09/28/2005
MONROE COUNTY BOARD OF COUNTY COMMISSIONERS
CLIENT AUTHORIZATION TO BIND COVERAGE
After careful consideration of your Excess Workers' Compensation and Accidental Death and
Dismemberment proposal dated September 2,2005, we accept your insurance program subject to
the following:
Please check the desired Options:
Specific Excess Workers Compensation
DOption I - Midwest Employers Casualty Corporation
o $1,000,000 SIR Deposit Premium $168,035
$25,000,000 Limit
o $1,000,000 SIR Deposit Premium $184,049
Statutory
~Option II - Safety National Casualty Corporation
~ $1,000,000 SIR Deposit Premium $158,377
Statutory
o Two year option Deposit Premium $316,753
o $500,000 SIR
Statutory
Deposit Premium $481,670
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Accidental Death and Dismemberment
~ Hartford Life and Accident Insurance Co
Annual premium $2,822
TRIA EXPIRATION DISCLOSURE
The Terrorism Risk Insurance Act (TRIA) Is set to expire on December 31, 2005. There is no certainty of
extension, thus the coverage provided by your insurers mayor may Dot extend beyond December 31, 200S.
In the event you have loan covenants or other contractual obligations requiring that terrorism coverage be
maintained throughout the duration of your policy period, we recommend tbat a separate "Stand AJone"
terrorism policy be purcbased to satisfy those obligations.
It is understood this proposal provides only a summary of the details; the policies will contain the actual
coverages.
We confirm the values, schedules, and other data contained in the proposal are from our records and
acknowledge it is our responsibility to see that they are maintained accurately. Please provide us with a
binder(s) and invoice(s) for the coverages agreed upon at y earliest convenience.
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Broker's Signature
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