EFTA00523631.pdf

I11111111111 IIIIHill111111#11)1111111111111111111111111111111111 DISCLOSURE PURSUANT TO TERRORISM RISK INSURANCE ACT Terrorism Coverage and Premium In accordance with the federal 'Icrronsm Risk Insurance Act (as amended "TRIA" ), we are required to make coverage available under your policy for "eenified acts of terrorism The actual coverage provided by your policy(ies) will be limited by the terms, onditions. exclusions, limits, and other provisions of your policylies), as well as any applicable rules of law. The portion olyour premium attnbinable to this terronsm coverage is shown in the premium section(s) of this quote proposal or binder. Definition of Certified Act of Terrorism A - certified act of !motion" means an act that is certified by the Secretary of the Treasury•. in concurrence with the Secretary of State and the Attorney General of the United States, to be an act of terrorism under TRIA The criteria contained in TRIA for a "certified act of temnsm" include the following: I. The act results in insured losses in excess of S5 million in the aggregate. attributable to all types of insurance subject to TRIA; and 2. The act results in damage within the United States, or outside the United States in the case of certain air carriers or vessels or the premises of an United States mission; and 3. The act is a violent act or an act that is dangerous to human life, property or infrastructure and is committed by an individual or individuals acting as part of an effort to coerce the civilian population of the United States or to influence the policy or affect the conduct of the United States Government by coercion. Disclosure of Federal Share of Terrorism Losses The United Sums Department of the Treasury will reimburse insurers for 85% of that portion of insured losses attributable to certified acts of terronsm that exceeds the applicable insurer deductible. However, if aggregate industry insured losses under TRIA exceed $100 Billion in a Program Year (January I through December 31), the Treasury shall not make any payment for any portion of the amount of such losses that exceeds S1(Xi billion. The United States government has not charged any premium for their participation in covering terrorism losses Cap on Insurer Liability for Terrorism Losses If aggregate industry msured losses atinbutable to "twilled acts of taronsm" under RIA exceed SI00 Billion in a Program Year (January I through Ikeetrber 31), and we have met, or will meet, our insurer deductible under TRIA, we shall not be liable for the payment of any portion of the amount of such losses that exceed 5100 billion. In such east, your coverage for terrorism losses may be reduced on a pro-rata basis in accordance with procedures established by the Treasury, based on its estimates of aggregate industry losses and our estimate that we will exceed our insurer deductible. In accordance with the 1 reasury's procedures, aminmts paid for losses may be subject to further adjustments based on differences between actual kisses and estimates. Note to Producer tai TRIA: The premium for terrorism coverage and the TRIA disclosures above must be provided to the insured or prospect at the time of quoting. Ifyou are not using this quote proposal. you can use Hartford's stand-alone TRIA disclosure form for quota and binders. which is available on EBC or from the company. Reference Number: 76ITEG974.1.1.fr - 003 Total Estimated Annual Premium fur Workers' Compensation: S 290 Page 11 II111111111111111111IIIIII111111IIIIIIIIIIIII111111IIIIII1111111111li r. EFTA00523631  IX11111 hIIIIVIIIVIIIVIIIVIIIVIIIVIIIII111111IIIII 00109547 VIIIVIIIIIVIIIHlhhIII 70 - HIll! Automatic Data Processing Insurance Agency. Inc. Workers' Compensation Loss History Affidavit X , do hereby certify and swear that (name of owner or officer) (Company name dba) has incurred X injuries within the last 36 months. (Number of Injuries) Note: It there have been no injuries, write (None) in the table above. Explanation if an individual claim amount exceeds S15,00O.00. Company Name Signed By: ate: X C Title/Position: Any person who knowingly and with intent to injure. defraud, or deceive any insurer files, statement of claim, or an application containing any false, incomplete, or misleading information with the purpose of avoiding or reducing the amount of premiums for workers compensation coverage or conceal information pertinent to the computation and application of an experience rating modification factor, is guilty of a felony of the third degree or as otherwise punishable as provided under the law. Page 12 11110111111111111111 VIII 11111 111111111111111 1111111111111111111111111111 'C01095471170 • EFTA00523632  111111111111 VIIIlullVIIIVIIIVIIIVIII VI1111111111 VIIIVIIIIIlullIUIIIIII C=IMIL,..._7 GENERAL INFO -11111111 Company, Client Codes 3011.• St A New York NY 10065 COMPANY TYPE SIC Code : FEIN : Years in Business : 0.25 r Individual F Corporation F Partnership Website : D8A : Total Employees: 1 r Subchapter S Corp. fJ LLC F Seasonal Client r INS ASO Campaign F Is construction company PRIMARY CONTACT Name: Email : Phone: 7 Fax No: PAYROLL INFO Payroll Platform • Run Payroll Frequency: BI•Weekly Est Payroll Start : 09/18/2012 PAYMENT INFO Payment Method : Direct Bill Pay by Pay Pike: S13 Per Payroll • Run, EasyPay, AutoPay BUSINESS DESCRIPTION ee does office work, design services for furniture. no store front or website, works on word of mouth. any furniture the client wants to purchase the client can buy through the vendor OFFICERS Name Title/Relationship Remuneration Duties IncIExc Ownership % member SO EXC 100 CPA CPA Name : Firm Name: Email : Phone: Tax Branch / Client code : Cell No : Fax No: REFERRAL INFO ead Source : Self Generated - Cold Call DM Service Center : DM Name: DM Code : SC Region: SC Rep Name: Carolina Hernandez Agency: POLICY DETAILS Carrier Name: (Regular) Hanford Date: 10/15/2012 Policy Number: Policy Effective Date: 10/15/2012 Est. Annual Premium ; 290 Policy Expiration Date 10/15/2013 Comments : Page 13 11111111111111111111111111111111111111111111111111111111 EFTA00523633  III 111111111111 IIIII'll 111111111111 ~Uliii~III11111111 *001095.47LAS02--' Automatic Data Processing Insurance Agency, Inc. ADDRESS CITY STATE Zip 575 Lexington Ave etti Floor C/O FORK New York NY 10022 301E 66th St Aix lit Ilr New York NY 10065 CONTACTS CONTACT NAME PRIMARY COMPANY NAME EMAIL PHONE•EXT CELL FAX Y True CLASS CODES DUTIES REMUNERATION FULL TIME EMPLOYEES PART TIME EMPLOYEES CLASS CODE clerical $25,O00.00 1 0 8810 LOSS HISTORY YEAR No. OF CARRIER CLAIMS AMOUNT PAID RESERVER DETAIL 2012 0 2011 0 2010 0 Officer Signature:, Date: /O// 5/20/. Page 14 I Iligill=1111111M EFTA00523634