HomeMy WebLinkAboutRoyal & Sun Alliance
Augusta Richmond GA
DOCUMENT NAME: \?-~ c\ :iJ.\\ oLlJ..Dnce.
DOCUMENT TYPE:
YEAR: 0<9
BOX NUMBER: \S
FILE NUMBER: \~q6C)
NUMBER OF PAGES: I.~
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f rr DIRESTORS AND OFFICERS L ,81LiTY
ANO ORGA~:J.Z.!l..Tl.ON REIMBURSEMENT APPLICATION
'..
" ROY~
.' " SU!':lAlLIANCE
1.
THIS FORM IS FOR NON-PROFIT ORGANlZA nONS (RENEWAL ONLY)
(a) Name of Organization .
~~~~e,lziP~~ ('3 LdU
'i3tJ (!yr-eene Sl-re.eJ.., Rrn.:2/7 I AUj~1tL C,43.eQtl
2.
The Officer of the Organization designated to receive notice from the Insurer concerning this insurance is:
.5anc1V'tL lti r-t'4 hi-
(Name) <.l
f!t51< ~ tnf!Jr/ f/ILfUJ@8cer
(Title)
3.
Date Organized
01 - () I -q 0
Purpose of Organization It.
. JlUlLJ1(it~&~ &tu1' c.;
tis n 51) l/dt1Jed CtJ tier I1mef1 f
4. (a) Does the Applicant maintain Comprehensive General Liability Coverages?
o Yes ~ No
(b) If so, what limit?
(c) Are the following coverage afforded?
(i) False Arrest, Detention or Imprisonment and Malicious Prosecution?
o Yes ~NO
(II) Libel, Slander, Defamation and Violation of Right of Privacy?
DYes JiQ No
(Hi) Wrongful Entry and Eviction or other Invasion of Right of Occupancy?
o Yes ~ No
5, Please attach a list of names, titles and affiliations of all Directors and Officers of the Organization and its Subsidiary companies.
6. List all Subsidiaries and affiliates and indicate if any operate for profit
. RSUINPR-OOOOa (ED. 6/92)
\.
Please, indicate various Limit(s) of Liability ana Retentions for which quotations are desired:
LIMIT
RETENTION
:J ,O~O {JOO
-4 t fit) CUJO
The undersigned authorized Officer of the Organization, on behalf of the Directors and Officers and the Organization, warrant that to the best of
his/her knowledge and belief the statements set forth herein are true and he/she agrees that this Renewal Application is a supplement to the application
completed for the issuance of the first policy, and that application together with this Renewal Application and information fumished pursuant hereto shall
be the basis of the contract should a policy be issued and such applications will be attached and become part of the policy. The Insurer is hereby
authorized to make any investigation and inquiry it deems necessary in connection with this application.
NOTICE TO NEWYORK APPLICANTS
Your state insurance department requires applicants to be informed that any person who knowingly and with intent to defraud any insurance company or
other person files an application for insurance containing any false information, or concerns for the purpose of misleading, information conceming any fact
material thereto, commits a fraudulent insurance act, which is a crime.
NOTE: This application must be signed by the Chairman of the Board or President and dated within 30 days of binding should an order be given.
The Undersigned authorized officer agrees that iHlfe:information supplied on this application changes between the date of this application and the
effective date of the insurance, he/she (undersigned) will immediately notify the insurer of such changes, and the insurer may withdraw or modify
any outstanding quotations and/or authorization or agreement to bind the insurance.
Title Mayor ~};t/.l7-
March 19, 2002
Organization
Augusta-Richmond County
Date
One copy of each of the following documents is attached and made part of this proposal:
(a) AUDITED ANNUAL REPORT (complete financial statements for the most recent three (3) years)
(b) LATEST INTERIM FINANCIAL STATEMENT
(c) COPY OF CURRENT SCHEDULE OF INSURANCE
(d) COPY OF BY-LAWS INCLUDING THE INDEMNIFICATION PROVISIONS
Submitted By
Date
(Producer)
NOTE: This Application and all exhibits shall be treated in the stridest of confidence.
RSUINPR-00008 (ED. 6/92)
FE~.28.2002
4: 27PM,. JSl>HRRISON-KER~IC
J. ~mtth L,anzer & CO.
Ins'UTmg People and Business" .Sln@ 1SBQ
JSL/Uarison-Kerzic
P. O. Box 211110 * 2501 Commons Avenue *' ~,ugusta, GA 30907
.~~'2/2
............. J N V 0 ICE -_IJI........__
Augustq Riohmond County i ,Commission-Cou
530 Green Street Room 217
Augusta, GA 30911
Invc Ice Date
Inv~ ice No.
Bill. ro Code
Cllel,t Code
rnv l )rder No.
Commission"Coll '
Amcunt Remitted! $
02/28/02
70591
lSAUGUSTARIC
18AUGUSTARIC
18*77074
Named Insured: Augusta Richmond County i
PI~;e retu/IIlhls parikll\ Vofl/l your P~nl.
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Make checks payable to: JSL/Harison-Kerzio
04/19/02
to
04/19/03
oyal & SunAlliance
olicy No. 4B52754PUBLICOFF&EM
*Renewal - Public Officials Liabillty
:".,;;1
57,200.00
Invoioe Number: 70591
Am:>unt Due:
57,200.00
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