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WA Res 26-13 Agreement with Box Insurance for WA Insurance Products and Svcs
Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 1 of Westlake Academy (the “Academy”), a public charter school operated by the Town of Westlake, Texas (the “Town”), is soliciting proposals from qualified and experienced firms to provide insurance brokerage services for its property and casualty insurance programs. The purpose of this Request for Proposals (RFP) is to identify a qualified firm to assist the Town and the Academy (collectively, the “Town and Academy”) in the placement, administration, and ongoing management of their insurance coverages, including but not limited to property, liability, workers’ compensation, automobile, and student accident insurance. The selected firm will serve as the insurance broker of record for the Town and Academy and will provide professional services including market analysis, coverage recommendations, policy placement, claims support, and risk management consultation. The Town and Academy seek a partner with demonstrated experience in serving public sector and/or educational organizations, with the ability to deliver comprehensive coverage solutions, competitive pricing, and a high level of service. This RFP outlines the scope of services, proposal requirements, and evaluation criteria to be used in selecting the firm that provides the best overall value to the Town and Academy. CONTRACT TERM: The contract shall be for an initial term of one (1) year beginning July 1, 2026, and ending June 30, 2027, with the option to renew for four (4) additional one-year terms, for a total possible contract term of five (5) years. Renewal of the contract is contingent upon satisfactory performance, mutual agreement of the parties, and annual budgetary appropriation by the Townand Academy. Westlakereserves the right to renew or not renew the contract at its sole discretion. Proposers are encouraged to provide multi-year rate guarantees or clearly identify any projected rate adjustments applicable to renewal terms. POSTED DATE: May 7, 2026 PROPOSAL DUE DATE: June 2, 2026 PROPOSAL DUE TIME: 12:00 PM CST CONTACT: SandyM. Garza, Purchasing Agent E-mail: sgarza@westlaketx.gov REQUEST FOR PROPOSAL 5)3:HVWODNH$FDGHP\3URSHUW\ /LDELOLW\,QVXUDQFH 352326$/180%(5 5)3±:HVWODNH$FDGHP\3URSHUW\ /LDELOLW\,QVXUDQFH Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 2 of 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@westlaketx.gov 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 Name and Title (Typed or Printed): Federal ID Number (TIN) or SSN and Name Signature Telephone No. Date: Email address: BoxInsuranceAgency AdamSyswerda 82-1453817 817-865-1806 adamboxinsurance.com 5/27/26 Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 3 of TABLE OF CONTENTS Table of Contents …………………………………………………………….. 3 Acknowledgement of Receipt ......………….……………………….............. 4 Questionnaire…………………………………………………………………… 5 General Requirements and Instructions.……………………………………. 6 Policy Requirements and Limits ...……………………………………. ........ 9 Property Insurance, Fire and Extended Equipment Coverage ... ........ 9 General Liability, EPLI, EBLI, ELLI, D&O Insurance …………. ........... 11 Automobile and Physical Damage Insurance …………………………. 14 Umbrella Liability Insurance ………………………………………. ........ 16 Crime Insurance ……………….…………………………………… ........ 18 Workers’ Compensation Insurance.….……………………………. ....... 20 International Travel Insurance ...………….………………………. ........ 22 Student Accident Insurance....…...……….………………………. ......... 24 Cyber Liability Insurance …………………………………………… ....... 26 Proposal Submittal Format.……………………………………………. ........ 28 Exhibit “A” - Property Schedule………………………………………. ......... 29 Felony Conviction Notice Form.………………………………………. ......... 30 Non-Collusion Statement.……………………………………………… ........ 31 Conflict of Interest Questionnaire ….…………………………………. ........ 32 W-9 Form ...…………………………………………………………… ........... 34 Form 2270 ...……………………………………………………………. ......... 40 Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 4 of 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 May 22, 2026 to: Sandy M. Garza Town of Westlake / Westlake Academy sgarza@westlaketx.gov Name of Firm: _________________________________________________ Address: _____________________________________________________ City/State/Zip: _________________________________________________ Phone: (_____) ________________________________________________ E-Mail: _______________________________________________________ Name: (Print) __________________________________________________ Title: _________________________________________________________ Signature: ____________________________________________ Date: _________________________ _______Yes, our company does have an interest in responding. BoxInsuranceAgency 1200SMainStreet,Ste.1600 Grapevine,TX76051 817 865-1806 adamboxinsurance.com AdamSyswerda President X Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 5 of QUESTIONNAIRE 1. Who will have primary responsibility for Westlake Academy’s account? _______________________________________________________________________ a. Number of years in the insurance business: ___________________________________ b. Insurance background: ____________________________________________________ _____________________________________________________________________ c. Number of schools or public entities serviced: __________________________________ 2. Who will be the back-up person for Westlake Academy’s account? _____________________________________________________________________ a. Number of years in the insurance business: ___________________________________ b. Insurance background: ___________________________________________________ __________________________________________________________________________ c. Number of schools or public entities serviced: __________________________________ 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. DustinParker 20 CEO,BoxInsuranceAgency 7 AdamSyswerda 13 President,BoxInsuranceAgency 7 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 July 1, 2026 through June 30, 2027. 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@westlaketx.gov. 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 sgarza@westlaketx.gov . 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 May 8, 2026. Advertisements will be posted for two (2) weeks in the Town’s newspaper of record (Fort Worth Star-Telegram) on May 10, 2026 and May 17, 2026. %LEGAL 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. &COMMUNICATION Proposals should reference “RFP 26-0 – Westlake Academy Property & Liability Insurance”. Proposer is required to provide an electronic copy of proposal to: Sandy M. Garza sgarza@westlaketx.gov Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 6 of D. COMMUNICATION WITH TOWN OF WESTLAKE/WESTLAKE 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. (TIME FRAME The RFP package will be available for download from our website at httpV://www.westlakeW[RUJ%LGV3URSRVDOV.Vendors WILL NOT be notified of additional information/addendapostings. It is the vendor’sresponsibility to view the web page regularly, or prior to submitting aproposal response, to ensurethat no addenda or additional information have been issued for thesolicitation. Proposals: must be delivered electronically via email to sgarza@westlaketx.gov , 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., Tuesday, June 2, 2026. The parties submitting the selected proposals will be notified by June 5, 2026 of the Academy’s decision. The effective date for proposals is July 1, 2026. Policies or coverage documents are to be provided to the Academy by June 30, 2026. The Academy reserves the right to not pay any premium until valid policies or coverage documents are received. )PROPOSALS 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. Each party submitting a proposal is asked to screen their designated proposals for correctness and compliance with the specifications. The contents of the proposals shall be kept confidential during the process of review. *DISQUALIFICATION AND REJECTION OF PROPOSALS 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. +SELECTION OF VENDOR 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. Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 7 of Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 8 of 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 I.TERMS OF AGREEMENTS 1. Westlake Academy desires to receive proposals for a twelve (12) month period, beginning on July 1, 2026 through June 30, 2027. 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 e 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. Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 9 of POLICY REQUIREMENTS AND LIMITS 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. PROPERTY, FIRE, AND EXTENDED EQUIPMENT INSURANCE A.BACKGROUND INFORMATION 1. Please contact Purchasing Agent at sgarza@westlaketx.gov 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 July 1, 2026 is as follows: Description Limit Deductible Coinsurance Building Physical Property $57,611,607 Building Personal Property $4,782,550 Business Income and Extra Expense $444,000 Total Property Limits $62,839,157 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 $57,611,607 Building Personal Property $4,782,550 Business Income and Extra Expense $444,000 $25,000 100% $25,000 100% $25,000 100% $25,000 100% 72Hours Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 10 of 2. Is automatic coverage for newly acquired property provided: Yes No If yes, please attach description. 3. Does coverage include equipment breakdown? Yes No If yes, please attach description. 4. Is there additional deductible or exclusion for wind, hail or earthquake? 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 07/01/2026 to 06/30/2027): $________________________________ 2. Alternate Property, Fire, and Extended Equipment Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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: 127,807 ChubbIndemnityInsuranceCompany A++XV ✔ ✔ ✔ ✔ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 11 of GENERAL LIABILITY INSURANCE A.BACKGROUND INFORMATION 1. All coverage in Section “B” must be included. Please contact Purchasing Agent at sgarza@westlaketx.gov for loss runs. 2. Estimated student count is 910. Grades K-8: 585 Grades 9-12: 325 3. Estimated number of full-time equivalent employees is 113. Total employees (including substitute teachers) is approximately 170. 4. Sports programs include: Football, basketball, volleyball, baseball, softball, track, cross country track, tennis, golf, softball, cheerleading, soccer and swimming. 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 Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 12 of C.QUOTED COVERAGE PROVISIONS 1. Coverage Detail Per Occurrence Aggregate Deductible General Liability Products/Completed Operations Personal & Advertising Injury Damage to Rented Premises Medical Expenses Employee Benefits Liability Abuse & Misconduct Liability Professional Liability – D&O Educators Legal Liability Employment Practices Liability 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 07/01/2026 to 06/30/2027): $________________________________ 2. Alternate General Liability, EPLI, EBLI, EELI, and D&O Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ 1,000,000 2,000,000 1,000,000 2,000,000 1,000,000 2,000,000 1,000,000 10,000 1,000,000 3,000,000 1,000 1,000,000 1,000,000 0 1,000,000 2,000,000 10,000 1,000,000 2,000,000 10,000 1,000,000 1,000,000 10,000 36,848.00 Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 13 of E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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: UticaMutualIns.Co./UticaNationalInsuranceGroup AXIV ✔ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 14 of AUTOMOBILE & PHYSICAL DAMAGE INSURANCE $BACKGROUND INFORMATION Please contact Purchasing Agent at sgarza@westlaketx.gov for loss runs. Current list of vehicles: 2018 Blue Bird Bus – 77 passengers 2020 Blue Bird Bus – 77 passengers 2023 Chevrolet Express Van – 15 passengers 2023 Chevrolet Express Van – 15 passengers 2023 Chevrolet Express Van – 15 passengers &KHYUROHW*LUDUGLQ Bus - 18 passengers &KHYUROHW6partans Bus - 20 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: Coverage Detail 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 Collison $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 Per Occurrence Aggregate Deductible Bodily Injury & Property Damage Personal Injury Protection Uninsured Motorist Underinsured Motorist Medical Expenses Physical Damage Coverage Comprehensive Vandalism Collison $1,000,000 Accident $1,000 $2,500 Person $0 $1,000,000 Accident $0 $1,000,000 Accident $0 ACV/Repair Loss $1,000 ACV/Repair Loss $0 1,000,000 Aggregate $1,000 Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 15 of 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 07/01/2026 to 06/30/2027): $________________________________ 2. Alternate Automobile Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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: 14,589.00 UticaMutualIns.Co./UticaNationalInsuranceGroup AXIV ✔ ✔ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 16 of 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: Coverage Detail Limit Per Aggregate General Liability $5,000,000 Occurrence $5,000,000 Personal & Advertising Injury $5,000,000 Person/Org. $5,000,000 Wrongful Acts – Claims Made Basis $1,000,000 Occurrence $1,000,000 Aggregate Limit $5,000,000 Self-Insured Retention $10,000 2.Include a listing of additional coverage and coverage extensions. 3. Include a list of exclusions. C.QUOTED COVERAGE PROVISIONS 1. Coverage Detail Limit Per Aggregate General Liability Personal & Advertising Injury Wrongful Acts – Claims Made Basis Aggregate Limit Self-Insured Retention 2. Is prior acts coverage provided? Yes No If yes, please give effective date(s) and explanation. D.QUOTATION 1. Umbrella Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ 2. Alternate Umbrella Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ $5,000,000 Occurrence $5,000,000 $5,000,000 Person/Org. $5,000,000 $1,000,000 Occurrence $1,000,000 $5,000,000 $10,000 11,148.00 ✔ RetroDate:8/31/2011 Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 17 of E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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: UticaMutualIns.Co./UticaNationalInsuranceGroup AXIV ✔ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 18 of 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: 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 2.Include a listing of additional coverage and coverage extensions. 3. Include a list of exclusions. C.QUOTED COVERAGE PROVISIONS 1. Coverage Detail Single Loss Limit Retention Employee Theft ________________ _____________ ERISA Fidelity ________________ _____________ Forgery or Alteration ________________ _____________ On Premises ________________ _____________ In Transit ________________ _____________ Money Orders/Counterfeit ________________ _____________ Computer Fraud ________________ _____________ Program/Restoration Expense ________________ _____________ Funds Transfer Fraud ________________ _____________ Claim Expense ________________ _____________ D.QUOTATION $100,000 $250,000 $5,000 $250,000 $250,000 $250,000 $250,000 $250,000 $250,000 $250,000 $2,500 $0 $2,500 $2,500 $2,500 $2,500 $2,500 $2,500 $2,500 $0 Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 19 of 1. Crime Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ 2. Alternate Crime Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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: TravelersInsuranceCompany AXV ✔ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 20 of WORKERS’ COMPENSATION INSURANCE A.BACKGROUND INFORMATION 1. Please contact Purchasing Agent at sgarza@westlaketx.gov for loss runs. 2. Experience Modifier is currently 0.77. 3. Estimated FY 26-27 payroll schedule is below. 4. Estimated number of regular employees is 116 (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 26-27 payroll is as follows: Payroll Code Annual Amount Employees 8868 105 (does not include substitute teachers) 8810 7 9101 $ 90,000 1 Total Estimated Payroll: $ 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. D.QUOTATION 1.Workers’ Compensation Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ 2. Alternate Workers Compensation Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 21 of E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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: TheHartford A+XV ✔ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 22 of 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 Limit Per Aggregate Medical Expense Limit $ 50,000 Person $ 50,000 Dental Treatment $ 250 Tooth $ 500 Room and Board Average semi-private room rate ICU Room and Board Charges Twice the semi-private room rate Treatment of Pregnancy Treated as any other medical condition Preexisting Conditions Treated as any other medical condition Chiropractic Care $ 35 Visit $ 350 Emergency Medical Evacuation 100% Expenses Repatriation of Remains 100% Expenses Chaperone Replacement $ 2,000 Accidental Death & Dismemberment $ 10,000 Student Accidental Death & Dismemberment $ 50,000 Faculty Kidnap/Ransom $ 100,000 Event $ 100,000 Aggregate Limit $ 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 Limit Per Aggregate 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 _________ _________ ___________ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 23 of 2. Does coverage include evacuation/repatriation? Yes No D.QUOTATION 1.International Travel Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027) 2. Alternate International Travel Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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 26/27 Comprehensive Insurance RFP Page 24 of 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: 910 Grades K-8: 585 Grades 9-12: 325 3. Estimated Sports Participation is as follows: 4. Football (grades 9-10): 9 Football (grades 11-12): 12 5. All other sports (grades 9-10): 44 All other sports (grades 11-12): 87 6. Batting cages or trampolines are not within the scope of the program. B. INSURANCE COVERAGE IS TO INCLUDE THE FOLLOWING: 1. Liability Limits & Coverage: Limit Deductible Accident Medical Expense $ 25,000 $ 0 Accidental Death Benefit $ 15,000 $ 0 Accidental Dismemberment $ 50,000 $ 0 AD&D Aggregate Limit $ 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: Limit Deductible Accident Medical Expense _________ _________ Accidental Death Benefit _________ _________ Accidental Dismemberment _________ _________ AD&D Aggregate Limit _________ 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 07/01/2026 to 06/30/2027): $________________________________ 2. Alternate Student Accident Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 25 of E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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 26/27 Comprehensive Insurance RFP Page 26 of CYBER RISK LIABILITY 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: Limit Deductible Liability Coverages Networks and information security $ 1,000,000 $10,000 Communications and media $ 1,000,000 $10,000 Regulatory defense expenses $ 500,000 $10,000 1st Party coverage Crisis Management event expenses $ 500,000 $10,000 Security Breach remediation and $ 500,000 $10,000 notification expenses E-commerce extortion $ 500,000 $10,000 Business interruption and additional $ 500,000 24 Hours Expenses 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: Limit Deductible Liability Coverages Networks and information security __________ __________ Communications and media __________ __________ Regulatory defense expenses __________ __________ 1st Party coverage __________ __________ Crisis Management event expenses __________ __________ Security Breach remediation and __________ __________ notification expenses E-commerce extortion __________ __________ Business interruption and additional __________ __________ expenses Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 27 of D.QUOTATION 1. Cyber liability Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ 2. Alternate Cyber liability Insurance Quote (Attach complete coverage information) Annual Premium (Period 07/01/2026 to 06/30/2027): $________________________________ E. INSURANCE COMPANY/RISK POOL INFORMATION Name of Company: _________________________________________________________ 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 26/27 Comprehensive Insurance RFP Page 28 of 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 26/27 Comprehensive Insurance RFP Page 29 of 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 22,278 14,505,852 100% concrete tile #2: 20,260 10,355,419 100% concrete tile #3 10,492 5,302,872 100% concrete tile #4: 8,400 6,706,997 80% concrete tile, 20% flat membrane #5: 8,900 3,447,870 75% seam metal, 25% flat membrane #6: 8,900 4,171,687 25% concrete tile, 75% flat membrane #7: 19,820 6,960,683 75% seam metal, 25% flat membrane #8: 12,500 2,249,100 100% Shingle #9: 12,500 2,249,100 100% Shingle #10 1,554,786 Turf #11 107,241 Lights/Scoreboard Property (Blanket) Limits: 2. Contents: $57,612,607 $4,782,550 3. Business Income and Extra Expense:$ 444,000 4. Total Property Limits $62,839,156 4 Benchmarq Property Quote Number: 0019131688 Quote Date: 05/22/2026 Account: WESTLAKE ACADEMY Agent: BOX BONDING AGENCY LLC DBA BOX INSURANCE AGENCY Producer Code: I00851 / 0082188-00154 Writing Company: Chubb Indemnity Insurance Company Effective Date: 06/30/2026 - 06/30/2027 Commercial Property Premium $127,807.00 Total Quoted Premium $127,807.00 Terrorism (Included in Commercial Property Premium) $2,774.00 Property $2,774.00 Ensuing Fire $555.00 Machinery Breakdown Included in Property The portion attributable to surcharges / assessments / taxes is an estimate. If bound, the insured is responsible for the total amount shown on the premium bill, regardless of the amount shown above. If you elect not to purchase coverage for terrorism, and your policy provides commercial property insurance in a jurisdiction that has a statutory standard fire policy, the premium shown above for ensuing fire is the amount attributable to the insurance provided pursuant to that statutory standard fire policy. This coverage cannot be rejected. 5 Commercial Property - Coverages Commercial Property - Premises Schedule Premises # Described Premises 1 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Policy Level – Coverages Deductible Waiting Period Extended Period $25,000 24 Hours 365 Days Premises #1, Building #1 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $14,505,852 Personal Property Automatic Increase in Limits 4% $1,600,000 Business Income with Extra Expense Automatic Increase in Limits 4% $334,000 Business Income - Civil Authority $50,000 Premises #1, Building #2 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $10,355,419 Personal Property Automatic Increase in Limits 4% $830,550 Business Income with Extra Expense Automatic Increase in Limits 4% $15,000 Business Income - Civil Authority $15,000 Premises #1, Building #3 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $5,302,872 Personal Property Automatic Increase in Limits 4% $525,000 Business Income with Extra Expense Automatic Increase in Limits 4% $15,000 Business Income - Civil Authority $15,000 Premises #1, Building #4 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $6,706,997 6 Personal Property Automatic Increase in Limits 4% $399,000 Business Income with Extra Expense Automatic Increase in Limits 4% $15,000 Business Income - Civil Authority $15,000 Premises #1, Building #5 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $3,447,870 Personal Property Automatic Increase in Limits 4% $367,500 Business Income with Extra Expense Automatic Increase in Limits 4% $15,000 Business Income - Civil Authority $15,000 Premises #1, Building #6 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $4,171,687 Personal Property Automatic Increase in Limits 4% $462,000 Business Income with Extra Expense Automatic Increase in Limits 4% $15,000 Business Income - Civil Authority $15,000 Premises #1, Building #7 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $6,960,683 Personal Property Automatic Increase in Limits 4% $577,500 Business Income with Extra Expense Automatic Increase in Limits 4% $15,000 Business Income - Civil Authority $15,000 Premises #1, Building #8 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $2,249,100 Personal Property Automatic Increase in Limits 4% $10,500 Business Income with Extra Expense Automatic Increase in Limits 4% $10,000 7 Business Income - Civil Authority $10,000 Premises #1, Building #9 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $2,249,100 Personal Property Automatic Increase in Limits 4% $10,500 Business Income with Extra Expense Automatic Increase in Limits 4% $10,000 Business Income - Civil Authority $10,000 Premises #1, Building #10 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $1,554,786 Premises #1, Building #11 - 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Coverages Limits of Insurance Building Automatic Increase in Limits 4% $107,241 8 Policy Level – Additional Coverages Coverages Limits of Insurance Arson or Theft Reward $25,000 Errors or Omissions $25,000 Goods in Transit $50,000 Lessor - Tenant Relocation Expenses $25,000 Paved or Concrete Surfaces $25,000 Policy Level – Sublimits, Deductibles, and Exclusions for Specific Perils Specific Perils Limits of Insurance Abrupt and Accidental Breakdown Included Change in Flavor, Change in Temperature, and Spoilage Applicable to all locations in the declaration $100,000 Leakage from Fire Protection Equipment and Discharge of Water Deductible $50,000 Waiting Period 48 Hours Any Other Location Exhibition, Fair, or Trade Show In Transit Specified Catastrophe Perils Earthquake Earthquake Policy Annual Aggregate Limit of Insurance $2,500,000 Limit of Insurance Earthquake Includes Earthquake Sprinkler Leakage Premises Annual Aggregate Limit of Insurance $2,500,000 Per Occurrence Limit of Insurance $2,500,000 Property Damage Dollar Deductible $100,000 Waiting Period 24 Hours Premises • 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Flood Flood Policy Annual Aggregate Limit of Insurance $2,500,000 Limit of Insurance Flood Includes Inundation, Back-Up, and Mudflow Premises Annual Aggregate Limit of Insurance $2,500,000 Per Occurrence Limit of Insurance $2,500,000 Property Damage Dollar Deductible $100,000 9 Waiting Period 48 Hours Premises • 2600 J T Ottinger Rd, Westlake, TX 76262-8012 Windstorm Windstorm Deductible or Waiting Period Property Damage Percentage Deductible 3% Property Damage Minimum Dollar Deductible $100,000 Waiting Period 72 Hours Premises • 2600 J T Ottinger Rd, Westlake, TX 76262-8012 10 Covered Premises – Automatic $250,000 Blanket Limit of Insurance Coverages Included in the Blanket Limit of Insurance $250,000 Blanket Limit of Insurance Accounts Receivable Included Electronic Data Processing Property Included Fine Arts Included Leasehold Interest Bonus Payment Prepaid Rent Sublease Profit Tenants' Lease Interest Included Included Included Included Included Leasehold Interest - Undamaged Tenant's Improvements and Betterments Included Included Non-Owned Detached Trailers Included Outdoor Trees, Shrubs, Plants, or Lawns Included Pair and Set Included Public Safety Service Charges Included Research and Development Property Included Valuable Papers Included Property Coverages – Automatic Limits of Insurance Additional Premises Coverages Automatic Total Fungus Clean-Up or Removal $25,000 $25,000 Loss of Master Key $15,000 $15,000 Loss Prevention Expenses $15,000 $15,000 Money and Securities On Premises $15,000 $15,000 Processing Water $10,000 $10,000 Additional Coverages Automatic Total Any Other Location $50,000 $50,000 Deferred Payments $25,000 $25,000 Exhibition, Fair, Or Trade Show $50,000 $50,000 In Transit $50,000 $50,000 Installation Any Job Site In Transit $25,000 $25,000 $25,000 $25,000 Mobile Communication Property (Greater Than 1,000 Feet from a Premises Shown Under Premises Schedule) $15,000 $15,000 Pollutant Clean-Up or Removal $25,000 $25,000 11 Money and Securities Off Premises $15,000 $15,000 Preparation Of Loss Fees $10,000 $10,000 Debris Removal Coverage Automatic Total Debris Removal At Premises $100,000 $100,000 Any Other Location $25,000 $25,000 In Transit $25,000 $25,000 Newly Acquired Premises or Newly Acquired or Constructed Property Coverages Automatic Total Building $2,500,000 $2,500,000 Electronic Data Processing Property $1,000,000 $1,000,000 Fine Arts $25,000 $25,000 Personal Property $1,000,000 $1,000,000 Personal Property - Existing Premises $100,000 $100,000 Business Income Coverages – Automatic Limits of Insurance Additional Premises Coverages Automatic Total Business Income - Contractual Penalties $10,000 $10,000 Business Income - Ingress and Egress $25,000 $25,000 Business Income - Loss of Utilities $15,000 $15,000 Additional Coverages Automatic Total Business Income - Any Other Location $25,000 $25,000 Business Income - Dependent Business Premises $50,000 $50,000 Business Income - Exhibition, Fair, or Trade Show $10,000 $10,000 Business Income - Pollutant Clean-Up or Removal $10,000 $10,000 Business Income - Preparation of Loss Fees $10,000 $10,000 Lessor Tenant Relocation Expenses $25,000 $25,000 Coverage Automatic Total Business Income - Newly Acquired Premises $100,000 N/A CRIME DECLARATIONS Travelers Casualty and Surety Company of America POLICY NO.106364590 Hartford, Connecticut (A Stock Insurance Company, herein called the Company) ITEM 1 NAMED INSURED: WESTLAKE ACADEMY D/B/A: Principal Address: 1500 Solana Boulevard Building 7, Suite 7200 WESTLAKE, TX 76262 Inception Date:August 31, 2025 Expiration Date:August 31, 2028 ITEM 2 POLICY PERIOD: 12:01 A.M. standard time both dates at the Principal Address stated in ITEM 1. ITEM 3 ALL NOTICES OF CLAIM OR LOSS MUST BE SENT TO THE COMPANY BY EMAIL, FACSIMILE, OR MAIL AS SET FORTH BELOW: BSIclaims@travelers.com ITEM 4 COVERAGE INCLUDED AS OF THE INCEPTION DATE IN ITEM 2: Crime CRI-2001 Ed. 01-09 Printed in U.S.A. Page 1 of 4 ©2009 The Travelers Companies, Inc. All Rights Reserved 1-888-460-6622 Travelers Bond & Specialty Insurance Claim P.O. Box 2989 Hartford, CT 06104-2989 Travelers Bond & Specialty Insurance Claim One Tower Square, MN06 Hartford, CT 06183 Mail: Overnight Mail: For questions related to claim reporting or handling, please call 1-800-842-8496. Email: Fax: CRI-2001 Ed. 01-09 Printed in U.S.A. Page 2 of 4 ©2009 The Travelers Companies, Inc. All Rights Reserved ITEM 5 CRIME Single Loss Limit of Insurance Single Loss Retention Insuring Agreement A. Fidelity B. Forgery or Alteration C. On Premises D. In Transit E. Money Orders and Counterfeit Money F. Computer Crime 1. Computer Fraud 2. Computer Program and Electronic Data Restoration Expense G. Funds Transfer Fraud H. Personal Accounts Protection 1. Personal Accounts Forgery or Alteration 2. Identity Fraud Expense Reimbursement I. Claim Expense $250,000 $500,000 Not Covered $250,000 $2,500 $2,500 $2,500 $250,000 $250,000 $250,000 $250,000 $100,000 $2,500 $2,500 $250,000 Not Covered Not Covered $5,000 $2,500 $0 $2,500 $2,500 $0 1. Employee Theft 2. ERISA Fidelity 3. Employee Theft of Client Property ITEM 5. (Cont’d) If “Not Covered” is inserted above opposite any specified Insuring Agreement, or if no amount is included in the Limit of Insurance, such Insuring Agreement and any other reference thereto is deemed to be deleted from this Crime Policy. Policy Aggregate Limit of Insurance: If a Policy Aggregate Limit of Insurance is applicable, then the Policy Aggregate Limit of Insurance for each Policy Period for Insuring Agreements A through H, inclusive, is: Not Applicable If a Policy Aggregate Limit of Insurance is not included, then this Crime Policy is not subject to a Policy Aggregate Limit of Insurance as set forth in Section V. CONDITIONS B. PROVISIONS AFFECTING LOSS ADJUSTMENT AND SETTLEMENT 1. Limit of Insurance a. Policy Aggregate Limit of Insurance. Cancellation of Prior Insurance: By acceptance of this Crime Policy, the Insured gives the Company notice canceling prior policies or bonds issued by the Company that are designated by policy or bond numbers ,Not Applicable such cancellation to be effective at the time this Crime Policy becomes effective. INSURED’S PREMISES COVERED: All Premises of the Insured in the United States of America, its territories and possessions, Canada, or any other country throughout the world, except: Not Applicable ITEM 6 ITEM 7 FORMS AND ENDORSEMENTS ATTACHED AT ISSUANCE: PREMIUM FOR THE POLICY PERIOD: $9,402.00 Policy Premium $3,134.00 ACF-7006-0511; CRI-3001-0109; CRI-19060-0713; CRI-19072-0315; CRI-19101-1117; CRI-19085-0919; CRI-19122-1120; CRI-5044-0613; CRI-4019-0911 Applicable Not Applicable Annual Installment Premium CRI-2001 Ed. 01-09 Printed in U.S.A. Page 3 of 4 ©2009 The Travelers Companies, Inc. All Rights Reserved Quote Proposal Policy Summary Quote Proposal Page 3 of 10 COVERAGE POLICY TERM POLICY NUMBER PREMIUM COMMISSION Workers' Compensation Property and Casualty Insurance Company of Hartford 06/30/2026 –06/30/2027 46WE AZ0P18 $18,939.00 8.0% Total Estimated Account Premium $18,939.00 Premium may include surcharges, taxes, and assessments. Commission percentages shown are for base commission only and do not include any applicable supplemental commission or other forms of compensation.The premiums identified above may contain surcharges and/or assessments to which the commission percentages shown above may not apply.Workers'compensation commission percentage applies to the standard premium before application of any premium discount. Business Travel Accident - Premium Indication We are pleased to provide you with the following non-binding premium indication for Business Travel Accident (BTA) insurance based upon the information used to quote the coverages shown above.Information such as employee count, class of business,risk state,and other assumptions were used to generate this non-binding indication.If you are interested in learning more including how to pursue a formal quote,additional details can be found on a separate page within this quote proposal. This premium indication is optional and is not included in the Total Estimated Account Premium in the Premium Summary Section above. AD&D, Business Only, with Additional Benefits, per below Policy Term AD&D Limit Aggregate Limit Premium Standard 06/30/2026 - 06/30/2027 5 x salary to a maximum of $500,000 $5,000,000 per Accident $1,000 Please see detailed section contained later in this quote proposal for important terms and conditions. Quote Proposal Coverage Selection Quote Proposal Page 5 of 10 WORKERS’ COMPENSATION - 46WE AZ0P18 SHORT SUMMARY Employers Liability Limit: Bodily Injury (Each Accident/Disease Policy Limit/Disease Each Employee) $1,000,000/$1,000,000/$1,000,000 States Covered by Workers Compensation Insurance (Part 1 or 3A) TX States Covered by Other States Insurance (Part 3 or 3C)All states except: Monopolistic states (ND, OH, WA, WY), US Territories, and states listed above in Part 1 or 3A Total Payroll $7,181,798 The "States Covered by Workers Compensation Insurance (Part 1 or 3A)"all have the Employer Liability Limits listed above unless higher limits are required by state law for CA, MA, NJ, NY or OR." Workers’ Compensation & Employer’s Liability Summary Premium Total Class Premium $17,877 Increased Limits Part Two $250 Waiver of Subrogation $358 Total Premium Subject to Experience Modification $18,485 Experience Modifier $185 Schedule Rating Factor -$373 Terrorism $1,724 Expense Constant $180 Premium Discount -$1,262 Total Estimated Annual Standard Premium $18,297 TOTAL ESTIMATED ANNUAL WORKERS’ COMPENSATION PREMIUM $18,939.00 MOD Experience Mod ID WC Experience Mod Mod Status TX Intrastate - 420969449 1.010 Actual EXTENDED SUMMARY State - Writing Company Name & Class Payroll Company Base Rate Premium Texas Property and Casualty Insurance Company of Hartford 9740 Terrorism Risk Insurance Program Reauthorization Act Disclosure Endorsement 7,181,798 0.024 $1,724 Quote Proposal Coverage Selection Quote Proposal Page 6 of 10 Texas Property and Casualty Insurance Company of Hartford 9741 Catastrophe (other than certified acts of terrorism)7,181,798 0.000 $0 8868 SCHOOL: PROFESSIONAL EMPLOYEES 6,499,973 0.210 $13,650 8810 CLERICAL OFFICE EMPLOYEES NOC 367,585 0.030 $110 9101 SCHOOL - ALL OTHER EMPLOYEES & DRIVERS 314,240 1.310 $4,117 0930 Waiver charge 0.020 $358 9887 Schedule Rating Factor 0.980 -$373 9812 Emp liab increased limits 0.014 $250 9898 Experience modifier 1.010 $185 Total Payroll/ Estimated Annual Premium (after credits/discounts/surcharges) $7,181,798 $18,939.00 WORKERS' COMPENSATION COMMISSION BREAKDOWN Commission Payable Premium Commission $18,297.00 8.00% WC DISCLAIMER Workers compensation commission percentage applies to the standard premium before application of any premium discount.Premium is based on an estimated payroll and subject to annual audit.Merit and Experience Mods are tentative and subject to final calculation. WC PENDING RATE DISCLAIMER A rate change filing is being considered by the proper regulatory authority.The filing may result in rates different from the rates shown on the policy. If it does, we will issue an endorsement to show the new rates and their effective date. WC STATE DISCLAIMER The following short-rate fee disclosure applies to California policies: The Hartford charges a fee if the insured cancels the policy before the end of the policy term.This means that the final premium may be increased by a short-rate or penalty cancellation fee,which varies depending on how early the policy is cancelled or whether your policy is subject to an annual minimum premium.The range of the penalty is 5%to100%of the full policy premium. 1 April 28, 202 6 Meagan Richenberger Box Insurance Agency 1200 S. Main Street Suite 1600 Grapevine, TX 76051 Dear Meagan: I am pleased to offer a flat renewal proposal for Westlake Academy. Please review the renewal terms below, which are the same as expiring. Named Insured: Westlake Academy Eligibility: Class 1: All students of the Policyholder Class 2: All faculty and staff of the Policyholder Coverage Term: June 30, 2026 to June 30, 2027 Policy Number: GLM N14302943 Renewal Premium: $2,000 Covered Activities: Educational Travel Coverage Out-of-Country Medical Expense Benefits Benefit Maximum: $50,000 per person Deductible: $0 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: 100% of covered expenses Outpatient Co-insurance: 100% of covered expenses Coinsurance: 100% of the Usual and Customary Charges Incurral Period: 30 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: 180 days any single trip Accidental Death & Dismemberment Benefit: Class 1: $10,000 Class 2: $50,000 Accident & Health Division 1330 Post Oak Boulevard, suite 800 Houston, TX, 77056, USA Shannon.roy@chubb.com 2 Aggregate Limit: $250,000 Chaperone Replacement Benefit $2,000 Emergency Reunion Benefit $2,000 Emergency Medical Benefit: up to $10,000 Emergency Medical Evacuation: 100% of the Covered Expenses Repatriation Benefit: 100% of the Covered Expenses The premium is calculated at 15% commission. The proposal is valid until June 30, 2026. If by that date you have not accepted the terms we have offered in this proposal, it will no longer be valid. We look forward to being of service to you and our mutual client. Sincerely, Shannon Roy, MBA Underwriter, Accident and Health 1330 Post Oak Boulevard, suite 800 Houston, TX, 77056, USA 346-539-3651 E: shannon.roy@chubb.com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`!`%--%'' ! H!,+-%$G + H!)5!" [KHJ%--J)'%' + H!)5!" b'$ ' +:!([3-)%:')(!) :%"%' !(! JGD#cd#3-)![J)'! ,+" H! " !(`(% %"5%"7+(:) %+"' J:% ! [3H)"5!' + H! " !(`(" :)G)77!$ e + ) %+"[ !"# $%&%''%$$%()"%*+%(% %(%&,)%($-'%.%()420567086902:;3 6;5<0=>420567086?5@:7A7B0801:6 C>DEEE02F0865<0 >EEG 5/13/25, 12:34 AM Sircon Platform https://platform.sircon.com/#/license-print 1/1 LICENSE NUMBER: 2192228 NPN: 18427110 Issue Date: 05/31/2017 Expiration Date: 05/31/2027 General Lines Agency Qualification Effective Dates Property and Casualty 05/31/2017 Life, Accident, Health & HMO 07/20/2020 BOX BONDING AGENCY, LLC NPN: 18427110 DBA: BOX INSURANCE AGENCY 1200 S MAIN ST STE 1600 GRAPEVINE, TX 76051-7529 is authorized to transact business as described above License No: 2192228 Issue Date: 05/31/2017 Expiration Date: 05/31/2027 Generated by Sircon 346010606 THIS IS TO CERTIFY THAT BOX BONDING AGENCY, LLC 1200 S MAIN ST STE 1600 GRAPEVINE, TX 76051-7529 IS HEREBY AUTHORIZED TO TRANSACT BUSINESS IN ACCORDANCE TO THE LICENSE DESCRIPTION SHOWN BELOW: General Lines Agency Property and Casualty, Life, Accident, Health & HMO Generated by Sircon 346010606 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. INSURER(S) AFFORDING COVERAGE INSURER F : INSURER E : INSURER D : INSURER C : INSURER B : INSURER A : NAIC # NAME:CONTACT (A/C, No):FAX E-MAILADDRESS: PRODUCER (A/C, No, Ext):PHONE INSURED REVISION NUMBER:CERTIFICATE NUMBER:COVERAGES IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must have ADDITIONAL INSURED provisions or 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 endorsement(s). 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. OTHER: (Per accident) (Ea accident) $ $ N / A SUBR WVD ADDL INSD 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. $ $ $ $PROPERTY DAMAGE BODILY INJURY (Per accident) BODILY INJURY (Per person) COMBINED SINGLE LIMIT AUTOS ONLY AUTOSAUTOS ONLY NON-OWNED SCHEDULEDOWNED ANY AUTO AUTOMOBILE LIABILITY Y / N WORKERS COMPENSATION AND EMPLOYERS' LIABILITY OFFICER/MEMBER EXCLUDED? (Mandatory in NH) DESCRIPTION OF OPERATIONS below If yes, describe under ANY PROPRIETOR/PARTNER/EXECUTIVE $ $ $ E.L. DISEASE - POLICY LIMIT E.L. DISEASE - EA EMPLOYEE E.L. EACH ACCIDENT EROTH-STATUTEPER LIMITS(MM/DD/YYYY)POLICY EXP(MM/DD/YYYY)POLICY EFFPOLICY NUMBERTYPE OF INSURANCELTRINSR DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (ACORD 101, Additional Remarks Schedule, may be attached if more space is required) EXCESS LIAB UMBRELLA LIAB $EACH OCCURRENCE $AGGREGATE $ OCCUR CLAIMS-MADE DED RETENTION$ $PRODUCTS - COMP/OP AGG $GENERAL AGGREGATE $PERSONAL & ADV INJURY $MED EXP (Any one person) $EACH OCCURRENCE DAMAGE TO RENTED $PREMISES (Ea occurrence) COMMERCIAL GENERAL LIABILITY CLAIMS-MADE OCCUR GEN'L AGGREGATE LIMIT APPLIES PER: POLICY PRO-JECT LOC CERTIFICATE OF LIABILITY INSURANCE DATE (MM/DD/YYYY) CANCELLATION AUTHORIZED REPRESENTATIVE ACORD 25 (2016/03) © 1988-2015 ACORD CORPORATION. All rights reserved. CERTIFICATE HOLDER The ACORD name and logo are registered marks of ACORD HIRED AUTOS ONLY 3/25/2026 Professional Insurance Agents of Texas c/o Cindy Cicack 16515 Pilgrims Circle Spring TX 77379 817-865-1806 817-424-1404 certificates@boxinsurance.com Utica National Insurance of TX 43478 BOXINSU-01 Box Bonding Agency LLC dba Box Insurance Agency Box Professional Insurance Agency, LLC; Box Home and Auto, LLC; Box Insurance Agency, Inc; Box Bonding Agency, LLC 1200 S. Main Street, Suite 1600 Grapevine TX 76051 974231810 A Errors & Omissions 5330160EO 2/18/2026 2/18/2027 Each Loss Aggregate $10,000,000 $11,000,000 Deductible: $25,000 each loss, $75,000 aggregate (loss and litigation) Named Insureds: Box Bonding Agency, LLC dba Box Insurance Agency; Box Professional Insurance Agency LLC; Box Home and Auto LLC, Box Insurance Agency Inc.; Box Bonding Agency LLC **For Informational Purposes Only** Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 30 of 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 giveadvancenoticetothedistrictifthepersonoranowneroroperatorofthebusinessentityhas 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 districtdeterminesthatthepersonorbusinessentityfailedtogivenoticeasrequiredbySubsection(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.” THISNOTICEISNOTREQUIREDOF A PUBLICLY-HELDCORPORATION I,theundersignedagentforthefirmnamedbelow,certifythattheinformationconcerningnotification of felony has been reviewed by me and the following information furnished is true to the best of my knowledge. VENDOR’S NAME: AUTHORIZEDCOMPANYOFFICIAL’SNAME(PRINTED) Pleasecheckallthatapply: Myfirmispublicly-heldcorporation,therefore,thisreportingrequirementisnotapplicable. My firm is neither owned nor operated by anyone who has been convicted of a felony. Myfirmisownedoroperatedbythefollowingindividual(s)whohas/havebeenconvictedofa felony: Name: DetailsofConviction(s): Contractor/CompanyOfficial Signature Date Westlake Academy – FY 26/27 Comprehensive Insurance RFP Page 31 of 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: Address: City/State/Zip: Phone: Fax: Name of Representative(s): Signature of Representative(s): Date: CONFLICT OF INTEREST QUESTIONNAIRE For vendor doing business with local governmental entity FORM CIQ OFFICE USE ONLY Date Received This questionnaire reflects changes made to the law by H.B. 23, 84th Leg., Regular Session. This questionnaire is being filed in accordance with Chapter 176, Local Government Code, by a vendor who 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. 1 Name of vendor who has a business relationship with local governmental entity. 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 CIQ 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 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? Yes 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 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 Signature of vendor doing business with the governmental entity Date ownership interest of one percent or more. Form provided by Texas Ethics Commission www.ethics.state.tx.us 5HYLVHG 3DJHRI 5HYLVHGForm provided by Texas Ethics Commission www.ethics.state.tx.us 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) A vendor 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 W-9 (Rev. March 2024) Request for Taxpayer Identification Number and Certification Department of the Treasury Internal Revenue Service Go to www.irs.gov/FormW9 for instructions and the latest information. Give form to the requester. Do not send to the IRS. Before you begin. For guidance related to the purpose of Form W-9, see Purpose of Form, below. Pr i n t o r t y p e . Se e Sp e c i f i c I n s t r u c t i o n s on p a g e 3 . 1 Name of entity/individual. An entry is required. (For a sole proprietor or disregarded entity, enter the owner’s name on line 1, and enter the business/disregarded entity’s name on line 2.) 2 Business name/disregarded entity name, if different from above. 3a Check the appropriate box for federal tax classification of the entity/individual whose name is entered on line 1. Check only one of the following seven boxes. Individual/sole proprietor C corporation S corporation Partnership Trust/estate LLC. Enter the tax classification (C = C corporation, S = S corporation, P = Partnership) . . . . Note: Check the “LLC” box above and, in the entry space, enter the appropriate code (C, S, or P) for the tax classification of the LLC, unless it is a disregarded entity. A disregarded entity should instead check the appropriate box for the tax classification of its owner. Other (see instructions) 3b If on line 3a you checked “Partnership” or “Trust/estate,” or checked “LLC” and entered “P” as its tax classification, and you are providing this form to a partnership, trust, or estate in which you have an ownership interest, check this box if you have any foreign partners, owners, or beneficiaries. See instructions . . . . . . . . . 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Exempt payee code (if any) Exemption from Foreign Account Tax Compliance Act (FATCA) reporting code (if any) (Applies to accounts maintained outside the United States.) 5 Address (number, street, and apt. or suite no.). See instructions. 6 City, state, and ZIP code Requester’s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. See also What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number – – or Employer identification number – Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and, generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here Signature of U.S. person Date General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to www.irs.gov/FormW9. What’s New Line 3a has been modified to clarify how a disregarded entity completes this line. An LLC that is a disregarded entity should check the appropriate box for the tax classification of its owner. Otherwise, it should check the “LLC” box and enter its appropriate tax classification. New line 3b has been added to this form. A flow-through entity is required to complete this line to indicate that it has direct or indirect foreign partners, owners, or beneficiaries when it provides the Form W-9 to another flow-through entity in which it has an ownership interest. This change is intended to provide a flow-through entity with information regarding the status of its indirect foreign partners, owners, or beneficiaries, so that it can satisfy any applicable reporting requirements. For example, a partnership that has any indirect foreign partners may be required to complete Schedules K-2 and K-3. See the Partnership Instructions for Schedules K-2 and K-3 (Form 1065). Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS is giving you this form because they Cat. No. 10231X Form W-9 (Rev. 3-2024) 6 of nds, you are not required 8 2 1 Form W-9 (Rev. 3-2024)Page 2 must obtain your correct taxpayer identification number (TIN), which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. • Form 1099-INT (interest earned or paid). • Form 1099-DIV (dividends, including those from stocks or mutual funds). • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds). • Form 1099-NEC (nonemployee compensation). • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers). • Form 1099-S (proceeds from real estate transactions). • Form 1099-K (merchant card and third-party network transactions). • Form 1098 (home mortgage interest), 1098-E (student loan interest), and 1098-T (tuition). • Form 1099-C (canceled debt). • Form 1099-A (acquisition or abandonment of secured property). Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. Caution: If you don’t return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued); 2. Certify that you are not subject to backup withholding; or 3. Claim exemption from backup withholding if you are a U.S. exempt payee; and 4. Certify to your non-foreign status for purposes of withholding under chapter 3 or 4 of the Code (if applicable); and 5. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting is correct. See What Is FATCA Reporting, later, for further information. Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • 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). Establishing U.S. status for purposes of chapter 3 and chapter 4 withholding. Payments made to foreign persons, including certain distributions, allocations of income, or transfers of sales proceeds, may be subject to withholding under chapter 3 or chapter 4 of the Code (sections 1441–1474). Under those rules, if a Form W-9 or other certification of non-foreign status has not been received, a withholding agent, transferee, or partnership (payor) generally applies presumption rules that may require the payor to withhold applicable tax from the recipient, owner, transferor, or partner (payee). See Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities. The following persons must provide Form W-9 to the payor for purposes of establishing its non-foreign status. • In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the disregarded entity. • In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the grantor trust. • In the case of a U.S. trust (other than a grantor trust), the U.S. trust and not the beneficiaries of the trust. See Pub. 515 for more information on providing a Form W-9 or a certification of non-foreign status to avoid withholding. Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person (under Regulations section 1.1441-1(b)(2)(iv) or other applicable section for chapter 3 or 4 purposes), do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515). If you are a qualified foreign pension fund under Regulations section 1.897(l)-1(d), or a partnership that is wholly owned by qualified foreign pension funds, that is treated as a non-foreign person for purposes of section 1445 withholding, do not use Form W-9. Instead, use Form W-8EXP (or other certification of non-foreign status). Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a saving clause. Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes. If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items. 1. The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien. 2. The treaty article addressing the income. 3. The article number (or location) in the tax treaty that contains the saving clause and its exceptions. 4. The type and amount of income that qualifies for the exemption from tax. 5. Sufficient facts to justify the exemption from tax under the terms of the treaty article. Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if their stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first Protocol) and is relying on this exception to claim an exemption from tax on their scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption. If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233. Backup Withholding What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 24% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include, but are not limited to, interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third-party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding. You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return. Payments you receive will be subject to backup withholding if: 1. You do not furnish your TIN to the requester; 2. You do not certify your TIN when required (see the instructions for Part II for details); 3. The IRS tells the requester that you furnished an incorrect TIN; 4. The IRS tells you that you are subject to backup withholding because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only); or 5. You do not certify to the requester that you are not subject to backup withholding, as described in item 4 under “By signing the filled- out form” above (for reportable interest and dividend accounts opened after 1983 only). Form W-9 (Rev. 3-2024)Page 3 Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information. See also Establishing U.S. status for purposes of chapter 3 and chapter 4 withholding, earlier. What Is FATCA Reporting? The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all U.S. account holders that are specified U.S. persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information. Updating Your Information You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you are no longer tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account, for example, if the grantor of a grantor trust dies. Penalties Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect. Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty. Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment. Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties. Specific Instructions Line 1 You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return. If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9. •Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name. Note for ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040 you filed with your application. •Sole proprietor. Enter your individual name as shown on your Form 1040 on line 1. Enter your business, trade, or “doing business as” (DBA) name on line 2. •Partnership, C corporation, S corporation, or LLC, other than a disregarded entity. Enter the entity’s name as shown on the entity’s tax return on line 1 and any business, trade, or DBA name on line 2. •Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. Enter any business, trade, or DBA name on line 2. •Disregarded entity. In general, a business entity that has a single owner, including an LLC, and is not a corporation, is disregarded as an entity separate from its owner (a disregarded entity). See Regulations section 301.7701-2(c)(2). A disregarded entity should check the appropriate box for the tax classification of its owner. Enter the owner’s name on line 1. The name of the owner entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner’s name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity’s name on line 2. If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN. Line 2 If you have a business name, trade name, DBA name, or disregarded entity name, enter it on line 2. Line 3a Check the appropriate box on line 3a for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3a. IF the entity/individual on line 1 is a(n) . . . THEN check the box for . . . • Corporation Corporation. • Individual or • Sole proprietorship Individual/sole proprietor. • LLC classified as a partnership for U.S. federal tax purposes or • LLC that has filed Form 8832 or 2553 electing to be taxed as a corporation Limited liability company and enter the appropriate tax classification: P = Partnership, C = C corporation, or S = S corporation. • Partnership Partnership. • Trust/estate Trust/estate. Line 3b Check this box if you are a partnership (including an LLC classified as a partnership for U.S. federal tax purposes), trust, or estate that has any foreign partners, owners, or beneficiaries, and you are providing this form to a partnership, trust, or estate, in which you have an ownership interest. You must check the box on line 3b if you receive a Form W-8 (or documentary evidence) from any partner, owner, or beneficiary establishing foreign status or if you receive a Form W-9 from any partner, owner, or beneficiary that has checked the box on line 3b. Note: A partnership that provides a Form W-9 and checks box 3b may be required to complete Schedules K-2 and K-3 (Form 1065). For more information, see the Partnership Instructions for Schedules K-2 and K-3 (Form 1065). If you are required to complete line 3b but fail to do so, you may not receive the information necessary to file a correct information return with the IRS or furnish a correct payee statement to your partners or beneficiaries. See, for example, sections 6698, 6722, and 6724 for penalties that may apply. Line 4 Exemptions If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you. Exempt payee code. • Generally, individuals (including sole proprietors) are not exempt from backup withholding. • Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends. • Corporations are not exempt from backup withholding for payments made in settlement of payment card or third-party network transactions. • Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC. The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space on line 4. 1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2). Form W-9 (Rev. 3-2024)Page 4 2—The United States or any of its agencies or instrumentalities. 3—A state, the District of Columbia, a U.S. commonwealth or territory, or any of their political subdivisions or instrumentalities. 4—A foreign government or any of its political subdivisions, agencies, or instrumentalities. 5—A corporation. 6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or territory. 7—A futures commission merchant registered with the Commodity Futures Trading Commission. 8—A real estate investment trust. 9—An entity registered at all times during the tax year under the Investment Company Act of 1940. 10—A common trust fund operated by a bank under section 584(a). 11—A financial institution as defined under section 581. 12—A middleman known in the investment community as a nominee or custodian. 13—A trust exempt from tax under section 664 or described in section 4947. The following chart shows types of payments that may be exempt from backup withholding. The chart applies to the exempt payees listed above, 1 through 13. IF the payment is for . . .THEN the payment is exempt for . . . • Interest and dividend payments All exempt payees except for 7. • Broker transactions Exempt payees 1 through 4 and 6 through 11 and all C corporations. S corporations must not enter an exempt payee code because they are exempt only for sales of noncovered securities acquired prior to 2012. • Barter exchange transactions and patronage dividends Exempt payees 1 through 4. • Payments over $600 required to be reported and direct sales over $5,0001 Generally, exempt payees 1 through 5.2 • Payments made in settlement of payment card or third-party network transactions Exempt payees 1 through 4. 1 See Form 1099-MISC, Miscellaneous Information, and its instructions. 2 However, the following payments made to a corporation and reportable on Form 1099-MISC are not exempt from backup withholding: medical and health care payments, attorneys’ fees, gross proceeds paid to an attorney reportable under section 6045(f), and payments for services paid by a federal executive agency. Exemption from FATCA reporting code. The following codes identify payees that are exempt from reporting under FATCA. These codes apply to persons submitting this form for accounts maintained outside of the United States by certain foreign financial institutions. Therefore, if you are only submitting this form for an account you hold in the United States, you may leave this field blank. Consult with the person requesting this form if you are uncertain if the financial institution is subject to these requirements. A requester may indicate that a code is not required by providing you with a Form W-9 with “Not Applicable” (or any similar indication) entered on the line for a FATCA exemption code. A—An organization exempt from tax under section 501(a) or any individual retirement plan as defined in section 7701(a)(37). B—The United States or any of its agencies or instrumentalities. C—A state, the District of Columbia, a U.S. commonwealth or territory, or any of their political subdivisions or instrumentalities. D—A corporation the stock of which is regularly traded on one or more established securities markets, as described in Regulations section 1.1472-1(c)(1)(i). E—A corporation that is a member of the same expanded affiliated group as a corporation described in Regulations section 1.1472-1(c)(1)(i). F—A dealer in securities, commodities, or derivative financial instruments (including notional principal contracts, futures, forwards, and options) that is registered as such under the laws of the United States or any state. G—A real estate investment trust. H—A regulated investment company as defined in section 851 or an entity registered at all times during the tax year under the Investment Company Act of 1940. I—A common trust fund as defined in section 584(a). J—A bank as defined in section 581. K—A broker. L—A trust exempt from tax under section 664 or described in section 4947(a)(1). M—A tax-exempt trust under a section 403(b) plan or section 457(g) plan. Note: You may wish to consult with the financial institution requesting this form to determine whether the FATCA code and/or exempt payee code should be completed. Line 5 Enter your address (number, street, and apartment or suite number). This is where the requester of this Form W-9 will mail your information returns. If this address differs from the one the requester already has on file, enter “NEW” at the top. If a new address is provided, there is still a chance the old address will be used until the payor changes your address in their records. Line 6 Enter your city, state, and ZIP code. Part I. Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. If you are a resident alien and you do not have, and are not eligible to get, an SSN, your TIN is your IRS ITIN. Enter it in the entry space for the Social security number. If you do not have an ITIN, see How to get a TIN below. If you are a sole proprietor and you have an EIN, you may enter either your SSN or EIN. If you are a single-member LLC that is disregarded as an entity separate from its owner, enter the owner’s SSN (or EIN, if the owner has one). If the LLC is classified as a corporation or partnership, enter the entity’s EIN. Note: See What Name and Number To Give the Requester, later, for further clarification of name and TIN combinations. How to get a TIN. If you do not have a TIN, apply for one immediately. To apply for an SSN, get Form SS-5, Application for a Social Security Card, from your local SSA office or get this form online at www.SSA.gov. You may also get this form by calling 800-772-1213. Use Form W-7, Application for IRS Individual Taxpayer Identification Number, to apply for an ITIN, or Form SS-4, Application for Employer Identification Number, to apply for an EIN. You can apply for an EIN online by accessing the IRS website at www.irs.gov/EIN. Go to www.irs.gov/Forms to view, download, or print Form W-7 and/or Form SS-4. Or, you can go to www.irs.gov/OrderForms to place an order and have Form W-7 and/or Form SS-4 mailed to you within 15 business days. If you are asked to complete Form W-9 but do not have a TIN, apply for a TIN and enter “Applied For” in the space for the TIN, sign and date the form, and give it to the requester. For interest and dividend payments, and certain payments made with respect to readily tradable instruments, you will generally have 60 days to get a TIN and give it to the requester before you are subject to backup withholding on payments. The 60-day rule does not apply to other types of payments. You will be subject to backup withholding on all such payments until you provide your TIN to the requester. Note: Entering “Applied For” means that you have already applied for a TIN or that you intend to apply for one soon. See also Establishing U.S. status for purposes of chapter 3 and chapter 4 withholding, earlier, for when you may instead be subject to withholding under chapter 3 or 4 of the Code. Caution: A disregarded U.S. entity that has a foreign owner must use the appropriate Form W-8. Form W-9 (Rev. 3-2024)Page 5 Part II. Certification To establish to the withholding agent that you are a U.S. person, or resident alien, sign Form W-9. You may be requested to sign by the withholding agent even if item 1, 4, or 5 below indicates otherwise. For a joint account, only the person whose TIN is shown in Part I should sign (when required). In the case of a disregarded entity, the person identified on line 1 must sign. Exempt payees, see Exempt payee code, earlier. Signature requirements. Complete the certification as indicated in items 1 through 5 below. 1. Interest, dividend, and barter exchange accounts opened before 1984 and broker accounts considered active during 1983. You must give your correct TIN, but you do not have to sign the certification. 2. Interest, dividend, broker, and barter exchange accounts opened after 1983 and broker accounts considered inactive during 1983. You must sign the certification or backup withholding will apply. If you are subject to backup withholding and you are merely providing your correct TIN to the requester, you must cross out item 2 in the certification before signing the form. 3. Real estate transactions. You must sign the certification. You may cross out item 2 of the certification. 4. Other payments. You must give your correct TIN, but you do not have to sign the certification unless you have been notified that you have previously given an incorrect TIN. “Other payments” include payments made in the course of the requester’s trade or business for rents, royalties, goods (other than bills for merchandise), medical and health care services (including payments to corporations), payments to a nonemployee for services, payments made in settlement of payment card and third-party network transactions, payments to certain fishing boat crew members and fishermen, and gross proceeds paid to attorneys (including payments to corporations). 5. Mortgage interest paid by you, acquisition or abandonment of secured property, cancellation of debt, qualified tuition program payments (under section 529), ABLE accounts (under section 529A), IRA, Coverdell ESA, Archer MSA or HSA contributions or distributions, and pension distributions. You must give your correct TIN, but you do not have to sign the certification. What Name and Number To Give the Requester For this type of account:Give name and SSN of: 1. Individual The individual 2. Two or more individuals (joint account) other than an account maintained by an FFI The actual owner of the account or, if combined funds, the first individual on the account1 3. Two or more U.S. persons (joint account maintained by an FFI) Each holder of the account 4. Custodial account of a minor (Uniform Gift to Minors Act) The minor2 5. a. The usual revocable savings trust (grantor is also trustee) The grantor-trustee1 b. So-called trust account that is not a legal or valid trust under state law The actual owner1 6. Sole proprietorship or disregarded entity owned by an individual The owner3 7. Grantor trust filing under Optional Filing Method 1 (see Regulations section 1.671-4(b)(2)(i)(A))** The grantor* For this type of account:Give name and EIN of: 8. Disregarded entity not owned by an individual The owner 9. A valid trust, estate, or pension trust Legal entity4 10. Corporation or LLC electing corporate status on Form 8832 or Form 2553 The corporation 11. Association, club, religious, charitable, educational, or other tax-exempt organization The organization 12. Partnership or multi-member LLC The partnership 13. A broker or registered nominee The broker or nominee 14. Account with the Department of Agriculture in the name of a public entity (such as a state or local government, school district, or prison) that receives agricultural program payments The public entity 15. Grantor trust filing Form 1041 or under the Optional Filing Method 2, requiring Form 1099 (see Regulations section 1.671-4(b)(2)(i)(B))** The trust 1 List first and circle the name of the person whose number you furnish. If only one person on a joint account has an SSN, that person’s number must be furnished. 2 Circle the minor’s name and furnish the minor’s SSN. 3 You must show your individual name on line 1, and enter your business or DBA name, if any, on line 2. You may use either your SSN or EIN (if you have one), but the IRS encourages you to use your SSN. 4 List first and circle the name of the trust, estate, or pension trust. (Do not furnish the TIN of the personal representative or trustee unless the legal entity itself is not designated in the account title.) *Note: The grantor must also provide a Form W-9 to the trustee of the trust. ** For more information on optional filing methods for grantor trusts, see the Instructions for Form 1041. Note: If no name is circled when more than one name is listed, the number will be considered to be that of the first name listed. Secure Your Tax Records From Identity Theft Identity theft occurs when someone uses your personal information, such as your name, SSN, or other identifying information, without your permission to commit fraud or other crimes. An identity thief may use your SSN to get a job or may file a tax return using your SSN to receive a refund. To reduce your risk: • Protect your SSN, • Ensure your employer is protecting your SSN, and • Be careful when choosing a tax return preparer. If your tax records are affected by identity theft and you receive a notice from the IRS, respond right away to the name and phone number printed on the IRS notice or letter. If your tax records are not currently affected by identity theft but you think you are at risk due to a lost or stolen purse or wallet, questionable credit card activity, or a questionable credit report, contact the IRS Identity Theft Hotline at 800-908-4490 or submit Form 14039. For more information, see Pub. 5027, Identity Theft Information for Taxpayers. Form W-9 (Rev. 3-2024)Page 6 Victims of identity theft who are experiencing economic harm or a systemic problem, or are seeking help in resolving tax problems that have not been resolved through normal channels, may be eligible for Taxpayer Advocate Service (TAS) assistance. You can reach TAS by calling the TAS toll-free case intake line at 877-777-4778 or TTY/TDD 800-829-4059. Protect yourself from suspicious emails or phishing schemes. Phishing is the creation and use of email and websites designed to mimic legitimate business emails and websites. The most common act is sending an email to a user falsely claiming to be an established legitimate enterprise in an attempt to scam the user into surrendering private information that will be used for identity theft. The IRS does not initiate contacts with taxpayers via emails. Also, the IRS does not request personal detailed information through email or ask taxpayers for the PIN numbers, passwords, or similar secret access information for their credit card, bank, or other financial accounts. If you receive an unsolicited email claiming to be from the IRS, forward this message to phishing@irs.gov. You may also report misuse of the IRS name, logo, or other IRS property to the Treasury Inspector General for Tax Administration (TIGTA) at 800-366-4484. You can forward suspicious emails to the Federal Trade Commission at spam@uce.gov or report them at www.ftc.gov/complaint. You can contact the FTC at www.ftc.gov/idtheft or 877-IDTHEFT (877-438-4338). If you have been the victim of identity theft, see www.IdentityTheft.gov and Pub. 5027. Go to www.irs.gov/IdentityTheft to learn more about identity theft and how to reduce your risk. Privacy Act Notice Section 6109 of the Internal Revenue Code requires you to provide your correct TIN to persons (including federal agencies) who are required to file information returns with the IRS to report interest, dividends, or certain other income paid to you; mortgage interest you paid; the acquisition or abandonment of secured property; the cancellation of debt; or contributions you made to an IRA, Archer MSA, or HSA. The person collecting this form uses the information on the form to file information returns with the IRS, reporting the above information. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation and to cities, states, the District of Columbia, and U.S. commonwealths and territories for use in administering their laws. The information may also be disclosed to other countries under a treaty, to federal and state agencies to enforce civil and criminal laws, or to federal law enforcement and intelligence agencies to combat terrorism. You must provide your TIN whether or not you are required to file a tax return. Under section 3406, payors must generally withhold a percentage of taxable interest, dividends, and certain other payments to a payee who does not give a TIN to the payor. Certain penalties may also apply for providing false or fraudulent information. 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