New broadenings to General Liability, if no additional premium, Included immediately apply Parking non -owned autos on or on ways next to owned or rented Included premises Personal and Advertising Injury assumed in an "insured contract" Included Personal and Advertising Injury definition includes mental anguish, Included shock, and humiliation "Personal injury" covers non -employment discrimination — other carriers Included may call this Third -Party Employment Practices Liability Pollution incidents occurring inside buildings due to sanctioned Included classroom activities Property Damage to personal property in your care, custody or control Applies on excess basis Unintentional failure to disclose hazards will not prejudice your rights to Included coverage Watercraft • While ashore on premises owned or rented Included • Non -owned boats not for hire, profit or rides to/from school Included if no other insurance • Nonowned watercraft No length limitation Who Is Insured broadened to include: ■ Appointed or elected administrative officials Included • Auxiliary instructors; not employee or volunteer teacher Included • Board Members or commissioner if a public board or Included commission • Employees Included • Limited Liability Company including managers and members Included • Student and volunteer workers participating in: Included • Internships, • School to work or similar programs • Trustees or Board of Governors Included • Student teachers Included • Subsidiaries if no other insurance Included This summary represents an outline of coverage available from the companies of the Utica National Insurance Group. No coverage is provided by this summary. Coverage availability, terms and conditions are dictated by the policy and may vary by state. For questions on coverages, contact your independent agent. 086 Utica National Insurance Group VAF Insurance that starts with you:`" Utica Mutual Insurance Company and its affiliated companies. New Hartford, NY 13413 www.uticanational.com 9110 7-A-469 Ed. 02-2018 Page 2 of 2 rh- - �-` EDUCATIONAL INSTITUTIONS Utica National Insurance Group cuss Minimize the Chance of Employment Issues! Toll -Free Advice Line Available for Employment Practice Questions Utica National has partnered with Jackson Lewis P.C., a law firm specializing in employment law, to provide risk management services that can help you prevent employment issues, out-of-pocket expenses, and damage to your reputation. Take advantage of employment practices advice to get the help you need when you need it — provided at no additional cost to our school policyholders! Legal context and advice on workplace law issues including: • What you should generally do when faced with a sexual harassment, discrimination, or retaliation issue • Points to consider when adding a section to the employee handbook about references • What employment training you are required by law to offer? Which topics will best help you prevent adverse employment situations Advice Line ® Service is always confidential. • Available from 9:00 a.m. to 5:00 p.m. If there is an unusually high volume of inquiries, calls are returned the same day or within 24 hours. How It Works School administrators and human resource staff can call 1-844-635-8696 and seek the employment practices advice they need. You will be asked for your Utica National CPP policy number. Take advantage of this new risk management resource to reduce the risk of accusations! For more information on the hotline, contact Jackson Lewis P.C. at 1-844-635-8696 or your agent. If you have a claim to report, email us at claimsnewreport@uticanational.com or call us at 1-800-216-1420. In responding to helpline calls, Jackson Lewis P.C. cannot provide legal advice on specific employment matters, such as the firing or other treatment of specific employees, or on complex matters such as employee benefits, executive compensation, non -competition or other employment agreements, reductions -in -force, or transactional matters. In situations where Jackson Lewis P.C. is asked to give advice on complex matters or the legal risks of, or strategies for, a particular course of action, you will be advised to retain an attorney to conduct a proper review of surrounding facts and applicable laws. VUtica National Insurance Group Insurance that starts with you:' Utica Mutual Insurance Company and its affiliated companies, New Hartford, NY 13413 www.uticanational.com • 1.800.598.8422 14W TRAVELERS) Sharon Minitre BOX INSURANCE AGENCY 1200 S MAIN ST STE 1600 GRAPEVINE, TX 76051 RE: Insured Name: Expiring Policy Number: Policy Period: Dear Sharon Minitre: WESTLAKE ACADEMY 1500 Solana Boulevard Building 7, Suite 7200 WESTLAKE, TX 76262 106364590 August 31, 2019 to August 31, 2020 Wrap+`0 On behalf of Travelers Casualty and Surety Company of America we are pleased to provide the attached proposal of insurance for your review. The quotes contained in this document are valid until the expiration of your current policy, and are subject to the provision of, and Travelers' review and acceptance of, the required underwriting information noted in the Contingencies section. Travelers reserves the right to change the quotes in this document, or to refuse to bind coverage entirely, based on review of the required underwriting information or based on adverse change in the risk(s) to be insured prior to the quote expiration date noted in this document. Please note that we require a response to this document prior to expiration of the Insured's current policy in order to facilitate policy renewal. The insured's current policy will expire and not be renewed in the absence of a request, and Travelers' agreement, to bind coverage. Travelers is pleased to offer Risk Management PLUS+ Online®, the industry's most comprehensive program for mitigating your management liability exposures, which is available to you at no additional cost. Please visit www.rmplusonline.com to view the services that are available. If you have additional questions about the site please contact your Underwriter. Travelers Casualty and Surety Company of America, a subsidiary of The Travelers Companies, Inc., has consistently earned high ratings for financial strength and claims -paying ability from independent rating services, including a current A.M. Best rating of A++*. Founded in 1853, The Travelers Companies, Inc. is a Fortune 500 company, a component of the Dow Jones Industrial Average, and a leading provider of property casualty insurance for businesses. Thank you for considering Travelers for your client's insurance coverages. We look forward to discussing this opportunity with you. Sincerely, Savannah M Peterson Travelers Bond & Specialty Insurance *A.M. Best's rating of A++ applies to Travelers Casualty and Surety Company of America as well as to certain insurance subsidiaries of Travelers that are members of the Travelers Insurance Companies pool; other subsidiaries are included in another rating pool or are separately rated. For a listing of companies rated by A.M. Best and other rating services visit www.travelers.com. Ratings listed herein are as of October 2018, are used with permission, and are subject to changes by the rating services. For the latest rating, access www.ambest.com. LTR-4000 Rev. 07-16 Page 1 of 3 © 2016 The Travelers Indemnity Company. All rights reserved. Travelers Casualty and Surety Company of America QUOTE OPTION #1 CRIME COVERAGES: Crime Single Loss Single Crime Single Loss Single Insuring Limit of Loss Insuring Limit of Loss Agreements Insurance Retention Agreements Insurance Retention A - Fidelity F - Computer Crime 1. Employee Theft $250,000 $2,500 1. Computer Fraud $250,000 $2,500 2. ERISA Fidelity $250,000 $0 2. Computer Program and Electronic $100,000 $2,500 3. Employee Theft of Client Not Covered Data Restoration Expense Property B - Forgery or Alteration $250,000 $2,500 G - Funds Transfer Fraud $250,000 $2,500 C - On Premises $250,000 $2,500 H - Personal Accounts Protection 1. Personal Accounts Forgery or Alteration Not Covered 2. Identity Fraud Expense Reimbursement Not Covered D - In Transit $250,000 $2,500 1- Claim Expense $5,000 $0 E - Money Orders and $250,000 $2,500 Counterfeit Money Insured's Premises Covered: Worldwide, except Not Applicable TOTAL ANNUAL PREMIUM - $2,850.00 (Other term options listed below, if available) LIMIT DETAIL: Shared Additional Defense Limit of Liability: Crime Policy Aggregate Limit of Insurance: PREMIUM DETAIL: Policy Term is 8/31 /2019-8/31 /2022 N/A N/A Term Payment Type Premium Taxes Surcharges Total Premium Total Term Premium 2 Year Prepaid $5,416.00 $0.00 $0.00 $5,416.00 $5,416.00 3 Year Prepaid $8,124.00 $0.00 $0.00 $8,124.00 $8,124.00 2 Year Installment $2,850.00 $0.00 $0.00 $2,850.00 $5,700.00 3 Year Installment $2,850.00 $0.00 $0.00 $2,850.00 $8,550.00 POLICY FORMS APPLICABLE TO QUOTE OPTION # 1: CRI-2001-0109 Crime Declarations Page CRI-3001-0109 Crime Policy Form ENDORSEMENTS APPLICABLE TO QUOTE OPTION # 1: ACF-7006-0511 Removal of Short -Rate Cancellation Endorsement CRI-19060-0713 Replace General Agreement E - Change of Control - Notice Requirements Endorsement CRI-19072-0315 Global Coverage Compliance Endorsement — Adding Financial Interest Coverage and Sanctions Condition and Amending Territory Condition CRI-19085-0516 Social Engineering Fraud Insuring Agreement Endorsement CRI-19097-0517 Replace Exclusion BB. Endorsement CRI-19101-1117 Amendatory Endorsement for Certain ERISA Considerations CRI-4019-0911 Texas Changes Endorsement CRI-5044-0613 Texas Cancellation or Termination Endorsement LTR-4000 Rev. 07-16 Page 2 of 3 © 2016 The Travelers Indemnity Company. All rights reserved. Accident Fund- Box Bonding Agency, LLC dba Box Insurance Agency To: WESTLAKE ACADEMY From: Accident Fund General Ins Co Agency: Box Bonding Agency, LLC dba Box Insurance Agency Agency Code: 9044630 Agency Contact: Date: Friday, July 30, 2021 Insured: WESTLAKE ACADEMY Quote Id: 6212680-01 City/State: WESTLAKE, TX FEINisSN: 752449357 Policy Effective 08/31/2021 Date: Policy Expiration 08/31/2022 Date Transaction 8/31/2021 Effective Date: Premium: $18,492.00 Minimum $250.00 Premium: Premium: Dividend Plan: VAR NATIONAL DIVIDEND PL NDP1 nip . Payment Plan: Direct Bill - 10 Pay (Deposit 10%) Each Accident Disease - Policy Limit Disease - Each Employee $1,000,000.00 $1,000,000.00 $1,000,000.00 Installment # Date Due Installments Amount($) 1 8/31/2021 WC Policy - Initial Installment - 10% 1,849.20 2 9/30/2021 WC Policy - Installment 1,849.20 3 10/31/2021 WC Policy - Installment 1,849.20 4 11/30/2021 WC Policy - Installment 1,849.20 5 12/31/2021 WC Policy - Installment 1,849.20 6 1/31/2022 WC Policy - Installment 1,849.20 7 2/28/2022 WC Policy - Installment 1,849.20 8 3/31/2022 WC Policy - Installment 1,849.20 9 4/30/2022 WC Policy - Installment 1,849.20 10 5/31/2022 WC Policy - Installment 1,849.20 Total Installments $18,492.00 A per bill fee may apply. 1 Pay (Deposit 100%) 2 Pay (Deposit 50%) 4 Pay (Deposit 25%) 12 Pay (Deposit 8%) Premium Finance - Full Pay AccuPremium State LocationClass Code Class Description Texas 1 8810 CLERICAL OFFICE EMPLOYEES NOC Texas 1 8868 SCHOOL; CHURCH Texas 1 9101 SCHOOL ALL OTHER EMPLOYEES Subtotal Texas 1 9740 Texas 1 9812 Texas 1 0930 Texas 1 9898 Texas 1 9887 Texas 1 9874 Texas 1 0063 Texas 1 0900 Subtotal Total for Location Total State Premium Total For Policy Premium Basis $328,000.00 $5,800,000.00 $280,400.00 TERRORISM $6,408,400.00 INCR LIMITS OF EMPLOYERS LIAB $35,627.00 WAIVER OF SUBROGATION 2% $0.00 EXPERIENCE MODIFICATION $36,839.00 SCHEDULE CREDIT $24,682.00 TX HEALTHCARE NETWORK CREDIT $20,733.00 PREMIUM DISCOUNT $18,245.00 EXPENSE CONSTANT $0.00 Rate per $100/Factor 0.1000 0.4800 2.6600 0.0240 0.0140 1.0000 0.6700 0.8400 0.8800 0.0790 0.0000 Est. Annual Premium $328.00 $27,840.00 $7,459.00 $35,627.00 $1,538.00 $499.00 $713.00 ($12,157.00) ($3,949.00) ($2,488.00) ($1,441.00) $150.00 ($17,135.00) $18,492.00 $18,492.00 $18,492.00 CHUBB Named Insured: Westlake Academy Eligibility: Class 1: All students of the Policyholder Class 2: All faculty and staff of the Policyholder Coverage Term: August 021 to Aug t 31 022 Policy Number: GLM N143O2943 Renewal Premium: $2,000 Covered Activities: Educational Travel Coverage Out -of -Country Medical Expense Benefits Accident & Health Division 2 Riverway, Ste goo Houston,T\ 77o56 USA Benefit Maximum: $50,000 per person Deductible: $o per Covered Accident or Sickness Preexisting Conditions: Treated as any other medical condition Dental Treatment: $500 (Injury & Alleviation of Pain) Pregnancy Benefit: Treated as any other medical condition Room & Board: Average semi private room rate Intensive Care: Two times the average semi private room rate Chiropractic Care: $350 ($35 per visit up to a maximum of 10 visits) Prescription Drugs: Inpatient Co-insurance: t00% of covered expenses Outpatient Co-insurance: t00% of covered expenses Coinsurance: t00% of the Usual and Customary Charges Incurral Period: 3o Days from the date of a Covered Accident or Sickness Maximum Benefit Period: The earlier of the date the Covered Person returns to his or her Home Country or Country of Permanent Assignment, or 26 weeks from the date of a Covered Accident or Sickness Maximum Coverage Period: 18o days any single trip Accidental Death & Dismemberment Benefit: Class 1: $10,000 Class 2: $50,000 Aggregate Limit: $250,000 Chaperone Replacement Benefit $2,000 Emergency Reunion Benefit $2,000 Emergency Medical Benefit: up to $10,000 Emergency Medical Evacuation: l00% of the Covered Expenses Repatriation Benefit: t00% of the Covered Expenses CHUESB PHILADELPHIA INSURANCE COMPANIES A Member of the Tokio Marine Group Westlake Academy Student Accident Insurance Quotation For August 31, 2021 Coverage, Benefits & Limits Accident Medical Expense: Accident Medical Expense Aggregate: Benefit Amount: Accident Dental Expense: Deductible: Deductible Type: Benefit Period: Plan Type: Accidental Death: Accidental Dismemberment: Accidental Paralysis: AD&D and Paralysis Aggregate: See Schedule of Additional Benefits & Limits below Premium Policy Premium: Minimum and Earned Policy Premium: Eligible Persons All enrolled students of the Policyholder, grades Pre-K to 12. $25,000 (per Participant, per Accident) No Aggregate 100% of Usual & Customary Charge Included in Medical $0 None 1 year Full Excess $25,000 Up to $50,000 per Schedule of Covered Losses $50,000 $500,000 (per Accident) $5,943.00 $300.00 Covered Activities Policyholder supervised and sponsored school -time activities, including interscholastic sports, including interscholastic tackle football. Underwriting & Administration The plan is underwritten by Philadelphia Indemnity Insurance Company (PIIC). PIIC is rated, A++, Superior, by A.M. Best & Company. If the terms are acceptable, we will issue the policy to the agent. The invoice will be issued on a direct bill basis to the agent's customer. Claims are administered by NAHGA Claim Services, Inc. of Bridgton, Maine. This quotation is based upon the underwriting information submitted. Changes to the underwriting information must be reported and may affect quotation. Page 1 of 2 PHILADELPHIA INSURANCE COMPANIES A Member of the Tokio Marine Group Schedule of Additional Benefits & Limits DEFERRED DENTAL EXPENSE BENEFIT ENDORSEMENT Deferred Treatment Period to age 21 Deferred Treatment Maximum Benefit $1,000 Benefit Percentage 100% ACCIDENTAL DEATH AND DISMEMBERMENT BENEFITS Each of the fallavring Covered Losses may be included or deluted at tho -option al the Policyhrolde-r. Benefit .arnounts .are, variable and may be w4presse-.i as a percenra.ge of Rio Principal Sumor as a dullar .arr-,ount.. Principal Surn Loss must Ce=ur within S25., VIAL MS Jays of be Covered Accdoril Schedube of Covered Lass Coyared Loss Benefit Loss of Lite 1013% of the Principal Sun' Loss of Two or Mzir'v Hands or Peel 241G% of ff)b, Principal 'Bum Lass of Sight of firth Eyes 2,Doge of the PrincipalSum Lost: of One Hand Dr Fwl: and Sight irr Une Eye Quadriplegia Parapfeg ia. pentiplegia. Loss of ► ne- Hand of Fc- t Lcns of Sight in One E� o LLxs of Speech Loss of Hearing in Bath Ears Loss c"31 l hur ib aOd lhd&x Fir3cier' al the Same Hand Aggregate Limit of Indemnity 4,pt ie.s 10: 2i1G% of the- Principal Sum 2110% of if ie, Principal. Sum 200% or the Principal Surn 20G%, of the. (Principal Sum 100% of ft- Principal Sum 1-013%or Mom Principal Surn t+OG`3% of IhLx Principal Sun! 100%- of Itre Principar Sum KT, cif the Priri+cipad Surn. S 50 o'Do i Ail Curiditluns or Coverage PathlD 13650074 Page 2 of 2 COVERAGE 3rd Party Coverages: Data Compromise Liability Network Security Liability Electronic Media Liability 1 st Party Coverages: Data Compromise Response Expense Computer Attack and Cyber Extortion Response Expense Identity Recovery LIMITS $1,000,000 Per Occurrence $1,000,000 Per Occurrence $1,000,000 Per Occurrence $ 500,000 Per Occurrence $ 500,000 Per Occurrence $1,000,000 Per Occurrence $ 25,000 Per Occurrence Utica National Insurance Group Cyber Suite Cyber Suite Coverages: Applicable Limit Data Compromise Response Expense covers personal data compromises Included in aggregate limit, and affords: unless otherwise noted • Notification of Affected Individuals 12 Months • Services to Affected Individuals, which can include credit monitoring 50% sublimit of aggregate limit • Legal review 50% sublimit of aggregate limit • Forensic review to determine the nature and extent of breach $5,000 • Public relations services $50,000 named malware Computer Attack and Cyber Extortion coverage includes: Included in aggregate limit, • Data restoration, data recreation and system restoration unless otherwise noted • Business income/extra expense Up to 50% of aggregate limit • Public relations services $5,000 sublimit • Cyber Extortion covers the cost of a professional firm to assist the $25,000 if aggregate limit is insured through a cyber extortion threat and the costs of approved $250,000 or more extortion payments. Data Compromise Liability covers defense and settlement costs for claims Included in aggregate limit brought by or on behalf of affected individuals due to theft or loss of personal) identifying information. Network Security Liability covers defense and settlement costs due to the Included in aggregate limit unintended forwarding of malicious code, the breach of third party business information, or the unintended abetting of denial of service attack. Electronic Media Liability Coverage covers defense and settlement costs in Included in aggregate limit the event of a suit alleging that the insured infringed on a copyright or trademark, defamed a third party, or violated a person's right to privacy. Identity Recovery covers expense reimbursement and case management $25,000 services for the chief school administrator, chief financial officer, and/or treasurer. Response Expense coverage for personally identitfying information posted to Included the internet in error Coverage for personally identifying information stored with a cloud service Included provider Defense applies Inside the limits Coverage for paper breach or data proven to have been breached through an Included oral disclosure. Consent required for settlement Yes Initiating breach response services required before Data Compromise Yes Liability coverage applies This summary represents an outline of coverage available from the companies of the Utica National Insurance Group. No coverage is provided by this summary. All coverages are individually underwritten. Coverage availability, terms and conditions are dictated by the policy and may vary by state. In the event of a loss, the terms of the policy issued will determine the coverage provided. V j Utica National Insurance Group Insurance that starts with you. ut-ca maual insurance Company and its affa�atcd companies. New Nartlord, NY 13417 www. ulicanation0l corn 91 r Our Four -Point Claim Promise to You Peace -of -Mind Equa JR; of the CLASS" Trust Utica National to Handle Claims for Your Educational Institution Accidents happen. When they do, and you have to submit a claim, our claims staff is responsive and works through the issues thoroughly. Here's why 97%* of our customers report high claims satisfaction: We've seen it. For over 45 years„ we've worked on thousands of unique school claims. There's a great chance we've handled a situation like yours and can help you navigate it. Guidance on emerging issues. Our claims staff is available to discuss recent trends to help illuminate new challenges at your school. Educational law specialists. If a claim should turn into a lawsuit, we use law firms specializing in educational law to defend schools, administrators and employees. Our Four -Point Promise to you: OWe explain our process to the insured school and its agent to describe our position. ® We diSCUSS all aspects of the claim before denying any claim. © We listen to pertinent information from the insured school and its agent before making any settlement offers. 0 Our legal team will inform the insured about how a case is progressing. 'Based on 2018 Claimant Satisfaction Survey Utica National strives to keep schools secure and to work collaboratively to give you wbat matters most: specialized coverage, risk management and claims expertise! For more information, contact an independent insurance agent representing the Utica National companies. VUtica National Insurance Group Insurance that starts with you® Utica Mutual Insurance Company and its affiliated companies, New Hartford, NY 13413 www.uticanational.com • 1.800.598.8422 COVERAGE ANNUAL PREMIUM Property - Crum Forster $103,995 General Liability Education Package - Utica $15,347 - Abuse or Molestation Liability - School District and Educators Legal Liability Coverage - Employee Benefits Program Liability Coverage - Employment Practices Liability Coverage Business Auto - Utica $5,394 Umbrella - Utica $7,505 Crime - Travelers $2,850 Workers Compensation - Accident Fund $18,492 Travel - International $2,000 Student Accident $5,943 Cyber Liability $400 Total $161,926 EFFECTIVE: 0813112020 COVERAGE EXPIRING PREMIUM RENEWAL PREMIUM Property - Crum Forster $91,995 $103,995 General Liability Education Package - Utica $14,461 $15,347 - Abuse or Molestation Liability - School District and Educators Legal Liability Coverage - Employee Benefits Program Liability Coverage - Employment Practices Liability Coverage Business Auto - Utica $5,029 $5,394 Umbrella - Utica $7,138 $7,505 Crime - Travelers $2,850 $2,850 Workers Compensation - Accident Fund $25,924 $18,492 Travel - International $2,000 $2,000 Student Accident $5,943 $5,943 Cyber Liability $400 $400 Total $155,740 $161,926 EFFECTIVE: 0813112021 OPTION TOTAL ANNUAL PREMIUM Crum Forster: Travelers: Philadelphia: CHUBB: Utica: Accident Fund: TOTAL DUE NOW Total Premium By Carrier $103,995 $2,850 $5,943 $2,000 $28,646 $18,492 Direct Bill Terms Available from each carrier (Interest Free) INSURED: Westlake Academy INSURED SIGNATURE: DATED:g' / `0 / —:'OV