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Home My WebLink AboutAugusta Richmond County Commission Council Augusta Richmond GA DOCUMENT NAME: ADfl(J'S\a- \L\QJ('f)()(10 tcurru 1 Co\Y)rY)\ ~~\Of) J '~~D\ ...~ . DOCUMENT TYPE:?'(~so.J YEAR: q 1.9 BOX NUMBER: "D'6 FILE NUMBER: \ '6D \~ NUMBER OF PAGES: ~ . ....!.. .. coREGiS INSURANCE ORGANlZAnONS :~. , ~ppllcatlon PROPOSAL FOR .. ; PUBLIC OFFICIALS AND EMPLOYMENT UABIUTY INSURANCE ,.. ; , . THIS IS ~N APPUCAnON FOR A CLAIMS MADE AND REPORTED POUCY. 1. a. Name of Public Entity AIl~usta-Richmond County Commission Council b. Mailing Address Telephone (z!lD) R? 1 -? 'i () ? 530 Greene Street, RID. 217, Augusta, GA 30911 , Street City State Zip c. Date organized or incorporated Januarv 1. 1996 Is the Entity operationaJ? a No (J Yes d. Scope of Operations: Local m RegionaJ 0 State a Natic)n a Other a 0# e. Purpose: Provide Uni ue services to Local -Communit ers 1. AffiliatedlRelated entity{ies): NONE Ust full address and applicable financials (Question SA) on Supplemental Section. 2. Population, according to latest census 1 QQ() 1 RQ 71 Q {If Public Entity is a utility, Number of users N / A 3. Actual year end financials (for past three years): Year 1993 1994 1995 Total Revenue 81.339.742 82,946,028 81,291,370 Total Expenses 83,954,538 80,759,355 77,865,369 Accumulated Surplus (+) or Deficit (-) + 13,963,352 +20,949,675 +23,536,799 4. a. Nttmber of members comprising governing board 11 b. Members are YES elected and/or appointed by c. '~~mber of employees (Full time) 2 :,156 (Part time) 259 Volunteers 0 d. Number of licensed or'certffied positions 1.500 attorneys 0 architects and engineers 3 other (specify) CPA's - 1 , 5. Does the Public Entity own and operate any of the following units: No Yes If Yes indicate total revenue a. School 0 a Nt A b. Airport a GD 5,720.000 c. HospitaJ a a N / A d. Clinic a a N/A e. Nursing Home{s) a a N / A f. UtUities a s 33,096,742 g. Housing Authority '" a a N / A h. Transit Authority a Ii 3.065.000 (It Yes, and if coverage is requested for these units, submit separate proposal) a Total amount of outstanding bonds $ 55,000 ,817 b. Latest Bond Rating (Moody's or Standard & Poor's) Current Al c. Has any bond proposal been defeated within the last three years? d. If yes, has the proposal been resubmitted or is it expected to be resubmitted? e. Has the Public Entity been in default on principal or interest of any bond? f. Does the Public Entity invest funds on behalf of any other entity? If yes to any of the above, explain on SupplementaJ Section. 8. a Describe any current Public Officials and Employment Uability Insurance or similar insurance to that being applied for. ." - ...., ';" . # , 6. Does the Entity currently carry: a. General Uability Insurance b. Personal Injury Insurance c. Coverage for Discrimination No 10 1D 1D Carrier ' Yes o o o 7. . Company NONE Poli,-y Term ,. i Umit Previous o No o No S No E No Al to Yes ~ Yes a Yes a Yes , Premium Umit Retention b. Have the carriers of any similar insurance to that being applied for been given notice of any claim or potential claim? ag No a Yes If yes, explain under Supplemental Section. IF THIS IS A COREGIS RENEWAL, SKIP TO PART 10 UNLESS A CHANGE IN FORM AND/OR UMIT IS DESIRED. For the purpose of this application, cJaim shall mean any demand for money or other relief as of right. Answer the following questions based on this definition. 9. Have any of the following situations occurred within the last three years? a Strike, slowdown or other disruption by the employees? b. Layoff of employees or reduction in services? c. Has any person, former employee or job applicant alleged unfair or improper treatment regarding employee hiring, remuneration, advancement, treatment or termination of employment? d. Disputes involving integration, segregation, discrimination, or violation of civil rights? . e. Has any person, former employee or,job applicant filed a complaint with the EEOC, Human Rights Commission or any similar state or federal agency? f. Has any claim been made or is now pending against the Entity or any person in his/her capacity as an official or employee of the Entity? g. Does any official or employee have any knowledge of any fact, circumstance or situation, which might reasonably be expected to give rise to a claim against them or against the Entity? If yes to any of the above, detail on the Supplemental Section. l!Sl No a Yes ~ No o Yes m No DYes ~ No a Yes 19 No o Yes !J No o Yes m No a Yes IT IS AGREED THAT IF ANY SUCH FACT, CIRCUMSTANCE OR SITUATION USTED OR NOT USTED IN Q9A-G EXISTS WHICH HAS NOT BEEN PREVIOUSLY REPORTED TO COREGIS, THEN ANY CLAIM BASED UPON, ARISING OUT OF, OR AITRIBUTABLE THERETO IS EXCLUDED FROM THE POUCY BEJNG APPUED FOR. 10. The undersigned being authorized by, and acting on behalf of, the applicant and all persons or concerns seeking insurance, has read and understands this Application, and declares all statements set forth herein are ~e, complete and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for, which may render inaccurate, untrue or incomplete any statement made herein will immediately be reported in writing to the Insurer. The undersigned acknowledges /""'''''0 r"I.""'''''' ........_ 1___.. , I.CJ"4'.'1. 4. 97 10 29 AM *HARISON KERZIC P02 I " 1, ,... HBVfJ any of 1h8 tonowtnt tItudan8 ~ within ""_lea' 0 yea..., (a) Slrlke, aJowclown or ather cs"'lMlOn by 'he employHl U Yes Ea No CJ y" i:) No r:J V- El No C YOG rm No !:l Yo. E1 No (b) Laycff 01 ~Ioye_ or ,.,;CIon In Ht'Y\OM (oJ AIIe;at1ana of unfair Of' ."'",..,. trMlment regBrdlng ."'plops hlrfng, remuneraUcn, ~noement, or _m1tnMlon Df ltmptaym8m !d) DiaputM fnvollllno integration: SOGreOnon. discrimination. or violation 01 cMll1gt'a (w) An)' grud jury ~on, r&CBIl procleedlngs or fn&:IJctments of any pLlbllQ oMdMi "JU, p..... provide full detalle 0" . Mpanlt& DIDef. . 'HI. ~- -..y ~.... '...ur_ ..... __.. _ 1.....__.... _ mny Gat, Oft'9r << Of'\1I~n whkih mlsrhl I1MIaQtlllbl, be -pected te olve rfse to a oIaim against hlmt 0 V.. Ii] No (If aa, attaGh full ~rer.}. It bllgrud tnat If ~,Ilnowtedge Of infonn8tIQf\-'att My claim 0' ecIIon aNln; the.efrom 18 exc(UGed 1'rom tt1itl prope.sa eeverag8. 18. AIIael'lII8l MCI etatue of all e~" and om\esfons ctalms mace against any propoaed Insured(s) durfng t"le past five Y8BI'B. Sf Nane. pie... chaolc nere: C NONS , .' , 1111 ClQrelKf that oIaims made prior to U'te inception of the DOlley period ant excluded ftam thl8 propcsed COYetag4t. ~ . .. THIS APPUCATION DOE!B NOT 8INO n1EAPPUOANT OR THe OOMPANYTO OCMPUm! THEU_VAANCI: IitVT IT 18 ACREE!) THAT lM1S !lOAM 8HAU. BE notE BASIS OF THE CONTRACT SHOULD A POUCV ee ISSUED. AND IT WU BE ATTACHED TO ANO MAD!! A PA.RT OF THE POLICY. THE APPLICANT AGREES THAT IF T~ INFORMATION SUPPUED ON THIS APPUCATlON CHANGES 8ETWE~ THE; DATe OF 'THIS ~UCAnON AND THE "ME WHEN THE POUCY /8I88UED. THE-"PPLlCANTWILL IMMeDIATELY NOnFV THE! COMPANY OF SUCH CHANGE. 81gl'\Itd NOTICE: IN New 'YORK AND OHIO. ANY PERSON WHO KNOWINGLY AND WITH INTefT'TO DEFRAUO ANV IN8tJRANC& COMPANY OR OTHER PERSON FILeS AN A"PUCAnON FOR INSURANCE OR STATeMENT OF CLA1M CONTAINING ANY MATERIALLV FALSE INPCRMATlON. OR CQNCeALS FOR THE PURPose OP IlISUiADINQt INFORMATION CONCERNING AMY FAt::r MATERIAL. THERETO. COMMITS A PRAUDU INSURANCE ACT. WHICH IS A CRIME. )6&0 ;:-~o-e./ / , ,-. oc. ~-17-97 PAo~ AtX)A!8$; 04/14/97 11:33 TX/RX NO.3658 P.002 . ~- -.,.; ............__:~-,-..-..~..,..,..... ~ T-' ..~ .. and agrees that the submission and the Insurer's receipt of such written report.,prior to the inception of the policy applied for, is a condition precedent to coverage. ' 11. If this is a Renewal Application, it shall be a supplement to the Application(s) attached to the current policy and said Applications together with this Renewal Application constitute the complete Application which shall be the basis of the contrad should a policy be issued and will be attached to and become part of the policy. The signing of this Application does not bind the undersigned to purchase the insuranre. nor does review of the Application bind the insurance company to issue a policy. This Application shall be the basis of the centrad should a policy :be'iSsued. / /l , /. , tie Date Executive Director of the Public Entity. Name of Agency Harison-Kerzic, Inc. Full Address 2601 Commons Boulevard :"":1 \",. ' Post Office Box 211110 Augusta, Georgia 30917-1110 City, State, Zip Contact Name and Phone (706) 737-:-8811 . Surplus Unes Ucense Number Admitted Ucense Number Coregis Countersigning Agent? a Yes a No State Tax 10 Number *CURRENT FINANCIALS NEEDED