HomeMy WebLinkAboutNYMIR 2026 Insurance Renewal DENIS NONCARROW Town Hall,53095 Main Road P.O.
TOWN CLERK of SQ�jpy Box 1179
�4a1► Orp Southold,New York 11971 Fax
REGISTRAR OF VITAL (631)765-6145 Telephone(631)
STATISTICS MARRIAGE OFFICER 765 18
RECORDS MANAGEMENT www.southoldto wnny.gov
OFFICER FREEDOM OF
INFORMATION OFFICER l�c�ldlH�•
OFFICE OF THE TOWN CLERK
TOWN OF SOUTHOLD
THIS IS TO CERTIFY THAT THE FOLLOWING RESOLUTION NO. 2025-948 WAS
ADOPTED AT THE REGULAR MEETING OF THE SOUTHOLD TOWN BOARD ON
DECEMBER 16,2025:
RESOLVED, that the Town Board of the Town of Southold hereby authorizes and directs the
Town Supervisor, Albert J. Krupski, Jr.,.to execute the NYMIR 2026 Insurance Renewal
Documents, including the Application and Supplemental Application and Schedules, for all
coverages maintained by the Town, for the period January 1, 2026 through December 31, 2026,
with an overall increase in cost from 2025 rates of approximately 3.7%, subject to Town
Attorney review.
Denis Noncarrow
Southold Town Clerk
RESULT: Adopted
MOVER: Councilman Mealy
SECONDER: Justice Evans
AYES: Councilman Mealy, Councilwoman Doherty, Justice Evans, Councilman
Doroski, Supervisor Krupski, Jr.
NAYES: None
Page 46 of 50
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
•r
NEW YaRK MUNICIPAL ]INSU1tANCE 1tECIPR(3CA1L
Insuring Our Own Future.
INSURANCE APPLICATION
APPLICATION CHECKLIST
1. ❑ Completed Supplemental Application and Acord Applications/Schedules.
2. ❑ Signatures on Applications and Statement of Values where required.
3. ❑ Copy of your most recent Budget provided. [Tentative/Preliminary acceptable.]
4. ❑ Currently valued six years Loss History,including large loss details.
Proposed effective date of policies: 0 1 / 0 1 /. 2 s
Date premium quote is needed*: 1 2 / 0 1 / 2 5
*We require a minimum of 30 days between the submission of a complete application (Including
supplemental information)to provide a quote. Additional tme,inay be neededif the expiring
premi .0,006.
PLEASE RETURN COMPLETED APPLICATION AND SUPPORTING DOCUMENTATION VIA MAIL OR EMAIL TO:
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
(518) 292-0069
Email to: rconway@wrightinsurance.com
9/2024
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
GENERAL MUNICIPAL INFORMATION
Name of Municipality Town of Southold County Suffolk
Address PO Box 1179 Website southoldtownny.gov
Telephone Number 631-765-4333 Fax Number 631-765-1366
Chief Executive/Title Albert J Krupski Jr,Supervisor Other Contact Michelle Nickonovitz,Comptroller
Email: al.krupski@town.southold.ny.us Email: michellen@southoldtownny.gov
Contact Person/Title Michelle Nickonovitz.Town Comptroller
Submitting Agency and Broker Roy H Reeve Agency Onc Telephone Number 631-298-4700
E-Mail Address kohnston@royreeve.com Fax Number 631-298-3860
PLEASE COMPLETE THE FOLLOWING INFORMATION:
Population: 24,000(approximate) Total#of Employees: 222 FT 62 PT
Town Population (Excluding Village):
Engineers 0
Attorneys 4
Does your municipality participate or cooperate in any joint activities with .other municipalities (i.e. Mutual Assistance
agreements,construction or maintenance projects,police or fire protection,etc....)? Yes ❑ No GZ
Does your municipality provide employees or equipment to any other local-governments?
Yes ❑ No
Has the municipality passed a local law allowing ATV and or snowmobile use on the municipality's public
streets and roads? Yes❑ No W
*If Yes,please confirm the municipality's local law or ordinance is in compliance with NYS Laws.
Authorized Signature Required:
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
CURRENT INSURANCE PROGRAM
This section must be completed to receive a quotation.
PREMIUM (NEW
LINE OF COVERAGE LIMIT DEDUCTIBLE* Business Only)
PROPERTY 28,780,342 5000
BOILER&MACHINERY/EQUIPMENT
BREAKDOWN 28,780,342
TOTAL FLOOD/EARTHQUAKE
GENERAL LIABILITY 1,000,000/3,000,000
CYBER
OCP n/a
PROFESSIONAL
HEALTHCARE LIABILITY
HEALTHCARE GENERAL LIABILITY
AUTOMOBILE LIABILITY SEEPAGE 18
AUTOMOBILE PHYSICAL DAMAGE see schedule 5000
UMBRELLA/EXCESS LIABILITY 1 0,000,000/20,000,000
PUBLIC OFFICIALS(E&0) F1,000,000/2,000,000
EMPLOYMENT
PRACTICES LIABILITY (if not included in Public
Officials premium) included in POL
LAW ENFORCEMENT LIABILITY 1,000,000/2,000,000
INLAND MARINE see schedule
CRIME see schedule
OTHER: 826.000(EDP)
*PLEASE INDICATE SIR"IF THE AMOUNT SHOWN IS ACTUALLYA SELF-INSURED RETENTION.
Please indicate below/if any lines of business have been non-renewed by an insurance carrier:
❑Yes-Indicate below what line(s) of coverage ❑ No
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
IF NOT WITH NYMIR For 6 Years
LARGE LOSS HISTORY(only Losses over$50,000)
Date of Claim ,Total Incurredclaiiii still,'-'
(Pai&Reserve E cri tiah.6ft kp!Bnse Des
Yes No
11 13
Yes No
El 0
Yes No
Ej E3
Yes No
0 El
Yes No
EJ 0
Yes No
El El
Yes No
El 0
Yes No
El El
Yes No
E) El
Additional Notes:
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
MUNICIPAL•EXPOSURE INFORMATION
IF YES, PLEASE COMPLETE CORRESPONDING EXPOSURE INFORMATION. ACORD not acceptable
rEXP05UREr, n <`YES NO CON7RAGTED EXPOSUFE BASE b r r
Beach/Lake Operations r ❑ ❑ #of Beaches
#of Months in Use
Bleachers
Under 100 Seats ❑ ❑ No Charge
100-500 Seats ❑ ❑ ❑ #of Locations
501-1,000 Seats ❑ D D #of Locations
1,001-5,000 seats ❑ ❑ ❑ #of'Locations
>5,000 Seats ❑ ❑ ❑ #of Locations
Boat Docks(No Services) ❑ ❑ Square Footage
Campgrounds ❑ ❑
Carnivals/Amusement Rides* ❑ ❑ SEE SPECIAL EVENTS APPLICATION
Concession Stands ❑ ❑ Receipts
Dams/Dikes/Levees/ ❑ D SEE DAM APPLICATION(If Downstream Exposure
Reservoirs** is needed.)
#of Children
Days/Hours Operation
Day Care Nurseries(Excluding ❑ Facility Used
Summer Rec.) ❑ Enrollment Forms Required?
Services Provided(Day Care/Day
Camp/Nursery/Other)
Drones ❑ Z ❑ SEE DRONE APPLICATION
Electrical Distribution Payroll
Generation/Distribution ❑ ❑ Generation Payroll
*** Certified Emergency #of Employees/Attendants
Medical Technicians (if not ❑ ❑ #of Volunteers
separately insured) Insurance Carrier-if insured
IF COVERAGE REQUIRED separately
*Pending Underwriter Approval
** Existence hazard coverage (trips and falls) due to the existence of dams, dikes, levees or reservoirs is automatically included. IF
DOWNSTREAM DAM FAILURE IS BEING REQUESTED,YOU MUST SUBMIT A COMPLETED QUESTIONNAIRE FOR EACH MUNICIPAL DAM.
A COPY OF THE MOST RECENT_INSPECTION DONE BY THE NEW YORK STATE—DEPARTMENT OF ENVIRONMENTAL CONSERVATION MUST BE
INCLUDED FOR EACH DAM.
***If Emergency Medical Personnel ARE separately insured,enter the name of the insurance company.
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
MUNICIPAL EXPOSURE INFORMATION (Cont.)
IF YES, PLEASE COMPLETE CORRESPONDING EXPOSURE INFORMATION.
EXPOSURE , s YES _ NO CONTRACTED EXPOS_URE BASE t 4 4
Fairs/Festivals/Parades
(Generates Receipts for ❑ ❑ SEE SPECIAL EVENTS APPLICATION
Municipality)
Fire Department/
Company/District PLEASE COMPLETE FIRE PROTECTIVE SERVICES
Name: ❑ 9 ❑
APPLICATION EVEN IF SERVICES ARE CONTRACTED
Fireworks ❑ ❑ #of Locations/Days
Garbage&Recycling Pick-
Up(Door to Door,pick up) ❑ ❑ Payroll(Do NOT include recycling center)
Golf Courses ❑ ® ❑ Receipts
Housing Department ❑ ® ❑ CONTACT YOUR NYMIR REPRESENTATIVE
Industrial Development
Agency/LDCs/Business ❑ ® ❑ SEE IDA APPLICATION
Improvement District/
Land Bank
Jails ❑ z ❑ Square Footage
Libraries(Stand Alone) ❑ ❑ Square Footage
Ports/Harbors/Terminals/
Square Footage
Marinas ❑ ❑ Yes ❑No ❑ Services Include Storage/Repair?
Yes ❑No ❑ Include Fueling Operations?
Sewer Facility/Sewer
Disposal (Stand Alone) ❑ ❑ Payroll
Skating Facilities
Ice Skating Rinks ❑ z ❑ Receipts
Roller Skating Rinks W ❑ ❑ #of Rinks
Skateboard Parks ❑ ❑ #of Parks
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
MUNICIPAL EXPOSURE INFORMATION (Cont.)
IF YES, PLEASE COMPLETE CORRESPONDING EXPOSURE INFORMATION.
EXPOSURE YES NO CONTRACTED EXPOSURE BASE
Ski Facility ❑ ❑ ReceiptsLifts
Special Events ❑ ❑ SEE SPECIAL EVENTS APPLICATION
Stadiums/Arena ❑ z ❑ Receipts
Seating Capacity over 2,500
Streets and Roads ❑ D 200 approx #of Miles for streets owned and/or
maintained under contract
Summer Recreation ❑ z ❑ See Special Events
Swimming Pools ❑ ® ❑ #of Pools(Excluding wading pools)
Transportation System ❑ z ❑
<50 Buses D D ❑ Square Footage of Terminal.
Watercraft ❑ GZ ❑ #Over 26 Feet
Vacant Buildings ❑ GZ ❑ Attach list of vacant properties
Payroll(do not include administration
Water Department/Utility ❑ z ❑ and meter readers; do include purification,
transmission,distribution)
#of Watercraft
Watercraft* ❑ ❑ various year/Model/Serial#/Length
Waterfront Property with
linear footage for Public Access Area
Public Access(not GZ ❑ ❑ only
otherwise specified)
❑ GZ ❑ #of Zoos
Zoos** #of Acres
*Coverage only available for watercraft less than 26 feet.
** Pending Underwriting Approval.
NOTE: NO AVIATION LIABILITY IS AVAILABLE THROUGH NYMIR
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
OTHER EXPOSURES
W Yes ❑ No Are there any owned watercraft in excess of 100 horsepower?
If "Yes" describe:
❑ Yes W No Are any buildings or industrial properties held for redevelopment?
Number of Buildings: Location Numbers:
If "Yes"describe:
❑ Yes W No Are any buildings used for commercial purposes?
If "Yes"describe:
GZ Yes ❑ No Are any dwellings owned/leased to others?
Number of Dwellings: Location Numbers:
If "Yes"describe:
❑ Yes Z No Are fundraising activities conducted(including fire dept.and emergency medical services)?
If "Yes"describe:
❑ Yes W No Do you have any railroad contracts,sidetrack,or easement agreements?
If"Yes" Please submit a copy of the entire agreement with the application.
❑ *Yes❑ No Are non-law enforcement employees permitted to carry firearms on municipal property?
*If yes, are employees carrying firearms Certified Peace Officers?❑Yes ❑ **No
**If No,,please provide an explanation of the position and necessity for carrying a firearm.
❑ Yes Z No Do you have any UAV/Unmanned Arial Vehicles(i.e.: Drones)?
If "Yes" describe:
9/2024 8 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
DAM EXPOSURE INFORMATION Not Applicable
DAMS AND RESERVOIR
(Note: If the entity operates more than one dam or reservoir,'a separate questionnaire must be completed for each structure.)
Name of Dam/Reservoir NONE
1. Capacity of Impounded Reservoir in: Acre Feet: Gallons: Cubic Feet:
(IF RESERVOIR[No DEC#Applies],DO NOT COMPLETE THE REMAINDER OF THIS FORM)
DEC ID# Deficiency Code Hazard Code
(A NY State DEC inspection report must be submitted for any dam over30 acre-feet,with a hazard grade of C or higher.)
2. Please submit the following:
• The Latest DEC visual inspection,usually one page.
• If there have been any recommendations made,a letter from the DEC or an engineering firm or contractor stating that
satisfactory repairs have been made and the recommendations/deficiencies are no longer a problem or no longer exist.
3. Location Year Built Under the direction of:
a. Name of Tributary rivers:
❑Upstream Ll Downstream
b. Purpose: ❑ Flood coni:rol ❑ Irrigation ❑ Water supply ❑ Industrial ❑Power
If power,describe alternate source in event of power failure:
C. Construction: ❑Concrete ❑ Earthen ❑Steel Sheered ❑Timber ❑Other
Spillway Construction:
d. Dimensions Height Top Width Base Width
e. Normal pond measures: Number of acres Acre-feet(Please fill in.)
f. Storage capacity(gallons)
Additional storage available in flood state? 0 Yes ONo
If yes describe:
4. Upstream exposure? ❑ Yes ❑No Describe,including distance(housing,industrial,complexes,etc.):
5. Downstream exposures(indicate if ex ure is present,including distance):
a. Housing Yes No❑ Distance: Number:
b. Other Structures Yes❑ No❑ Distance: Number:
C. Industrial Complexes Yes❑ No ❑ Distance: Number:
d. Public Utilities,type? Yes❑ No❑ Distance: Number:
e. Pumping Stations Yes ❑ No ❑ Distance: Number:
f. Lower Dams Yes ❑ No❑ Distance: Number:
g. Bridge(s) Yes ❑ No ❑ Distance: Number:
h. Highway(s) Yes ❑ No ❑ Distance: Number:
i. Railroads(s) Yes ❑ No ❑ Distance: Number:
j. Agricultural,type? Yes ❑ No El Distance: Number:
k. Recreational,type? Yes ❑ No❑ Distance: Number:
I. Schools(s) Yes ❑ No ❑ Distance: Number:
M. Hospital(s) Yes ❑ No ❑ Distance: Number:
n. Camp(s) Yes❑ No ❑ Distance: Number:
6. Maximum population Down Stream?
7. Does the entity have an emergency notification plan/Emergency Action Plan(EAP)? ❑ Yes EJ No
Describe:
Will be developed or updated as of: Month Day Year
8. Who inspects the dam?
9. How often? Date of last inspection: (Please include a copy.)
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
➢ Without this questionnaire, downstream exposure cannot be provided.
AUTHORITY EXPOSURE INFORMATION
INDUSTRIAL DEVELOPMENT AGENCIES(IDA)—LIMITED DEVELOPMENT CORP. (LDC)—BUSINESS IMPROVEMENT
DISTRICT—OTHER GOVERNMENT AUTHORITY INCLUDING LAND BANKS
1. Is the Authority separately insured,with what company?If yes,no other questions need to be answered.
r
2. What is the composition of the Authority's board?
3. How long has the Authority been in existence?
4. Has the operation of the Authority changed since its inception?
5. Are there any current or prior losses?
6. Is there any NYS or federal involvement with the Authority?
7. Provide a comprehensive description of the activities of the Authority including any construction operations that may be
associated with the Authority.
8. Provide a copy of the contract/charter/covering agreement under which the Authority operates.
9. Does the Authority own any property? Yes❑ No❑
If yes, please list.
9/2024 10 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
SPECIAL EVENTS EXPOSURE INFORMATION
COMMUNITY& RECREATIONAL EXPOSURES: Not Applicable
Special Events Organized Sports Boat Docks/Marinas
Parks& Recreation Fireworks—Sponsor Only Playgrounds
Bleachers, Grandstands Ice Skating Swimming
and Stadiums Parades Fairs/Festivals
Music Events/Shows Seasonal Events
SPECIAL EVENTS INFORMATION:
1 List each special event
Premises Estimated
Description rDaysR/ pis Coca#ion > Ow�edv Attendances
[]Yes ❑No
❑Yes ❑No
❑Yes ❑No
❑Yes ❑No
❑Yes ❑No
2. Describe your responsibility for each event/activity(i.e., provide premises,funds, personnel,etc.):
3. List each sponsor/co-sponsor and their responsibility for each event/activity:
4. Are Independent Contractors used to provide any services?
❑ Yes ❑ No
If"Yes",what services?
5. Are Certificates of Insurance obtained from sponsors and/or independent contractors?
❑ Yes ❑ No
If"Yes", limit required:
Does the Certificate of Insurance list the Municipality as an Additional Insured? ❑ Yes ❑ No
6. Will any mechanically operated amusement devices(such as bounce houses) be used in the event?
❑Yes ❑ No
7. Will any of the events involve racing activities?
❑Yes ❑ No
9/2024 11 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
SPECIAL EVENTS EXPOSURE INFORMATION (Cont.)
PARKS AND RECREATION:
1. Identify the recreational activities provided(check all that apply):
Activity Gross Receipts(if any)
❑ Baseball Fields
❑ Basketball Courts
❑ Bike Riding
❑ Boating/Kayaking
❑ Camping
❑ Equestrian Trails
❑ Football Fields
❑ Golf Courses/Clubs
❑ Hiking Trails
❑ Parasailing
Activity Gross Receipts (if any)
❑ Parks
❑ Playground Equipment
❑ Playgrounds
❑ Rollerblading(in-line skating)
❑ Skateboarding
❑ Ski Lifts/Ski Trails
❑ Soccer Fields
❑ Swimming
❑ Other:
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
2. Do you permit winter sports on the premises?
❑Yes ❑ No
If"Yes" Describe:
ORGANIZED SPORTS:
1. List organized recreational activities sponsored by the municipality
v
7Daes activity •.d SYa+•srs�'r*'ks, s.�s T a�,n3e�r,'e.y ." .yr ,exs 5� .'3Ird pf� ^a 4 a 'J.,�".
a wart �Etr .Fs"s .�.,;r•43 t 'x �,�s ''*'w :x.�,b,
t _. }{y a �a 1 .
s 2 S Qi1SOr � .
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.<,4 +«y * r ,•."-�: ,.s' r�'.r`.`" ', a�"e;`'`'""'e'' g',fiw s+ w,c'�•t�'`°'s . ,.;;2-''c�' 4 } t' �*
4Ctty P;artici an mu icipal 5pasoretl 5ponsareti �
f#y[Far fi p t x .
,,. 3?.";wx rw " .` �.„ ' ' # »^�«... T Y. F %'ak tl
$asebolj <' Youth/Actuit" owned ' Su�yrvised�h � perused? NlunicipaHty? }9
e# s .#' 'U i ` .' p t is€ 'z.as `t E;, Wf'
t 4' :`,y, �,`" r "�e• v ? e�,4 „ * 'a'.t r°`� C.Y °a' ,£'. �' .z.x".1 s: y
,Y,� .,s. r;'` r• ' -; i a. ro ,"`` �'°ta �„y -;w' ,ys "s*a�,�a , 'e`' 3`S
oo
Youth Yes NO �. (1ln bs Ph. Ms lua_,
❑ ❑ .
Adult LJ U L�
Youth Yes No P5 hs 16 Xe� LI�
Adult El ElLN �u y�
Youth Yes No LJ f
Adult lb �s f�L9e
y❑ ElYouthu u
Adult o 1 �j U`s � IS � P
Youth No
Adult Tff M I ins Ids Imo' ILI p
*Note: If Parks and Recreation brochures are available, please provide.
2. Do you secure liability waiver forms from all participants?
El Yes ❑ No
3. Do you own,operate,or maintain any"golf courses?
❑Yes ❑ No
If"Yes",Total annual rounds of golf:
9/2024 13 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
FIRE PROTECTIVE SERVICES
(FIRE COMPANIES, FIRE PROTECTIVE DISTRICTS, FIRE DEPARTMENTS)
1. List all fire departments/companies: Not ApoliCable
2. Are fire departments/companies paid or volunteer?
3. Name of fire department/company to be covered:
4. If coverage is requested for fire department/company,what oversight is provided by the municipality?
5. If coverage is not requested for the fire department or company, please list insurance carrier providing
coverage:
6. Is there a contract between the fire department/company and the municipality? ❑Yes ❑ No
If yes,does it include risk transfer? ❑Yes ❑ No-Please submit contract to NYMIR for review.
*If crime coverage is requested for the fire department, please fill out appropriate section of the crime application.
9/2024 14 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
NYMIR UNMANNED AIRCRAFT INSURANCE APPLICATION
Applicant's Name:
Address: I\I(1T C,DDI If G2' E
STREET CITY STATE ZIP
1. Is this address located on,or adjacent to,an airport? Yes ❑ No ❑
2. Has Applicant obtained a Certificate of Waiver or Authorization(CoA)from the FAA? Yes ❑ No ❑
(IF YOU ANSWER NO,PLEASE DISCONTINUE AND CONTACT YOUR UNDERWRITER)
3. Name of last Aircraft insurance carrier(if none so state)
Exp. Date
4. Describe all incidents,accidents,claims(hull and liability)with dates and amounts paid(even if none),which occurred in the
last five years.
5. Has any Insurance Company or Underwriter at any time declined an aircraft application submitted by or cancelled or
refused to renew an aircraft policy held by the applicant or any of the pilots named herein? Yes ❑ No ❑
If so,explain.
PILOT/OPERATOR
NAME(S)
Is the Pilot an employee?
Number of Years as a *Pilot/Operator
*Please provide a copy of the Pilot's License*
MAINTENANCE
1. Is all maintenance performed on the aircraft,and its individual components,completed in accordance to manufacturer
guidelines? Yes ❑ No ❑
2. Is a record of all maintenance maintained? Yes ❑ No ❑
1. If aircraft has no registration number or manufacturer's serial number,please describe how aircraft can be positively
identified in the event of an incident, accident,or claim:
2. Maximum Endurance(in hours)
3. Maxim um�Operating Altitude(in feet)
4. Maximum Range(Specify feet,yards,meters,miles,or kilometers)
5. Does the aircraft have the ability to independently detect and avoid other aerial traffic? Yes ❑ No ❑
6. In the event of a lost link between the ground control station and the aircraft,does the UAV contain an automated
recovery program that allows for it to safely return to a predetermined point?
Yes ❑ (please describe procedure below) No ❑
7. Aircraft Manufacturer's website:
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
PURPOSE OF USE
1. CHECK ALL APPLICABLE USES
❑ Police ❑ Fire ❑ Search&Rescue ❑ Surveillance
❑ Photography Wildlife Observation ❑ Construction/Engineering ❑ Video/Film Production
❑ Communications ❑ Pipeline/Powerline Patrol ❑ Thermal Imagery ❑ Aerial Marketing
❑ Employee Training ❑ Mapping
List all other uses not indicated above(explain)
2. How will photos/videos,from aircraft be stored?
3. Estimated number of hours the aircraft to be insured is/are to fly in the coming 12 months:
4. Number of flights
OPERATING ENVIRONMENT/CHARACTERISTICS
1. CHECK ALL APPLICABLE EXPOSURES
❑Urban (City centers, heavily populated areas)
❑Suburban/Semi-Urban(numerous nearby buildings/moderate population)
❑Industrial (Near numerous non-residential buildings)
❑Rural(Limited,if any,exposure to people and property)
❑Over water(rivers/ponds/small lakes) ❑ Over open water(large lakes/seas/oceans)
❑Night operations ❑ Severe Weather IFR weather operations
❑Other(describe)
2. Does any pre-and/or in-flight communication with Air Traffic Control take place for a typical flight? Yes ❑ No ❑
3. How many visual observers are used for a typical flight?(Do not include pilot/operator)
4. List all states where flights are anticipated to take place:
5. For applicants anticipating flights within the U.S.,please list specific states where operations are expected:
Policy and Procedures
1. Do you have a policy for the use of the aircraft?
2. Please attach copy of policy for use.
3. Will aircraft be secured to limit access to only authorized personnel?.
4. How will photos/video be stored?
5. Will a flight log be maintained?Yes ❑ No ❑
NOTICE TO NEW YORK APPLICANTS:ANY PERSON WHO KNOWINGLY AND WITH INTENTTO DEFRAUD ANY INSURANCE COMPANY
OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE
INFORMATION,OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
COMMITS A FRAUDULENT INSURANCE ACT,WHICH IS A CRIME,AND SHALL ALSO BE SUBJECTTO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.
Applicant's Signature: x '. & /�Z 4t � ?
gas �,
Date: /-2/z��zs- : - tr14 f G
Producer:Roy H Reeve Agency Inc
Address City State Zip:
Telephone: 631-2984700
Fax No. 631-298-3850
Email Address flohnston@royreeve.com
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
GENERAL LIABILITY COVERAGE
Name of Insurance Carrier NYMIR
Is current coverage provided on an occurrence or claims made basis? occurrence
(Please attach loss runs.)
If claims made,what is the Retro Date for current coverage?
1. Deductible Options Requested:
❑ $1,000 ❑$1o,000 ❑$1oo,000
❑ $2,500 0 $25,000 ❑$250,000
❑ $5,000 ❑ $50,000
On behalf of our municipality, I agree that this application is true to the best of my knowledge and that I have not suppressed or
misstated any material facts and I agree that this application shall be the basis of the contract with the Company. It is understood and
agreed that the completion of this application does not bind the Company to sell or the applicant to purchase this insurance.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information,or conceals for the purpose of misleading,information concerning any
fact material thereto, commits a fraudulent insurance act,which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the stated value of the claim for each such violation.
*SIGNATURE REQUIRED*
Signed X .r',�: � /�2' � Date ZT1-2
(Chief ExilLtive Officer)
S Uplrm Sty—
Roy H Reeve Agency Inc
Submitted by
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
PROPERTY SUPPLEMENTAL INFORMATION
1. Property Deductible Options Requested:
❑$250 ❑$2,500 ❑$15,000 ❑$75,000
❑$500 default m $5,000 ❑$25,000 ❑$100,000
❑$1000 1:1 $10,000 ❑$50,000 ❑$250,000
2. Percentage of Value
2 90% ❑ 100%
Property Valuation: Please note: Any property storing.vehicles requiring Master Battery Disconnect Switches that are not in
compliance,will be excluded from the blanket limit and covered at Actual Cash Value.
Replacement Cost(required for Policy Blanket Limits)
Actual Cash Value limits not included in Blanket Limit
Any Vacant Buildings?
* If yes,please identify on SOV,or attach separate exhibit;and describe how often your municipality monitors and inspects your
vacant buildings along with your maintenance program for all vacant locations.
none
Is vacancy permit coverage requested?
❑ Yes Z No
3. Any Buildings Listed on National Historical Registry?
Z Yes* ❑ No
*If"Yes";please indicate any buildings required to be preserved to its original historic state.
Town I ICI71 53095 Va e Sou thold NY 11971
_
4. Do you currently have any property in the"course of construction"or have any new additions, renovations or expansions
planned?
❑Yes ®No
If"Yes" Describe: Cost of Construction:
5. Do you have any hydro-electric equipment?
❑ Yes ®No
If"Yes" Describe:
6. Is o tional Flood Coverage requested above the automatic$1,000,000 limit provided by NYMIR?
BYes ®No
If"Yes" Requested Limit: Current Deductible:
Current Carrier: Current Limit:
NOTE: We will pay only for the amount of loss in excess of a $500,000 per building and a $500,000 contents occurrence deductible
applicable to all property located in Federal Flood Zones designated as A,AO,AH,Al—A30,AE,A99,AR,AR/AE,AR/AO,AR/Al—A30,AR/A,
AJJ,V,VE,or Vl—V30 and D.
a. Are there any premises insured in the National Flood Insurance Program?
❑Yes ❑No
b. Are higher limits requested?(Automatic$1MM Included)
❑Yes ❑No
7. Is Optional Earthquake Coverage requested?
❑Yes GZNo
If"Yes" Requested Limit: Current Deductible:
Current Carrier: Current Limit:
9/2024 18 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
ADDITIONAL PROPERTY LIMITS
'
NYKx|R's Property Enhancement automatically provides additional limits for many items. Higher limits may be
purchased on some lines. Please indicate additional limit desired.
PLEASE REVIEW K8PLl1G-11OGFOR COMPLETE TERMS&CONDITIONS
Pt
Accounts Receivable $75,000*
Airborne/Waterborne Personal Property Coverage included N/A
Broadened Water-Direct Damage $100,000 or Limit of Ins.
Whichever is Less N/A
Claim Data Expense $25,000 N/A
Commandeered Property Actual Loss You Sustain N/A
Communication Equipment,Computers and Media $75,000 N/A
Deductible
Municipal Property Deductibles included N/A
Disappearing Deductible included N/A
Extra Expense $250,000
Fine Arts $25,000 N/A
Fire Department Service Charge $25,000 N/A
Fire Extinguisher Recharge Expense $5,000 N/A
Food Contamination Shutdown—Planned Events $10,000 N/A
uested-
Foundations Coverage Included N/A
Lock Replacement Coverage $1,000 N/A
Loss of Incom Actual Loss You Sustain N/A
Loss of Income—Broadened Water $100,000
Loss of Income—Time to Restore Extension 30 Days ISO
Money,Securities and Stamps
Inside $10,000 N/A
Outside $10,000 N/A
Newly Acquired or Constructed Property
Building $1,000,000 N/A
Business Personal Property $500,000
Non-Owned Detached Trailers $5,000 N/A
Ordinance or Law Coverage
Loss to Undamaged Portion Included N/A
Demolition Cost $500,000*
Increased Cost of Construction $500,000*
Outdoor Fences Actual Loss You Sustain N/A
Outdoor Signs Actual Loss You Sustain N/A
Actual Loss You Sustain
Subject to a Limit of$10,000
Outdoor Trees,Shrubs and Plants Per Tree,Shrub or Plant N/A
Personal Effects and Personal Property of Others $10,000
Pollutant Cleanup and Removal $50,000 N/A
Pollutant Cleanup and Removal—Planned Events $10,000 N/A
Premises Extension Property 1,000 Feet N/A
Property off Premises Actual Loss You Sustain N/A
912024 19of44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
Refrigerated Property Actual Loss You Sustain. N/A
Roof Protection $1,000 N/A
Specified Appurtenant Structure
Public Use $100,000 N/A
Your Use $10,000 N/A
Contents $1,000 N/A
Transportation Actual Loss You Sustain N/A
Utility Services—Direct Damage Actual Loss You Sustain N/A
Utility Services—Planned Events Actual Loss You Sustain N/A
Valuable Papers and-Records—Cost of Research $75,000*
*Above limitsshowvmay beowersmdedu'the'Optional Coverage mcluded'sectiononform#Mm�00-0997
BUILDING SCHEDULE
Please attach typed Acmmds with the following information:
8uiloYngNome/Aokbess
Use
Age/YxBuilt .
Construction Types
Square Feet
Local Protection Class
2O0Y6 Building Values
10O96 Contents Values
CONSTRUCTION TYPE:
1. FRAME Wood walls and roof
I. MASONRY' Masonry walls and wood roof
3. NC-1 Metal prefabricated
4. NC'2' Masonry with non'connbustib|exxa||s/rnof
S. MODIFIED FIRE RESISTIVE
6. FIRE RESISTIVE
IMPORTANT NOTE: . |RwiUanangetoappraiseaUinsuredbui|dingsvvithava|ueinexcessof
Any discrepancies will be endorsed accordingly.
9/2024 20of44
`
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
Miscellaneous Property in the Open
(Please List on Acord or SOV.)
1. Fire Hydrants—must be listed to get coverage-#OF HYDRANTS AND THEIR TOTAL VALUE;CATEGORY
"HYDRANTS THROUGHOUT VILLAGE"
2. Railings—If not in the value of the structure, it needs to be scheduled. (This is to address handrails,which would
normally be attached to or just outside a building.) Although,some park locations have railings. This would not
include fences. Guard rails cannot be covered.
3: Lights/Light Poles owned by insured—must be listed to get coverage#OF LIGHTS AND THEIR TOTAL VALUE;
CATEGORY"LIGHTS/LIGHT POLES THROUGHOUT VILLAGE"
4. Benches—must be listed at each location
5. Monuments/Clocks—the value can be rolled into the main building(as a site improvement on the CBIZ
appraisal) or listed separately on SOV
6. Signs—locations must be on the Dec page and within 1,000 feet of a scheduled location to get the Muni Pac
extensions. Otherwise for coverage, list#OF SIGNS AND THEIR TOTAL VALUE;CATEGORY"SIGNS
THROUGHOUT VILLAGE"
7. Flagpoles—the value can be rolled into the main building(if listed as a site improvement on CBIZ appraisal) or
listed separately on SOV
8. Parks/playground equipment—list on the property schedule as separate location. Each piece of equipment
does not need to be listed separately.
9. Parking Meters—must be listed for coverage-#of PARKING METERS AND THEIR TOTAL VALUE;CATEGORY
"PARKING METERS THROUGHOUT VILLAGE"
10. Parking Machine—must be listed for coverage-#of PARKING MACHINES AND THEIR TOTAL VALUE;
CATEGORY"PARKING MACHINES THROUGHOUT VILLAGE"
11. Cemeteries—minimum value of$1000 to schedule; unless there is a structure which should have the proper
value. Does not include headstones or monuments.
12. Dugouts—the location where they are located must be listed in order to get the limits in the Muni-Pac
13. Tennis Courts/Basketball Courts—list on the property schedule with an address
14. Traffic Signals—#OF TRAFFIC SIGNALS AND THEIR TOTAL VALUE: CATEGORY"TRAFFIC SIGNALS
THROUGHOUT VILLAGE"
15. Fences—just value
912024 21 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
All of the above items are subject to the Commercial Property Flood Deductible; dictated by the flood zone the
item is located in.
NYMIR Inland Marine Categories
1. Auto Physical Damage
2. Contractor's Equip
3. Police Equip
4. EDP Equip.
5. Fine Arts
6. Fire Dept. Equip
7. Fire Dept. Vehicles
8. Miscellaneous
9. Other
10. Radios
11. Small Tools
12. Unscheduled equipment
13. Unscheduled Leased/Rented Equip
14. Voting Machines
15. Watercraft
16. Drones
Miscellaneous Unscheduled Equipment—Can be written up to a total value of$150,000 with a maximum of
$5000 per item. You can have a lower "Max any one item....", but anything higher needs to be listed on the IM
schedule. This can be used to cover the following items:
• Small Hand Tools
• Portable Generator
• Air Compressor
• Lawn Mowers
All Inland Marine items are subject to the$1,000,000 Flood Limit.
9/2024 22 of 44
NEWYORK MUNICIPAL INSURANCE RECIPROCAL
INLAND MARINE SUPPLEMENTAL INFORMATION
The inland Marine form includes the following extensions of
Debris Removal $25,000 Per Occurrence N/A
Emergency Services Personal Effects* $2,500 Per Person/$5,000 Per Occurrence
Emergency Services Equipment(Scheduled) $10,000 Per Occurrence
Rented/Leased/Borrowed* $100,000 Per Occurrence
Newly Acquired Scheduled Equipment $250,000 Per Occurrence N/A
Rental Reimbursement* $500 Per Day/$5,000 Aggregate
Fireman's Auto Physical Damage $1,000 Reimbursement N/A
Commandeered Property* $25,000 Occurrence/$50,000 Aggregate
Optional Limits are available and may be requested below.
1. Emergency Services Personal Effects Extension limit requested?
[] $2,s0O per peru,n/$5,0UU per occurrence automatically included
LJ Optional limits available otan increased premium,please specify requested limit:
z. Rented or Borrowed Equipment Extension limit requested?
[] gzOO'000 automatically included
[] Optional limits available at an increased premium,please specify requested limit:
a. Rental Reimbursement Extension limit requested?
[] $soo Per ooy/$s'oOo Aggregate automatically included
[] Optional limits available at an increased premium,please specify requested limit:
4. Commandeered Property Extension limit requested?
[] $zs'ou0Oounence/$s0,Uou Aggregate automatically included
[] Optional limits available at an increased premium,please specify requested limit:
INLAND MARINE SCHEDULE
DEW LE'd0flo
AUTO PHYSICAL DAMAGE $500 0$1,000 El $2,500
("Agreed Value subject to review) see schedule $5,000 0 $10,000
CONTRACTORS EQUIPMENT see schedule $2,500 0$5,000 []$10,000
FIRE VEHICLE-**(Replacement Cost LJ$Soo M$1,000 LU$2,5c)o
regardless of age subject to limit) 0$5,000 LJ$10,000
09 $1,000
FIRE EQUIPMENT R$250,000
EDP EQUIPMENT 1 ,000,000 R2,500 k6$5,000 0$10,000
leased/rented 250,000 R$2,500 L:1$5,000 [-]$10,000
la$2,500 [0$5,000 F]$10,000
9/2024 23of44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
NOTE: Please schedule mobile equipment licensed for road use on the Auto Liability Policy
*Consult with Broker for NYMIR Guidelines for determining Agreed Value limits.
VEHICLE/FLEET SCHEDULE
Please attach Auto Schedules with the following information:
Car number
Year See Schedule
Make/Model
Full VIN#
Gross Vehicle Weight
Use(see attached)/Class Code
Cost New
Comprehensive Deductible
Collision Deductible
Full Glass Option
Full glass is available for private passenger vehicles only—maximum deductible is$200 for these vehicles. Check if
you want this option. ❑
Hired Physical Damage Limit: (Check if this coverage is primary) ❑
Deductible:
Limits of Liability
Medical Payments: Per NYMIR Proposal
Mutual Aid:
OBEL:
Personal Injury Protection:
Supplementary Uninsured Motorists:
9/2024 24 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
CO E S lVlaster,°Butte Sai�tcfa?Requfred` kr ,P,HYSICAL'DAMAGE, Notes „aK,la ON
m `t
01479 LIGHT DUMP Auto Policy 0-10,000lbs Gross Vehicle Weight
01499 LIGHT TRUCKS Auto Polity 0-10,000lbs Gross Vehicle Weight
05181 URBAN BUS Auto Policy 1-8 passengers
05182 URBAN BUS Auto Policy 9-20 passengers
05183 URBAN BUS Auto Policy 21-60 passengers
05184 URBAN BUS Auto Policy over 60 passengers
05981 MUNICIPAL BUSES Auto Policy 1-8 passengers
05882 MUNICIPAL BUSES Auto Policy 9-20 passengers
05883 MUNICIPAL BUSES Auto Policy 21-60 passengers
05884 MUNICIPAL BUSES Auto Policy over 60 passengers
06181 SCHOOL BUS(1-8) Auto Policy
06182 SCHOOL BUS(9-20) Auto Policy
06183 SCHOOL BUS(21-60) Auto Policy
06184 SCHOOL BUS(OVER 60) Auto Policy
06201 OTHER SCHOOL BUS Auto Policy
06202 OTHER SCHOOL BUS Auto Policy
06203 OTHER SCHOOL BUS Auto Policy
06204 OTHER SCHOOL BUS Auto Policy
06281 OTHER SCHOOL BUS Auto Policy
06282 OTHER SCHOOL BUS Auto Policy
06283 OTHER SCHOOL BUS Auto Policy
06284 OTHER SCHOOL BUS Auto Policy
06293 OTHER SCHOOL BUS Auto Policy
06481 SOCIAL SERVICE BUS Auto Policy 1-8 passengers
06482 SOCIAL SERVICE BUS Auto Policy 9-20 passengers
06483 SOCIAL SERVICE BUS Auto Policy 21-60 passengers
06484 SOCIAL SERVICE BUS Auto Policy over 60 passengers
07201 DRIVER EDUCATION VEHICLES Auto Policy
07398 PRIVATE PASSENGER Auto Policy
07906 MOBILE EQUIPMENT Floater if Plated for Road Use
07909 FIRE PRIVATE PASS Auto Policy
07909 FIRE TRUCK-**MBS Floater
07911 POLICE Auto Policy Cost new should include enhancements to vehicle
07912 POLICE VAN Auto Policy
07919 AMBULANCE Floater
07926 DRIVER EDUCATION VEHICLE Auto Policy
07929 REGISTRATION PLATES/TRANSPORTER PLATES Auto Policy
07942 MOTORCYCLE Auto Policy
07964 SNOWMOBILE Floater
09620 ANgAZUE41UTOS Auto Policy
25
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
21453 MEDIUM GARBAGE-*MBS Floater 10,001-20,000 Lbs Gross Vehicle Weight
21479 MEDIUM DUMP-*MBS Floater 10,001-20,000 Lbs GVW:Plow,Wing and Sander Scheduled Separately or noted in Total Vehicle
21499 MEDIUM TRUCKS Auto Policy 10,001-20,000 Lbs Gross Vehicle Weight
31479 HEAVYDUMP-*MBS Floater 20,001-45,000 Lbs GVW:Plow,Wing and Sander Scheduled Separately or noted in Total Vehich
31499 HEAVY TRUCKS-*MBS Auto Policy 20,001-45,000 Lbs Gross Vehicle Weight
31453 HEAVY GARBAGE-*MBS Floater 20,001-45,000 Lbs Gross Vehicle Weight
34479 HEAVYTRACTOR(TRLR)DUMP-*MBS Floater Plow,Wing and Sander Scheduled Separately or noted in Total Vehicle Value
34499 HEAVY TRACTOR(TRLR)-*MBS Floater
40453 EXTRA HEAVY GARBAGE-*MBS Floater >45,000 Lbs Gross Vehicle Weight
40479 EXTRA HEAVY DUMP-*MBS Floater >45,000 Lbs GVW:Plow,Wing and Sander Scheduled Separately or noted in Total Vehicle Valut
40499 EXTRA HEA VY TRUCK-*MBS Auto Policy >45,000 Lbs Gross Vehicle Weight
50453 EXTRA HEAVY GARBAGE/TRACTOR-*MBS Floater >45,000 Lbs Gross Vehicle Weight
XTRA HEAVY TRACTOR(TRLR)DUMP
50479 *MBS Floater >45,000 Lbs GVW:Plow,Wing and Sander Scheduled Separately or noted in Total Vehicle Value
50499 EXTRA HEAVY TRACTOR(TRLR)-*MBS Floater >45,000 Lbs Gross Vehicle Weight
67479 SEMITRAILERS-DUMP-*MBS Floater
67499 SEMITRAILERS Auto Policy
68479 TRAILERS-DUMP Auto Policy
69499 TRAILERS Auto Policy
69479 SERVICE OR UTILITY TRAILERS-DUMP Auto Policy
69499 SERVICE OR UTILITY TRAILER Auto Policy
21499131499 BUCKET TRUCK-*MBS Floater
07906 Street Sweeper- *MBS Floater
*Master Battery Disconnect Switches are required as indicated.Non-compliance of any vehicle will result in Actual Cash
Value at the time of a loss.
CLASS CODE 7911 IS VALUED AT REPLACEMENT COST FOR VEHICLES 10 YEARS AND NEWER
ONLY PRIVATE PASSENGER VEHICLES ARE ELIGIBLE FOR FULL GLASS WITH A$200 DEDUCTIBLE
VEHICLES SCHEDULED ON THE FLOATER(INLAND MARINE) FOR PHYSICAL DAMAGE ARE ELIGIBLE FOR RENTAL EXPENSES OF$500
PER DAY UP TO$5,000
THE INLAND MARINE POLICY PROVIDES AUTOMATIC LEASED,RENTED OR BORROW COVERAGE FOR$100,000. HIGHER LIMITS
ARE AVAILABLE
DUMP TRUCKS SCHEDULED ON THE FLOATER WILL BE VALUED AT Agreed Value.Trucks 10 years&older are subject to review of
photos and maintenance logs.
ALL OTHER ITEMS SCHEDULED ON THE INLAND MARINE ARE Agreed Value
FIRE DEPARTMENT EQUIPMENT SCHEDULED ON THE FLOATER WILL BE VALUED AT REPLACEMENT COST FOR NEW SUBJECT TO
THE VALUE PER ITEM REGARDLESS OF AGE FIRE TRUCKS ARE ELIGIBLE FOR REPLACEMENT COST NEW REGARDLESS OF AGE(not to
exceed 150%of the purchase/invoice price)
912024 26 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
PLEASE SEE POLICIES FOR A FULL DESCRIPTION OF COVERAGES AND ENHANCEMENTS.
PUBLIC OFFICIALS' LIABILITY COVERAGE
(Application for a Claims Made policy)
1. Does the Municipal Entity presently carry Public Officials Liability or similar insurance?Yes ❑ No ❑
If Yes: Name of Insurance Carrier NYMIR
Is current coverage provided on an occurrence or claims made basis? Claims made
(Please attach loss runs.)
What is the Retro Date for Current Coverage(if Claims Made)? Full prior acts
Is Public Officials Coverage for Fire Department requested? Yes ❑ No ❑
Is Full Prior Acts requested? Yes W] No ❑
Current Deductible 25,000
Deductible Options Requested:
11 $1,000 ❑$10,000 ❑$75,000 ❑$500,000
❑ $2,500 Z $25,000 ❑$100,000 0$750,000
❑ $5,000 ❑ $50,000 ❑$250,000 0$1,000,000
2. During the past six years,have there been any incidents,acts, errors,omissions,claims,litigation or threat of litigation not
reported to NYMIR(including any Federal,State or Local actions against the Public Entity and/or its employees or officials)
which might give rise to a claim?*Yes ❑ No Z
*(If answer is yes,please attach full details.)
3. If the Municipal Entity proposed for this insurance has any subsidiary boards,commissions,authorities,or other units
operating under its jurisdiction and within an apportionment of its total operating budget,please include on a separate
page a list of all such boards or units and indicate whether they presently carry their own Public Officials Liability
Insurance. If no such units are in operation, please state:
Nn NF -
4. Has similar insurance on behalf of the Municipal Entity been declined,cancelled or non-renewed or otherwise refused:
(Please explain).
NeNE
On behalf of our municipality, I agree that this application is true to the best of my knowledge and that I have not suppressed or
misstated any material facts and I agree that this application shall be the basis of the contract with the Company. It is understood and
agreed that the completion of this application does not bind the Company to sell or the applicant to purchase this insurance.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information,or conceals for the purpose of misleading,information concerning any
fact material thereto, commits a fraudulent insurance act,which is a crime, and shall also be subject to a civil penalty not to exceed
five thousand dollars and the stated value of the claim for each such violation.
*SIGNATURE REQUIRED*
Signed 1�� ' ( / Date
(Chief Ex cutive Officer) . t"&k", J -Tw S owoc d,/—,
Submitted by: Name of Agent
9/2024 27 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
PUBLIC OFFICIALS' LIABILITY COVERAGE
Please indicate if Employment Practice Liability is needed for any of the following:
DESIGNATED FACILITIES OR OPERATIONS
Employment
Related Claims Designated Facility or Operation
Aircraft,Airfield,Runway,Hangar,Terminal or any other properties that are used for aviation
activities
Medical Clinic
Hospital,Nursing Home or other type of medical facility
Gas Transmission System or Public Gas Utility
Educational System including any Higher Education Institution or Community College
Day Care,Day Camp,Nursery'or similar-facility
Public Mass Transit or Public Transportation System,including but not limited to transport,
operations and premises
Fire Department
Housing Authority
Emergency Medical Services
Please indicate if Public Officials Liability Coverage is needed for any of the following:
DESIGNATED FACILITIES OR OPERATIONS
Public Officials
Liability Designated Facility or Operation
Aircraft,Airfield,Runway,Hangar,Terminal,or any other properties that are used for aviation
activities
Medical Clinic
Hospital,Nursing Home or other type of medical facility
Gas Transmission System or Public Gas Utility
Educational System including any Higher Education Institution or Community College
Day Care,Day Camp,Nursery,or similar facility
Public Mass Transit or Public Transportation System,including but not limited to transport,
operations and premises
Fire Department
Housing Authority
Emergency Medical Services
9/2024 28 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
LAW ENFORCEMENT LIABILITY COVERAGE (Cont.)
Please provide the following Officer Information:(Do not count any individual twice.)
ARMED POLICE OFFICERS UNARMED OFFICERS WITH ARREST AUTHORITY:
#of Full Time 76 #of Full Time
#of Part Time 10 #of Part Time
#of TOTAL Hours per #of TOTAL Hours per month
month for all Part Time for all Part Time
CORRECTION OFFICERS: ARMED COURT OFFICERS:
#of Part Time Armed Officers NIA #of TOTAL Hours per month
#of Armed with for all Part Time
Transportation Duty
SCHOOL RESOURCE OFFICERS*:
#of Armed:
*Please send copy of agreement between law enforcement and school district.
Who supplies medical,counseling,and dental services for jail operations?
Contact NYMIR for a NYMIR Health Care Facilities Liability Program Application.
Are they Contracted? Or Employed?
Medical: ❑ ❑
Counseling: ❑ ❑
Dental: ❑ ❑
If not employed by municipality,please provide certificate of insurance
Onaif of our,municipality, I agree that this application is true to the best of my knowledge and that I have not suppressed or
"MT—( any material facts and I agree that this application shall be the basis of the contract with the Company. It is understood and
;eoat the completion of this application does not bind the Company to sell or the applicant to purchase this insurance.
kQh '
knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statl im cor�aining any materially false information,or conceals for the purpose of misleading,information concerning any
fact reto,'commits a fraudulent insurance act,which is a crime, and shall also be subject to a civil penalty not to exceed
five Ilars and the stated value of the claim for each such violation.
*SIGNATURE REQUIRED*
Signed Date / L /2 S
(C, vr(Chief Executive Officer)
L -
fR"
ro
Submitted by Roy H Reeve Agency Inc
(Name of Agent)
9/2024 30 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
LAW ENFORCEMENT LIABILITY COVERAGE
(Including ARMED:Court Officers,Security Officers and Code Enforcement;Staffed by either Employees or Volunteers.)
Do you maintain a Law Enforcement Agency? Yes GZ No ❑
Is your Agency NYS Accredited? Yes ❑ No 121
Do you have Court Security? Yes ❑ No 91
Do you have Peace Officers? Yes ❑ No GZ
Do you have a Special Police Force? Yes ❑ No GZI
Do you have Constables? Yes 21 No ❑
Do you allow for Moonlighting? Yes gj No ❑
Do you have an Auxiliary Police Dept.? Yes ❑ No
Do you have a Tactical Unit? Yes ❑ No
If No,who provides Law Enforcement services?
If Yes, please complete all the information below.
Name of Insurance Carrier NYMIR
Is current coverage provided on an occurrence or claims made basis? occurrence
If claims made,what is the Retro Date for current coverage?
Current Deductible 25,000
Deductible Options Requested:
❑$1,000 ❑$10,000 ❑$75,000 ❑$500,000
❑$2,500 GZ$25,000 ❑$100,000 ❑$750,000
❑ $5,000 ❑ $50,000 ❑ $250,000 ❑ $1,000,000
1. During the past six years, have there been any incidents, acts, errors, omissions, claims, litigation, or threat of litigation not
reported to NYMIR (including any Federal,State or Local actions against the Public Entity and/or Law Enforcement Agency or its
employees or officials of each)which might give rise to a claim? Yes ❑ No GZ
(If answer is yes,please attach full details.)
"Please check if your municipality has developed and/or utilizes any of the following policies,procedures,and manuals:
**Policies
Procedures * Manuals
Use of Force
Deadly Force m m
Vehicle Hot Pursuit
Domestic Violence
De-Escalation ❑ m
Moonlighting ❑ ❑
Responding to Mental
Health Calls ❑ ❑
Anti-Bias Policing ❑ ❑
Body-Worn Cameras ❑ ❑
*Please provide copies of Law Enforcement manuals**Please provide Policies and
Procedures
9/2024 29 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
MEDICAL PROFESSIONAL LIABILITY
Does your Municipality have any medical professional employees or facilities- including but not limited to:jails,
nursing homes,traveling nurses, medical clinics, etc.?
❑ Yes GZ No
If"Yes", please fill out the additional "NYMIR Health Care Facilities Liability Program Application".
9/2024 31 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
GOVERNMENTAL CRIME COVERAGE
Faithful Performance is Automatic.
The following coverages are available at limits of:$1,000;$2,500;$5,000;$10,000;$15,000;$20,000;$25,000;$50,000;$75,000;
$100,000;$150,000;$250,000;$500,000;$750,000;$1,000,000;other options available upon request at underwriter discretion.
Deductibles Available:$100;$250;$500;$1,000;$2,500;$5,000;$10,000;$25,000;$50,000;$100,000;$250,000;$500,000.
Limits Requested Deductible Option
Employee Theft: $250,000 Per loss $
(Includes Tax Collector and Treasurer) ❑Per Employee
Forgery Alteration: $250,000 $
Inside the Premises:
Theft of Money and Securities $250,000 $
Robbery/Safe Burglary $5,000 $
Outside the Premises: $250,000 $
Money Orders and counterfeit Money $100-000 $
*Computer Fraud/Funds Transfer Fraud $100,000 $
*Please indicate if your municipality has a written policy in place to independently verify all requests for change of
payment instructions, invoice changes and all redirection of funds. ❑Yes ONO
Is Crime Coverage required for contracted employees? Yes ❑ No ❑
If yes, please provide details:
Are Separate Excess Limits required for Employee Theft? If yes,specify names and/or positions.
Name Position Excess Limit
Per expiring Per expiring $ Per expiring
$
$
Is Coverage requested for Volunteers(include for fire departments and/or fire companies)
Name Position Excess Limit
9/2024 32 of 44
NEW YORK MUNICIPAL INSURANCE RECIPROCAL
GOVERNMENTAL CRIME COVERAGE (Cont.)
Indicate what Security Provisions apply, and identify who performs the function/how often:
List all audits for municipality,elected officials and other organizations under control of municipality.
Supervisor/Mayor: Yes W No ❑ Performed Part of Town Annual Audit
Tax Collector/Receiver:Yes Z No ❑ Performed Part of Town Annual Audit
Judge:Yes Z No ❑ 'Performed Part of Town Annual Audit
Town/Village Clerk:Yes&6 No ❑ Performed Part of Town Annual Audit
Fire Dept., District, or Company:Yes Z No ❑ Performed Part of Town Annual Audit
Other: Yes ❑ No❑ Performed
Review of Bank Statements: Yes Z No ❑ Performed Comptroller&Deputy Comptroller
Countersignatures:Yes Z No ❑ Performed All disbursements over$10,000
Reconciliations:Yes Z No ❑ Performed monthly,quarterly,annually as required
Number of Ratable Employees Approx 50
Ratable Employees consist of all employees or volunteers who regularly handle,have custody or maintain records of money,
securities or other property,and all department and division heads and assistant managers.
*Please provide a list of any losses that have occurred in the past 6 years.*
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
EXCESS LIABILITY- Follow Form
Excess Policy Limits are available up to:
$16,000,000 Each Occurrence
$32,000,000 Aggregate
Excess Limit requested:
❑$1,000,000/$2,000,000 Aggregate
❑$2,000,000/$4,000,000 Aggregate
❑$3;000,000/$6,000,000 Aggregate
❑$4,000,000/$8,000,000 Aggregate
❑$5,000,000/$10,000,000 Aggregate
❑$6,000,000/$12,000,000 Aggregate
❑$7,000,000/$14,000,000 Aggregate
❑$8,000,000/$16,000,000 Aggregate
❑$9,000,000/$18,000,000 Aggregate
$10,000,000/$20,000,000 Aggregate
Additional Limits may be attained subject to underwriting approval.
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
Please Read Carefully
GENERAL FRAUD WARNING NOTICE
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information, or conceals for the purpose of misleading,information concerning
any fact material thereto,commits a fraudulent insurance act,which is a crime,and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
NEW YORK FRAUD WARNING
Auto: All applications for automobile insurance shall contain the following statement: Any person who knowingly makes or
knowingly assists, abets,solicits or conspires with another to make a false report of the theft,destruction,damage or conversion of
any motor vehicle to a law enforcement agency,the department of motor vehicles or an insurance company,commits a fraudulent
insurance act,which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the
subject motor vehicle or stated claim for each violation.
Fire Insurance: All applications for fire insurance shall contain the following statement: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 conceals for
the purpose of misleading,information concerning any fact material thereto,commits a fraudulent insurance act,which is a crime.
The proposed insured affirms that the foregoing information is true and agrees that these applications shall constitute a part of any
policy issued whether attached or not and that any willful concealment or misrepresentation of a material fact or circumstances
shall be grounds to rescinding the insurance policy.
Other Types of Insurance: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information,or conceals for the purpose of
misleading, information concerning any fact material thereto,commits a fraudulent insurance act,which is a crime,and shall also be
subject to a civil penalty not to exceed$5,000 and the stated value of the claim for each such violation.
I CERTIFY THE INFORMATION CONTAINED WITHIN THIS APPLICATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.
Your signature below acknowledges that you have read the General Fraud Warning Notice and the State Specific Fraud Warning
Notice that applies to your state domicile.
The undersigned is an authorized representative of the applicant and certifies the information provided to obtain this coverage is
accurate to the best of their knowledge;this includes any applications,location schedules,valuation statements,loss history
information and engineering reports.
SIG T I2�OFp ED INKS r' TITLE 11-- N 5L)l v) DATE
/1�
President
SIG A E OF ROPO GENT TITLE DATE
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
CYBER LIABILITY COVERAGE No Coverage Provided
Limit Requested: $250,000 ❑ $500,000 $1,000,000❑ $2,000,000 0
All limits have a $1,000 deductible.
1. Basic Municipal Details
Municipal Website Address:
Number of Employees (Full-time & Part-time):
Please specify the Financial Institution(s) used for municipal banking:
2. Primary Contact Details
Contact Name:
Position:
Email Address:
Telephone Number:
3. IT Infrastructure & Resourcing:
Name of Managed Service Provider/ IT Company (If Applicable):
Name &Title of IT/ Data Security/Managed Service Provider Contact:
Email Address of IT/ Data Security/Managed Service Provider Contact:
Phone Number of IT/ Data Security/ Managed Service Provider Contact:
4. Please approximate the following for your Municipality:
Current Year
#of Active Email Addresses
#of Desktop Computers
#of Laptops
Annual IT Budget
of Annual Budget Spent on IT or
Cybersecurity
5. Is any part of your IT infrastructure outsourced to a third-party provider, including software service
providers? [] YES [] NO
If'Yes/ please list your third-party providers, including a brief summary of the technology services they
provide to you.
6. Does the Municipality conduct due diligence on third-party vendors that have access to sensitive
information to ensure that their safeguards meet the Municipality's data security standards (e.g., require
contractual agreements to include harmless and indemnification agreements, risk assessments, security
documentation)? [] YES [] NO [ ] N/A (No External Vendors Used)
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
Data Storage & Management:
7. Which of the following types of data does the Municipality.collect, store, and/or process as part of its
municipal operations?
Q Sensitive Data (e.g., Social Security#, Passport Details, Driver's License, HR Information)
Financial Account Records (e.g., Credit Card #s, Bank Info)
tj Protected Health Information (PHI) (e.g., Medical Records)
[� Personal Data (e.g., Full Names,Addresses, Email Addresses)
❑Biometric Information & Identifiers
The Municipality Collects None of the Above Data
Please provide the approximate number of unique individuals that your Municipality collects, stores, and/or
processes personally identifiable information (PII)from, whether on your own system or with third parties:
8. Does the Municipality backup critical applications, servers, & data on a regular basis? ❑ YES []NO
If'Yes/ how frequently do you conduct (1) full system backups and/or (2) incremental/differential
backups of critical data? (Daily/Weekly/Monthly)
9. How does the Municipality store backups of critical data? (Select All That Apply)
Online (Cloud) (CJ
NAS/SAN
Hard Drive/Disk [n
Flash Drive �]
Other []
Please provide the following:
(a) Details on how you store your backups of critical data (e.g., online backups stored in live environment,
offline backups stored on removeable storage device that is fully disconnected and inaccessible from the live
environment, back-ups stored with online cloud provider, etc.)
(b) How many back-ups do you make?
10. Does the Municipality test the successful restoration and recovery of key server configurations and data
from back-ups? [j YES U NO
If'Yes/
(a) How do you test your backups?
(b) How frequently do you test your backups?
11. Does your Municipality secure your backups (e.g., back-ups are disconnected and inaccessible from the live
environment/immutable, MFA required for access to cloud backups, encryption of data backups, etc.)?
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
YES NO
If'Yes/ how do you secure your backups?
12. Does the Municipality encrypt data in transit, at rest, or stored on laptops or other portable media?
❑ YES ❑ NO
Perimeter& Endpoint Security
13. Does the Municipality have managed OR next-generation firewalls at the perimeter of the Municipality's
network? ❑ YES [] NO
14. Does the Municipality utilize real-time antivirus/anti-malware software OR endpoint protection on all
endpoints (e.g., computers, laptops, workstations, etc.)?
❑ YES (e.g., Signature Based, System Monitoring, Machine Learning, Endpoint Detection & Response)
[ENO ANTI-VIRUS SOFTWARE OR ENDPOINT PROTECTION USED
[] UNSURE
If'Yes,'
(a) Specify what anti-virus and anti-malware or endpoint detection and response (EDR) software is in
place.
(b) Do you have resources dedicated to responding to alerts generated from the software or tool?
15. Does the Municipality manage remote access to the municipal network?
❑ YES (e.g., Disable or close RDP and SMB Ports,VPN w/MFA)
❑ NO i
Cj N/A (NO REMOTE ACCESS AVAILABLE)
If'Yes,' explain how remote access is managed.
16. Has the Municipality implemented any of the following Multifactor Authentication (MFA) Controls?
�] ALL REMOTE ACCESS
�J ALL ADMIN/ PRIVILEGED ACCESS
❑ NO MFA IN PLACE
If MFA is in the place for'AII Remote Access/ is it in place for
(a) Cloud Based Applications
(b) Municipal Email
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
17. Does the Municipality conduct vulnerability scanning/penetration testing of the Municipal network?
❑ YES ❑ NO
If 'Yes,' how often.
18' Has the Municipality implemented an Intrusion Detection System? ❑Yes Q No 0 Unsure
19. Does the Municipality have measures in place to secure public Wi-Fi access?
❑ YES (e.g., Segmenting the Network, Secure Authentication Methods,Terms of Service Agreements)
❑ NO
❑ THE MUNICIPALITY DOES NOT HAVE PUBLIC WI-FI
If'Yes,' specify what measures you have to secure public Wi-Fi.
Online & Network Security
20. Does the Municipality have email security controls in place?
0 YES (e.g., Spam Filtering Tools, Email Authentication [SPF, DKIM, DMARC],Technology to
Differentiate External vs. Internal Emails, Secure Email Gateway, Sandboxing)
[] NO EMAIL SECURITY IN PLACE
d] UNSURE
If'Yes,'
(a) Specify what email security.controls are in place.
(b) (2) State the name of the Corporate Email or Email Security Systems in use (e.g., Office 365, Barracuda,
etc.).
(c) (3) If using Office 365, is (a) MFA enabled, (b) Unified audit log and mailbox audit logging enabled, (c) is
Data Loss Prevention (DLP) configured and enabled, (d) Office 365 Cloud Application Security,enabled?
21. Does the Municipality require complex employee passwords of at least 8 characters that includes a capital
letter, at least one number, and a special character? [ ] YES [] NO
Please provide details'on your password policy or use of complex passwords.
22. Does the Municipality review content prior to posting on their website of Municipal controlled Social
Media site(s)to ensure it does not contain any defamatory material or infringes on another's copyright,
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
trademark, service mark, or collective mark?B YES Q NO a N/A (No Municipality Website or Social
Media)
23. Does the Municipality manage user access and protect user accounts (i.e., use privileged access
management solutions, restrict privileged user accounts to specific devices, enhance monitoring of
accounts for anomalous usage, MFA for remote access and administrators, etc.)?0 YES 11 NO
If'Yes,' explain how you manage user access:
(a) Are local administrator rights on laptops/desktops removed for non-IT personnel?
(b) Is employee computer access revoked when an employee is terminated or officials'term is
complete?
(c) Is there a network monitoring solution to alert you of suspicious behavior on the network?
24. Does the Municipality allow personal mobile devices to conduct municipal business? [3 YES Cj NO
If'Yes,' are:
(a) Policies or technical defenses in place to protect PII and other sensitive data from being accessed?
(b) If email can be accessed through a non-municipal issues corporate device, is MFA in place?
25. Does your Municipality conduct patch management to ensure critical patches are applied in a timely
fashion (e.g., critical (software/firmware) updates, patches/hot-fixes, or Service Packs, etc.)?
[ ] YES [] NO [] UNSURE
26. What operating system is the Municipality running?
�] Windows 11, 10 Windows 8, 7 [] Other.
27. Does the Municipality use any software or hardware that has been officially retired (end-of-life) or legacy
systems that the manufacturer or developer is no longer supporting with updates and/or software
patches?[] YES 0 NO 11 UNSURE
If'Yes,'
(a) What end-of-life or legacy system(s) are used?
(b) How are they used?
(c) Is it segregated from the rest of the network?
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
Additional Controls
28. Does the Municipality provide cybersecurity awareness training for employees? [] YES [] NO
If'Yes/
(a) How often is cybersecurity awareness training offered?
(b) Are phishing simulations conducted or social engineering training offered?
29. Does the Municipality have physical security controls where computers, networking equipment, written
and electronic records are kept?[] YES (] NO
30. Has Municipality implemented a network and data security policy and/or an Incident Response Plan?
Q YES []NO
If'Yes/ does it include a playbook of common incidents affecting local governments, such as Ransomware,
Business Email Compromise (BEC), and Funds Transfer Fraud?
31. Does the Municipality have practices in place for verification of all Electronic Funds Transfers (EFT),
changes to banking information, or changes to vendor information? ❑ YES [] NO
If'Yes/
(a) Prior to making changes to a vendor's account details or transferring funds, do you obtain
authorization from the third party via an authentication method which is different to the
original methods used to request the change/transfer?
(b) Is MORE THAN one individual in the municipality permitted to authenticate and initiate ETFs or
banking changes?
32. Does the Municipality engage independent third parties to validate any of the network and data security
policies and procedures? ❑ YES ❑ NO ❑ N/A
33. Is the Municipality currently compliant with Payment Card Industry Data Security Standards (PCI-DSS)?
[ ] YES [ ] NO [ ] N/A(The Municipality does not store, maintain or process credit card data)
34. Is the Municipality currently compliant with HIPAA Privacy, Security, and Breach notice rules? YES ❑ NO
35. Does the Municipality comply with local, state, federal and international security and privacy laws for local
government and public entities? [3 YES ❑ NO
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
36. Does the Municipality collect, capture, use, access, safeguard, share, store, retain, convert, disclose, sell,
dispose of,transmit, distribute, or destroy any biometric identifiers or biometric information? [] YES [ ] NO
If'Yes,'
(a) Does the Municipality obtain consent from individual(s)for the collection, capture, use, access,
safeguarding, sharing, storage, retention, conversion, disclosure, sale, disposal,transmitting,
distributing, and destruction of such individual(s biometric identifiers and biometric
information?
(b) Is the Municipality compliant with all federal, state, and local laws regarding the collection, use,
access, safeguarding, sharing, storage, retention, conversion, disclosure, sale, disposal,
transmission, distribution, and destruction of any biometric identifiers or biometric
information?
(c) What biometric identifiers or information are collected, captured, used, accessed, safeguarded,
shared, stored, disclosed, or dispose of?
Please provide details of any major changes or controls that you have planned for your IT infrastructure or IT
practices in the next 12 months (If Any).
Claims History& Loss Information
1. Has the Municipality had any actual or potential claims, litigation, or losses during the past 3 years
arising from Information Security, Network Security, or Media activities? ❑ YES E] NO
2. Has the Municipality been subject to any government action, investigation, or subpoena regarding any
alleged violation of a privacy law or regulation during the past 3 years? ❑ YES❑ NO
If"Yes"to any of the questions in 1-2 above, please provide a complete description of the incident in an
addendum to this application, including costs, losses or damages incurred or paid, and any corrective
measures to respond to such incident.
3. Is the Municipality or any person proposed for this insurance aware of any fact, circumstance,
situation, event or transaction which could reasonably be expected to give rise to any claim or loss that
would fall within the scope of the proposed coverage? ❑ YES []NO
If"Yes" to question 3 above, please provide a complete description of the facts, circumstances, situations,
events or transactions in an addendum to this application.
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NEW YORK MUNICIPAL INSURANCE RECIPROCAL
*Please provide a list of any losses that have occurred in the past 3 years.*
9/2024 43 of 44
f•
COVER SHEET FOR DOCUMENTS
DEC 2d2
SENT T0: " > a�a7 `�
- z � 1-;sr as a -�
Sent By: TOWN ATTORNEY, PAUL M. DECHANCE
DEPUTY T/A, JACK SQUICCIARINI
ASSISTANT T/A, JULIE M. MCGIVNEY
ASSISTANT T/A, BENJAMIN JOHNSON
CONFIDENTIAL SECRETARY, AMY SCHLACHTER X
r
Type of Agreement �—
Nature of Contract/Agreement