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MAT Leasing, Inc.

Policy Effective Dates


Entity Coverage Carrier Effective
Marina Express GL C.N.A. 2/1/11
Marina Express Auto C.N.A. 2/1/11
Marina Express Cargo Crum & Forster 2/1/11
Marina Express WC Ullico 1/18/11
Marina Express Auto C.N.A. 2/1/11

MMT Property Admiral 3/29/11


MMT GL Landmark 3/29/11

Western Warehouse Property Indiana 4/6/11


Western Warehouse WC Ullico 4/1/11

Marina Cartage Property Indiana 5/1/11 $9,809 4450 S. Morga


Marina Cartage Auto Indiana 5/1/11
Marina Cartage GL Indiana 5/1/11
Marina Cartage Umbrella Zurich 5/1/11
Marina Cartage Umbrella Zurich 5/1/11
Marina Cartage, MAT, WC Ullico 1/18/11

T&B GL Nautilus 8/1/11


T&B Umbrella Naut/Ohio 8/1/11

MT GL Zurich 10/1/10

MAT Property Travelers 10/1/12 $20,261


MAT Cont. Equip. Zurich 10/1/12 $9,161
MAT Auto Zurich 10/1/12
MAT GL Zurich 10/1/12
MAT Umbrella Zurich 10/1/12
MAT Leasing PLL Zurich 10/1/12
MAT Lease Construction PLL Zurich 10/1/12

Riverbend GL Interstate 11/17/10


Riverbend Umbrella Interstate 11/17/10
S. Morgan

$39,231
###
Premium Summary
Current Excluding Marina Express
1@250,000 2@250,000 Proposed
2010-11 2011-2012 2011-2012 TRIA Carrier
I. Property & Contractors Equipment $42,183 $30,022 $30,022 $2,603 AXIS

II. Cargo $11,293 $9,889 $9,889 ACE Illinois

III. General Liability $34,650 $26,419 $26,419 $1,275 Burlington

IV. Automobile Liability $423,168 $193,800 $193,800 Hartford

V. Auto Physical Damage Included $15,575 $15,575 Great American

VI. Pollution Legal-Contractors $13,591 $26,803 $27,067 $4,163 Chartis


Pollution Legal-MAT Leasing $19,002 Included Included Chartis
$32,593

VII. Primary Excess Liab ### $99,578 $99,578 $1,180 Rockhill

VIII. Excess Liability ### $220,779 $115,000 $115,000 AdmittedGreat American

VIII. Worker's Compensation $439,024 $267,370 $240,211 Included Hartford

IX. Service Fee $18,500 $23,941 $23,941 N/A

Total $1,222,190 $808,397 $781,502

X. Expected Losses
Auto $53,125 $53,125
WC $159,777 $159,777
TPA Fees $20,000 $20,000

DeductibCurrent Program Has A $5,000 D ???


Sub-Total $1,222,190 ### $1,014,404

Savings $180,891 $207,786


###
Loss Scenarios
Current Excluding Marina Express
1@250,000 2@250,000 Proposed
ILLUSTRATION 1 2010-11 2011-2012 2011-2012 Carrier
I. Total Fixed Costs $1,222,190 $808,397 $781,502

II. Expected Losses


Auto $53,125 $53,125
WC $159,777 $159,777

III. Large Loss Add 1 Large Loss WC $150,000 $150,000

IV. TPA Fees $15,000 $15,000

V. Total $1,222,190 ### $1,159,404

Savings $35,891 $62,786

ILLUSTRATION 2
I. Total Fixed Costs $1,222,190 $808,397 $781,502

II. Expected Losses


Auto $53,125 $53,125
WC $159,777 $159,777

III. Large Loss Add 2 Large Losses $250,000 $250,000


$150,000 $150,000

IV. TPA Fees $20,000 $20,000

V. Total $1,222,190 ### $1,414,404

Savings/Loss -$219,109 -$192,214


###
Maximum Case Scenario
Current Excluding Marina Express
1@250,000 2@250,000 Proposed
ILLUSTRATION 3 2010-11 2011-2012 2011-2012 Carrier
I. Total Fixed Costs $1,222,190 $808,397 $781,502

II. Expected Losses


Auto $53,125 $53,125
WC $159,777 $159,777

III. Large Loss Add 3 Large Loss WC $250,000 $250,000


WC $150,000 $150,000
Auto $100,000 $100,000

IV. TPA Fees $35,000 $20,000

V. Total $1,222,190 ### $1,514,404

Savings/Loss -$334,109 -$292,214

ILLUSTRATION 4
I. Total Fixed Costs $1,222,190 $808,397 $781,502

II. Expected Losses


Auto $53,125 $53,125
WC $159,777 $159,777

III. Large Loss Add 4 Large Losses WC $250,000 $250,000


WC $150,000 $150,000
Auto $100,000 $100,000
Auto $100,000 $100,000

IV. TPA Fees $20,000 $20,000

V. Total $1,222,190 ### $1,614,404

Savings/Loss -$419,109 -$392,214


Minimum
Premium Commission Commission Commission
35% 15% $4,503 $4,503

15% $1,483 $1,483

$26,419 10% $2,642 $2,642

0% $0 $0

merican 15% $2,336 $2,336

15% $4,020 $4,060

25% 0% $0 $0

merican 10% $11,500 $11,500

0% $0 $0

$0 $0

$26,485 $26,525
2

Minimum
Premium
3

Minimum
Premium
MAT Leasing, Inc.
Coverage Options
RBN
Coverage Axis
I. Property
A. Earthquake - Annual Aggregate (4450 S. Morgan) $1,000,000
B. Flood Annual Aggregate (4450 S. Morgan) $1,000,000
C. Employee Tools On Premises
1) Maximum Per Item $10,000
2) Maximum Per Employee $75,000
3) Maximum Per Occurrence $250,000
D. Electronic Data Processing Equipment $250,000
E. Pollution Clean Up $10,000
F. Back Up Sewers, Pipes & Drains $100,000
G. Debris Removal $100,000
H. Equipment Breakdown $1,000,000
I. Property Deductible $10,000
J. Coinsurance Agreed Amount

II. Equipment Breakdown


Business Interruption $515,000
Civil Authority 14 Days
Ingress/Egress 14 Days
Business Interruption Deductible 72 Hrs.

III. Contractors Equipment $3,263,700


Premium $20,534
(Minimum Premium) $20,000

Coverage/Item Additional Premium Limit


K. Add 4450 S. Morgan-Building, Contents, BI $10,005 $7,514,000
L. Business Interruption-750 N. Kilbourn $2,396 $1,500,000
M. 4335-45 S. Western Ave - Building Limit $3,415 $2,800,000
N. 4335-45 S. Western Ave-Loss Of Rents $320 $138,000
O. 3468 S. California-Loss Of Rents $292 $120,000
P. 2005 W. 43rd St.-Loss Of Rents $301 $126,000
Q. Earthquake & Flood $1,150 $1,000,000
R. Contractors Equipment $350 $3,815,016
Premium $18,229 $38,763

Loss Limit Per Occurrence ###


25000000
MAT Leasing, Inc.
Coverage Changes

Coverage Return Premium


I. Named Insureds
A. Delete
1) NW Transfer All Coverage
2) Marina Express, InAuto, WC, & Cargo, but included in all other coverage.
3) Marina Xpress Int Auto, WC, & Cargo, but included in all other coverage.
4) Marina Xpress Auto, WC, & Cargo, but included in all other coverage.

MAT Leasing, Inc.


Coverage Items

Coverage Item
I. Property Add Agreed Amount
Add Equipment Breakdown
II. General Liability
Undeclared Operations
New Entities
Exclusion Certain Operations
Contractual Liability Amendment
Amendment-Exclusion g.
Schedule of Named Insureds

III. Automobile
Broadened PLL Does it cover defense?
Does it cover BI/PD?

MAT Leasing, Inc.


Items To Complete

Item Date Completed


I. Complete Bus. Int. Wksht

II. Loss of Rents Values


III. Surplus Lines Filings

IV. Terrorism Forms

V. Signed Statement of Values

VI. Service Fee Agreement

VII. Get List of Certificate Holders

VIII. Sub-Contractors Copy of Certificates of Insurance

IX. Automobile ID Cards

X. Claim Contacts

Claim Kit

MAT Leasing, Inc.


Standard Forms

Coverage Item
I. Personal Injury Discrimination or Humiliation Causing Injury To The Reputation of a Natu
Person Provided The Discrimination or Humiliation Is Done Without The
Direct Consent of Any Insured, Executive Officer, Director, Officer, etc.;
Is Not Related To Employment

II. Policy Territory


A. US Including Its Territories & Possessions, Puerto Rico & Canada
B. All Other Parts of the World If The Injury or Damages Arises Out of:
1) Goods or Products Made or Sold By You In The US
2) Personal Injury & Advertising Injury That Takes Place Through The Intern
Similar Electronic Means Of Communications.
E. Payroll Limitations Excluding Clerical & Sales
Current
Travelers

$0
$0

$0
$0
$0
$25,000
$25,000
$25,000
$0
$0
$5,000/$10,000
90%
Increase 4335 S. West Bld. To 2,800,000
$712,595 ###
Not Covered 0.15347 0.15347
Not Covered $1,094 $212
Not Covered 0.035 $38 0.035 $7 0.035
Not Covered 0.006 $7 0.006 $1 0.006
A $1,138 B $220 C
$3,282,516
$31,111 Original Quote $35,394
Bld. 1,500,000 $1,138
BI 1,500,000 $2,396
Rents 120,000 $192
S. Morgan $12,005
2012595
Limit
$7,514,000
Not Covered
$787,405 $15,731
$0
$0 $19,663
$0 0.279085
$0
$0 881
$39,231

-$7,531
Additional or
Return Premium

Included
In
Premium
Summary
ompleted
The Reputation of a Natural
on Is Done Without The
Director, Officer, etc.;
o Rico & Canada
ages Arises Out of:

lace Through The Internet Or

rical & Sales


BI Rents CE Increase 4335 S. West B
### ### ### ###
0.15347 0.15347 0.15347 0.15347
$184 $193 $493 $3,089
$6 0.035 $7 0.035 $17 0.035 $108
$1 0.006 $1 0.006 $3 0.006 $19
$192 D $201 E $513 F $3,215
5 S. West Bld. BI
###
0.15347
$2,302
0.035 $81
0.006 $14
$2,396
MAT Leasing, Inc.
2014-2015 Named Insureds
All Mar Exp All Mar Exp Contractors Site Primary Cont.
Name of Entity WC WC GL GL Auto Pollution Pollution Excess Excess Property Eqmt
Marina Cartage, Inc. X X X X X ADD X

Michael Tadin Building Account X X X X ADD X

Marina Leasing, Inc. X X X X ADD X

M.A.T. Leasing, Inc. X X X X X X X X X

M.A.T. Construction Leasing , Inc. X (C) X X (C) X ADD X

M.A.T.Construction, Inc. X X X X X X ADD X

MAT Waste Northwest, Inc. X X X X X X ADD X

Marina Waste Transfer X X X X X X ADD X


MAT Leasing, Inc.
2014-2015 Named Insureds
All Mar Exp All Mar Exp Contractors Site
Name of Entity WC WC GL GL Auto Pollution Pollution Excess Excess Property Eqmt
MT Transit, Inc. X X X X X X ADD

Marina Express, Inc. X (D) X X X

Marina Xpress Intermodal X (D) X X X

Marina Xpress X (D) X X X

MMT Investments, Inc. X X X X X ADD

Riverbend Real Estate Investment, X X X X ADD

Western Warehouse, Inc. X X X X X ADD

35th Street Partners X X X X ADD


MAT Leasing, Inc.
2014-2015 Named Insureds
All Mar Exp All Mar Exp Contractors Site
Name of Entity WC WC GL GL Auto Pollution Pollution Excess Excess Property Eqmt
T & B Ltd. X X X X ADD

T & B Limited Partnership X X X ADD

T & B Ltd. (A) X X X ADD


National Blvd. Bank & Trust
U/T8369 Dated 7/12/89 & All
Agents

T & B Ltd. (A) X X X ADD


Lakeside Bank & Trust 10-1310
Dated 11/12/87

Morgan Street Development, LLC No Coverage Provided To Morgan Street Development


MAT Leasing, Inc.
2014-2015 Named Insureds
All Mar Exp All Mar Exp 0 Contractors Site 0 0 0 0
Name of Entity WC WC GL GL Auto Pollution Pollution Excess Excess Property Eqmt
Cargo Cargo
X

MAT Waste Northwest, Inc.


M.A.T. Leasing, Inc.
Marina Cartage, Inc.
X MT Transit, Inc.

X
Cargo Cargo
Cargo Cargo
0 0
Cargo Cargo
MAT Leasing, Inc.
2012 to 2013 Named Insureds
All Mar Exp All Mar Exp Contractors Site Primary Cont.
Name of Entity WC WC GL GL Auto Pollution Pollution Excess Excess Property Eqmt Cargo
Marina Cartage, Inc. X X X X X ADD X X

Michael Tadin Building Account X X X X ADD X

Marina Leasing, Inc. X X X X ADD X

M.A.T. Leasing, Inc. X X X X X X X X X X

M.A.T. Construction Leasing , Inc X (C) X X (C) X ADD X X

M.A.T.Construction, Inc. X X X X X X ADD X X

MAT Waste Northwest, Inc. X X X X X X ADD X

Marina Waste Transfer X X X X X X ADD X


MAT Leasing, Inc.
2012 to 2013 Named Insureds
All Mar Exp All Mar Exp Contractors Site
Name of Entity WC WC GL GL Auto Pollution Pollution Excess Excess Property Eqmt Cargo
MT Transit, Inc. X X X X X X ADD

Marina Express, Inc. X D X X X

Marina Xpress Intermodal X D X X X

Marina Xpress X D X X X

MMT Investments, Inc. X X X X X ADD

Riverbend Real Estate Investmen X X X X ADD

Western Warehouse, Inc. X X X X X ADD

35th Street Partners X X X X ADD


MAT Leasing, Inc.
2012 to 2013 Named Insureds
All Mar Exp All Mar Exp Contractors Site
Name of Entity WC WC GL GL Auto Pollution Pollution Excess Excess Property Eqmt Cargo
T & B Ltd. X X X X ADD

T & B Limited Partnership X X X ADD

T & B Ltd. (A) X X X ADD


National Blvd. Bank & Trust
U/T8369 Dated 7/12/89 & All
Agents

T & B Ltd. (A) X X X ADD


Lakeside Bank & Trust 10-1310
Dated 11/12/87

Morgan Street Development, LLC No Coverage Provided To Morgan Street Development


MAT Leasing, Inc.
2012 to 2013 Named Insureds
All Mar Exp All Mar Exp 0 Contractors Site 0 0 0 0 0
Name of Entity WC WC GL GL Auto Pollution Pollution Excess Excess Property Eqmt Cargo
Cargo
General Liability - Burlington Ins. Co.
X Entity Included
( A ) Add Entity
T & B Ltd. National Blvd. Bank & Trust U/T8369 Dated 7/12/89 & All Agents
T & B Ltd. Lakeside Bank & Trust 10-1310 Dated 11/12/87
( B ) Delete NW
( C ) Correct Named Insured
Amend the Named Insured from M.A.T. Leasing Construction, Inc. to M.A.T. Construction Leasing , Inc.

( D ) Delete Effective 12/13/13 From GL Covering All Locations


NW Transfer
Marina Express, Inc.
Marina Xpress Intermodal
Marina Xpress

Excess Policy-Rockhill
X MAT Leasing, Inc. & M.A.T. Leasing, Inc.
( B ) Delete NW Transfer
( C ) Correct Named Insured
Amend the Named Insured from M.A.T. Leasing Construction, Inc. to M.A.T. Construction Leasing , Inc.

WC Hartford
( C ) Correct Named Insured
Amend the Named Insured from M.A.T. Leasing Construction, Inc. to M.A.T. Construction Leasing , Inc.
Cargo
Cargo
0
Cargo

Covered Entity
Delete Entity
Add Entity
asing , Inc.

asing , Inc.

asing , Inc.
MAT Leasing, Inc.

Excess Liability
Renewal Application
Effective Date
ASAP

Prepared By
Ronald J. Cowell
Revised
###
1c

Application Pollution Liability App


Workers' Compensation & Automobile
Site & Contractors Po
General Liability Application
General Liability

DISCLAIMER - The abbreviated Outline of Coverage used throughout this proposal is not
intended to express any legal opinion as to the nature of coverage. They are only visuals to a
basic understanding of the coverage provided. Please read your policy for specific details of
the actual coverage provided.
on Liability Application
Contractors Pollution
ral Liability

t this proposal is not


They are only visuals to a
cy for specific details of
MAT Leasing, Inc.
Renewal Application
Table of Contents
I. Acord Form

II. Named Insureds

III. Schedule of Locations

IV. Description of Operations

V. Umbrella Liability

VI. AJG TRIP Captive Program

VII. Automobile Liability & Physical Damage

VIII, Schedule of Vehicles

IX. General Liability

X. Workers Compensation Coverage

XI. Historical Payrolls

XII. Experience Modification

XIII. Historical Premium & Loss Summary

XIV. Loss Runs


MAT Leasing, Inc.

Table of Contents

I. Policy & Procedure Manual


II. Resume of Safety Personnel
III. Written Formal Safety Program
IV. Worker's Compensation
A. Drug Program
B. Return To Work Program / Light duty
C. New Hire Guidelines
D. New Employee Orientation
E. Disciplinary Procedures
F. Workers Compensation Accident Investigation
V. Automobile
A. Minimum Acceptable Driving Record Guidelines
B. Vehicle Maintenance Program
C. Vehicle Maintenance Program Forms
D. Automobile Accident Investigation Procedures
E. Supervisor Post Accident Investigation Procedures
F. Disciplinary Procedures
1c

Premium Summary Description of Operations

Carrier Financial Ratings Contractors Pollution-Named

Named Insureds Site Coverage-Schedule of

Schedule of Locations Site & Contractors Pollution

Workers CompProperty Revenues: City of Chicago Bi

Historical PayrGeneral Liability Historical Premium & Loss

Experience MoPollution Legal Liability Loss Runs

Automobile Liability & Physical Da Pictures of Each Location

Schedule of Vehicles

Umbrella Liability

Automobile Liability & Physical Damage

Schedule of Vehicles

Excess Liability-Primary Layer Property Coverage

Excess Liability Statement of Values

750 Kilbourn Diagram

Contractors Equipment Cove


General Liability
Contractors Equipment Sche
Umbrella Liability

Excess Liability

Automobile Policy
Workers Compensation Policy

Loss Runs
General Liability
Commercial General Form 125
Named Insureds
Description of Operations
Site & Contractors Pollution Le
Named Insureds
Named Insureds
Schedule of Locations
Umbrella & Excess Liability
Historical Payrolls

Historical Revenues & Mileage


Schedule of Lo
General Liability & Pollution Application
Automobile Lia
Automobile Application
Schedule of Ve
Worker's Compensation Application
Historical Reve
General Liability Historical Premium & Loss Summary
List of Drivers
Pollution Legal Historical Premium & Loss Summary
MVR's
Automobile Historical Premium & Loss Summary
General Liabili
Worker's Compensation Historical Premium & Loss Summary

Umbrella Historical Premium & Loss Summary

Safety 22062267 Site & Co

erage Pollution

edule General L

Automobile Liability & Physical Damage Primary E

Schedule of Vehicles Second L


Safer Report - Comment From Risk Manager Service T

Safety Program

Automobile Historical Premium & Loss Summary

Target Pricing

Loss Runs

Driver List/MVR
Schedule of Policies

Claim Reporting Contacts


Legal Liability Coverage
A.M. Best Ratings

Named Insureds By Coverage

Schedule of Locations By Coverage

Property, Equipment Breakdown, Co


Locations
Schedule of Values
Liability & Physical Damage Coverage
General Liability
Vehicles
Automobile Liability & Physical Dam
evenues & Mileage
Site-Pollution Legal Liability
rs
Contractors-Pollution Legal Liability

Excess Liability-Primary Layer


bility Coverage
Excess Liability-Excess Layer

Premium Summary

Contractors Pollution Liability Coverage Outline

on Applications

al Liability

ry Excess

d Layer Excess
e Team
ontractors Equipment

mage

y
MAT Leasing, Inc.

Acord Form
MAT Leasing, Inc.

Named Insureds
MAT Leasing, Inc.

Schedule of Locations
MAT Leasing, Inc.

Description of Operations
MAT Leasing, Inc.

Umbrella Liability
MAT Leasing, Inc.

AJG TRIP Captive Program


MAT Leasing, Inc.

Automobile Liability & Physical Damage


MAT Leasing, Inc.

Schedule of Vehicles
MAT Leasing, Inc.

General Liability
MAT Leasing, Inc.

Workers Compensation Coverage


MAT Leasing, Inc.

Historical Payrolls
MAT Leasing, Inc.

Experience Modification
MAT Leasing, Inc.

Historical Premium & Loss Summary


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Contractors Pollution

Automobile
Historical Premium & Loss Summary

Site Pollution
Site Pollution

Worker's Compensation Target Prici


Trend & Development Calculation
Financial Analysis
Target Pricing -- Trend & Development
nalysis Deductible Analysis Summary Deductible Calculation
ble Calculation
MAT Leasing, Inc. 1 of 2

General Information
Named Insured MAT Leasing, Inc. Etal. (See Named Insured Section)
4450 S. Morgan St.
Chicago, Illinois 60609

Type of Business Corporation S-Corp. X LLC


Individual Partnership Other

Description of Operations Marina Cartage intermodal, over th


Mat Leasing, Inc. Were running out
See Description of Operations Section MT Transit We do both, depends on

Main Contact Deb Tadin


Phone 773-254-3644
Fax
E-mail dtadin@marinacartage.com

President/Owner Michael Tadin


Phone 773-254-3644
Fax
E-mail dtadin@marinacartage.com

Accounting Contact Deb Tadin


Phone 773-254-3644
Fax
E-mail dtadin@marinacartage.com

Claim Manager Deb Tadin/Melony Acosta


Phone 773-254-3644
Fax
E-mail dtadin@marinacartage.com

Safety Director Melony Acosta


Phone 773-254-3644
Fax
E-mail macosta@marinacartage.com

Fein # 1 Name 36-2582263

Fein # 2 Name

WC - NCCI ID Number 12-0541579

Property - ISO Risk ID Number(s)

I hereby state that the information provided in this application and the attached applications represents
a true and complete description of the operations as they exist as of the date the application was signed.

Ronald J. Cowell 8/1/16


Agent Date
MAT Leasing, Inc. 2 of 2

General Information

Date Business Started

General Information Yes No


Is the applicant a subsidiary of another entity? X
Does the applicant have any subsidiaries? X
Has the business been placed in a trust? X

Has the applicant ever been convicted of arson? X


Any bankruptcy, tax, or leins against the applicant in the past 5 years? X

Has any policy been declined, cancelled or non-renewed in the past 3 years? X

Any past claims related to sexual abuse? X


Any past claims related to sexual molestation? X
Any past claims related to discrimination? X
Any past claims related to negligent hiring? X

Exposures Yes No
Any exposure to flammables, explosives, chemicals? X
Any catastrophic exposures? X
Any uncorrected fire or safety code violations? X

Safety Program Yes No


Is a Formal safety program in operation? X
Does Applicant have a formal Return To Work / Light Duty Program? X
MAT Leasing, Inc.
Premium Summary
Current Proposed AXIS AXIS AXIS AXIS
Carrier Carrier 2014-2015 2015-2016 2015-2016 2015-2016 2015-2016
I. Property & Contractors Equipment $43,520 $43,763 $43,763 $43,763

Original Quotations MAT Leasin MAT Construction


Burlington Indian Harbor Nautilus Indian Harbor Indian Harbor
II. General Liability $28,231 $35,692 $29,628 $31,610 $41,980 $35,000

Colony Navigators Nautilus Nautilus Nautilus Nautilus


III. Contractors PL $34,214 $34,187 Included $14,747 $18,966 $18,967

Navigators Nautilus Nautilus Nautilus Nautilus


IV. Site PL $0 $12,015 $17,588 $16,846 N/A N/A

Navigators Nautilus Nautilus Nautilus Nautilus


V. Excess Pollution $4,000,000 $0 $0 $18,892 $21,854 $0 $0

Rockhill Rockhill Rockhill Rockhill Rockhill Rockhill


VI. Primary Excess Liabilit $5,000,000 $111,100 $111,200 $111,200 $111,200 $25,000 $25,000

Grt AmericanGrt American


Grt American
VII. Excess Liability $25,000,000 $120,752 $125,099 $125,099 $120,752 $0 $0

VIII. Service Fee $20,000 $20,000 $20,000 $20,000 $0 $0

Total $357,817 $381,956 $366,170 $380,772 $85,946 $78,967


MAT Leasing, Inc. ### 86909
Premium Summary
$0
MAT Leasing, Inc.
Premium Summary
Current Proposed Burlington Berkley Revised
Carrier Carrier 2012-2013 2013-2014 2014-2015 2015-2016 2015-2016 2015-2016
I. Property & Contractors Equipment AXIS AXIS $37,237 $41,362 $43,520 $43,763 $43,763 $43,763

II. General Liability BurlingtonIndian Harbor $27,455 $29,047 $28,231 $36,225 $29,628 $31,617

III. Contractors PL Navigators Nautilus $32,593 $28,182 $34,214 $34,187 Included $14,234

IV. Site PL Navigators Nautilus $0 $0 $0 $16,897 $17,588 $16,330

V. Excess Pollution $4,000,000 Nautilus $0 $0 $0 $0 $18,892 $20,238

VI. Primary Excess Liabi $5,000,000 Rockhill Rockhill $99,578 $110,300 $111,100 $111,370 $111,370 $111,200

VII. Excess Liability $25,000,000Great American


Great American $115,000 $120,750 $120,752 $125,099 $125,099 $125,099

VIII. Service Fee $23,750 $23,367 $20,000 $20,000 $20,000 $20,000

Total $335,613 $353,008 $357,817 $387,541 $366,340 $382,481

General Liability Indian Harbor Is Owned By One of The Largest Companies -- XL Group, Exton, PA. A+XV.
MAT Leasing, Inc.
Premium Summary
Minimum Policy
Premium Minimum TRIA
I. Property & Contractors Equipment 35%

II. Cargo $11,293 $9,889 N/A

III. General Liability 25% 100% $1,275


Non Auditable

IV. Automobile Liability

V. Auto Physical Damage Included $15,575 $15,575 Great American

VI. Pollution Legal-Contractors


Pollution Legal-MAT Leasing 3870
111370

VII. Primary Excess Liability

VIII. Excess Liability

VIII. Worker's Compensation $439,024 $508,168 $259,672 N/A 0

IX. Service Fee

Total $15,576 -$15,576 (Savings)

Contractors Pollution Colony $22,800 $24,476 25%

Site Pollution Colony $13,243 $14,832 25%


Current Proposed
Carrier Carrier 2011-2012
AXIS AXIS $30,022

Burlington Burlington $26,419


Nautilus

$13,739 Colony Navigators $27,067 Burlington $36,650 $27,455


$14,747 Nautilus

$15,763 Navigators $0 Berkley ### ###


16846 Nautilus

$20,592 Navigators $0
21854 Nautilus

Rockhill Rockhill $99,578

Great AmericanGreat American $115,000

$18,500 $14,000
$23,941

$220,779

$18,500
New Entities
Independent Contractors-Minimum Requirements
Undeclared Operations Or Premises

Property & Contractors Equipment $2,602 $2,602


General Liability $945 $945
Contractors Pollution $1,455
Site Pollution
Primary Excess Liability $948 $680
Excess Liability $1,150 $1,208

$0

(Savings)
25% 10% $2,746 $27,454

0% $0 ###
A.M. BEST'S KEY RATING GUIDE 2008 EDITION

Surplus Lines
A risk exposure or a part of a risk for which Euclid Insurance Agencies Standard insurance market
are not willing to write the risk exposure. Coverage is then written by a Non-Admitted insurance c

Non-Admitted Insurance Company


An insurance company not licensed to do business in a particular state; such a company, however,
sell excess and surplus insurance in that state if admitted insurers lack the capacity or expertise.

Rating Levels & Categories

Secure Ratings

A++, A+ Superior
A, A- Excellent
B++, B+ Very Good

Vulnerable Rating

B, B- Fair
C++, C+ Marginal
C, C- Weak
D Poor
E Under State Supervision
F In Liquidation
S Rating Suspended

Financial Size & Categories Amount of Surplus


Class I Up to $1,000,000
Class II $1,000,000 $2,000,000
Class III $2,000,000 $5,000,000
Class IV $5,000,000 $10,000,000
Class V $10,000,000 $25,000,000
Class VI $25,000,000 $50,000,000
Class VII $50,000,000 $100,000,000
Class VIII $100,000,000 $250,000,000
Class IX $250,000,000 $500,000,000
Class X $500,000,000 $750,000,000
Class XI $750,000,000 $1,000,000,000
Class XII $1,000,000,000 $1,250,000,000
Class XIII $1,250,000,000 $1,500,000,000
Class XIV $1,500,000,000 $2,000,000,000
Class XV $2,000,000,000 or More
1C

insurance markets
itted insurance company.

mpany, however, may


ity or expertise.
MAT Leasing, Inc., Etal.
Carrier Financial & Service Capabilities
Carrier Parent Company Coverage Best Rating Licensed & Admitted Non Admitted
Axis Insurance Co. Property A XV No Yes

Burlington Insurance Co. General Liability A IX No Yes

Navigators Pollution A XIII No Yes

Rockhill Ins. Co. Excess Liability A XIII No Yes

Great American Insurance Co. Excess Liability A XIV Yes No

Trumbull Insurance Co. Hartford Ins. CoWorkers Comp A XV Yes No

Trumbull Insurance Co. Hartford Ins. Co Automobile A XV Yes No

Insurance Co. of the West WC A IX Yes No

Accident Fund WC A XIII Yes No

Amerisafe WC A XIII Yes No

Great Divide Berkley Group Automobile A XV Yes No

Great Divide Berkley Group Pollution A XV Yes No

RBN & Associates does not guarantee or make representation in regard to the financial conditions of insurers with which it places bus
As a matter of policy, however, we confine our placements to those companies, which meet certain criteria outlined in the Best Insura
1C

Lloyds of London Cargo A XV A+ Yes No

National Union Fire Ins. Co. A XV A

ACE/Illinois Union Ins. C Cargo A XV A No Yes

Lexington Insurance Co. Pollution A XV A No Yes

Hartford Ins. Co. Auto & WC A XV A Yes No

Hartford Steam Boiler Boiler

RTWI State Auto Ins. Co. A+

Ironshore Ins. Co. A- XI

places business.
Best Insurance Reports.
MAT Leasing, Inc., Etal.
RBN & Associates Contacts
Business Business Business Days Home
Primary Contact Phone Fax E-Mail Cell Phone Phone Responsibilities
Ron Cowell 312-861-7654 312-856-9420 rcowell@rbn500.com 847-373-0308 847-359-3138 Prepare Outline of Coverage;
Review Coverage With Client;
Identify Coverage Deficiencies;
Make Recommendations To Add or
Delete Coverage;
Identify Program Enhancements To
Reduce Overall Program Costs;
Resolve Claim Management Issues
Coordinate Safety Surveys
Market Renewal
Negotiate Renewal Pricing
Resolve All Client Problems

Account Executives
Marie Finn 312-801-8085 312-856-9420 mfinn@rbn500.com Provide Resolutions To Client Issues,
Concerns or Problems;
Answer Client Questions;
Primary Contact To Provide Instruction
To, To Make Policy Changes
Billings: CLEARLY Communicate To All
Clients Premium Amounts, Due Dates,
& Who To Pay;
Resolve Accounting Issues For Clients

Tech Support
Lisa Spencer 312-861-7659 312-856-9420 lspencer@rbn500.com Assist Marie & Clients Whenever Need

Accounting
Wally Wawzenek 312-861-7666 312-856-9420 wwawzenek@rbn500.com Accounting Questions
Account Executive Is Primary Contact

Claims
Pat Taylor 312-861-7654 312-856-9430 lhelm@rbn500.com Claim Management

Certificates of Insurance
Lisa Spencer 312-856-7659 312-856-9420 lpickett@rbn500.com Processes Certificate Requests
Add or

ents To

Issues

t Issues,

Instructions

cate To All
Due Dates,

or Clients

never Needed

Contact
MAT Leasing, Inc. 1

General Liability
I. Current Carrier Indian Harbor

II. Effective Date 10/1/16

III. General Liability


A. Each Occurrence $1,000,000
B. Designated Projects General Aggregate Excluding Products Completed Oper $5,000,000
Designated Projects Means Each Construction Project Described In A Separate Written
Contract & If Multiple Projects Are Grouped Under One Written Contract, All Such Projects
Will Be Considered One Project & Subject To A Single General Aggregate Limit.
C. General Aggregate Excluding Products Completed Operations & Pollution $2,000,000
D. Products & Completed Operations Aggregate $2,000,000
E. Damage To Premises Rented To You Any One Fire $50,000
F. Medical Expense Limit Per Person $1,000

IV. Additional Coverage Extensions


A. Contractual Liability
B. Blanket Additional Insured Applies Only When Required In A Written Contract;
C. Blanket Primary & Non Contributory Only When Required In A Written Contract;
D. Blanket Waiver of Subrogation Only When Required In A Written Contract;
E. Explosion, Collapse & Underground
F. Host Liquor
G. Incidental Medical Malpractice
H. # of Days Notice of Cancellation 90 Days

V. Personal Injury Including $1,000,000


A. Advertising Liability-The Use of Another's Idea In Your "Advertisement".
B. Infringing Upon Another's Copyright, Trade Dress, Slogan In Your "Ads".
C. False Arrest, Detention, Imprisonment
D. Malicious Prosecution
E. Wrongful Entry Into or Invasion Of A Premises That A Person Occupies
F. Oral/Written Publication, In Any Manner, of Material That Slanders/Libels a Person or Their Product
G. Oral/Written Publication, In Any Manner, of Material That Violates a Person's Right of Privacy

VI. Employee Benefits Liability


A. Each Claim & Aggregate Limit $1,000,000
B. Claims Made Or Occurrence Claims Made
C. Retro Active Date 10/1/05

VII. Defense Costs


A. Are In Addition To The Limit of Liability
B. Included In The Deductible (If Any)

VIII. Deductible
A. Bodily Injury, Property Damage, Personal Injury-Per Occurrence $2,500
B. Employee Benefits Liability: Each Employee $1,000
MAT Leasing, Inc. 2

General Liability Rating


XI. Rating Factors
A. Auditable or Non Auditable Auditable

XII. Rating - Target Pricing 2016-17 2016-17 2016-17


Classification Code Exposure Rate Premium
Trucking/Transfer Ops 99793 $690,000 $32.000 $22,080
Vacant Land 49451 62 $1.45 $90
Building-Office Lessors 61212 86,452 $32.00 $2,766
Parking -Private 46622 1,000 $38.00 $38
Warehouse 68702 41,098 $14.064 $578
Land-Lessor's Risk 45539 1 $0.00 $0
Sub-Contractor Work 91585 $10.00 $0
In Connection With $0
Insured Construction $0
Sub-Contractor Work 91585c $30.00 $0

Total $25,552
Surplus Lines Tax 3.50% $894
Stamping Fee 0.10% $26
Total $26,472

Optional Terrorism $945


MAT Leasing, Inc. 3

General Liability Exclusions


XIV. Partial List of General Liability Exclusions Except If Covered By Endorsement
A. Standard Policy Exclusions
B. Additional Insured-(Blanket) When A Written Contract Does Not Exist Prior To A Loss
C. Aircraft, Automobile, Watercraft Including Loading & Unloading
D. Aircraft Products - & Grounding
E. Asbestos, Asbestos Dust
F. Contractual Liability Indemnification Of Architects, Engineers or Surveyors For The Professional Service
G. Contractual Liability Indemnification Arising From The Sole Negligence Of Another Person or Organizati
H. Continuous or Progressive Injury or Damage
I. Cross Suits-Named Insured vs Named Insured
J. Cyber - Release of Personal Information
K. Economic Trade Sanction Violations of Laws Enforced By OFAC
L. Electromagnetic Force
M. Employment Practices
N. Errors Or Omissions-Construction Management
O. Expected Or Intended Injury
P. Financial Services
Q. Fungi, Mold or Bacteria Including Clean Up, Remediation, Containment or Removal
R. Illinois Changes-Civil Union & Religious Freedom Act
S. Illinois Changes-Defense Costs
T. Independent Contractors-Minimum Requirements:
1 Mil/Occurrence / 2 Mil Gen Agg; 2 Mil Comp. Operations
U. Intellectual Property (Patent,Copyright Infringement,Trade Dress,Trade Name,Trade Secret,Trademark)
V. Lead In Any Form or Products Containing Lead Bearing SubstanceS, Which Cause Poisoning, or Any Dise
W. Liquor Liability
X. Mobile Equipment While Being Transported By An Owned or Operated Auto
Y. New Entities MUST BE ADDED BY ENDORSEMENT BEFORE COVERAGE APPLIES
Z. Nuclear, War, Radio Active Material
AA. Primary & Non Contributory (Blanket) When A Written Contract Does Not Exist Prior To A Los
BB. Pollution
CC. Professional Liability-Engineers, Architects or Surveyors
DD. PD (Property Damage) To Owned Property
EE. PD To Premises You Sell, Give Away or Abandon
FF. PD To Property Loaned To You
GG. PD To Property In Your Care, Custody or Control (Must Be Insured Under Property)
HH. PD To That Part Of A Building Which You Are Performing Operations
II. PD To That Part Of A Bld Which Contractors Working Directly/Indirectly On Your Behalf Are Performing
JJ. PD To Your Product, Your Work
KK. Products Recall
LL. Punitive Damages Unless Insurable By Law; Criminal Fines, Penalties & Assessments
MM. Real or Personal Property In The Care, Custody or Control of the Insured
NN. Recording & Distribution Of Material In Violation of Law
OO. Silica, Silica Dust or Other Similar Fibrous Or Mineral Substances
PP. Subaqueous Operations, Dredging, Pile Driving, Caisson, Cofferdam, Sewer, Tunnel, Bridge, Levee, Dike
QQ. Terrorism
RR. Testing or Consulting E&O
SS. Violation of Statutes That Govern E-Mails, Fax, Phone Calls & Other Methods
TT. Waiver of Subrogation (Blanket) When A Written Contract Does Not Exist Prior To A Loss
UU. Workers' Comp/Employers Liability/Employee Injuries
VV. Wrap Up Program Work
WW. Wrap Up Program Work
YY. Workers' Comp/Employers Liability/Employee Injuries
ZZ. Wrap Up Program Work
MAT Leasing, Inc. 4

Personal Injury/Employee Benefits Exclusions


XV. Partial List of Personal Injury Liability Exclusions Except If Covered By Endorsement
A. Knowing Violation of Rights of Another
B. Material Published With Knowledge of Falsity
D. Material Published Prior to Policy Period
E. Criminal Acts
F. Contractual Liability
G. Breach of Contract
H. Quality or Performance of Goods-Failure To Conform To Statements
I. Wrong Description of Prices
J. Infringement of Copyright, Patent, Trademark, Trade Secret or Other Intellectual Property
K. Insureds In Media & Internet Businesses
L. Electronic Chatrooms or Bulletin Boards
M. Unauthorized Use of Another's Name or Product
N. Pollution
O. Pollution Related
P. War, Nuclear Material & Radioactivity
Q. Asbestos
R. Lead
S. Employment Related Practices
T. Professional Liability
U. Punitive Damages Unless Insurable By Applicable Law; Criminal Fines, Penalties & Assessments
V. Distribution of Material In Violation of Statutes

XVI. Partial List of Employee Benefits Liability Exclusions Except If Covered By Endorsement
A. Failure To Maintain Insurance
B. Available Funds
D. Damages Arising Out of Insufficiency of Funds
E. Inadequacy of Performance of Investment/Advice
F. Worker's Compensation
G. ERISA
H. Dishonest, Fraudulent, Criminal or Malicious Act, Error or Omission
I. Taxes, Fines or Penalties
J. Damages Arising Out of Failure of Performance of Contract By Any Insurer
X

X
X

heir Product

IX. Subject To:


A. Signed TRIA Form; Signed Acord App;
B. Contractors Supplemental Application-Completed & Signed
C. Construction or Service Trades
2012 to 2013
2013 to 2014
X. Premium $26,500 $27,250
Taxes 0.10% $27 $27
Stamping Fee 3.50% $928 $954
Total $27,454 $28,231

$549,768
2014-2015 2014-20152014-2015
Exposure Rate Premium
$330,725 $21.8541 $7,228
$200,000 $69.0987 $13,820
62 $4.07 $252
86,452 $60.03 $5,189
1,000 $40.59 $41
41,098 $17.40284 $715
1 $4.52 $5
$0
$0
$0
$0

$27,250
$0
$0
$27,250

$945
XIII. Rating 2015-20162015-2016 2015-2016
Classification Code Exposure Rate Premium
Trucking/Tra 99793 ### $41.982 $29,422
Road Resurf 99315 Included $41.982 $0
Vacant Land 49451 62 $1.45 $90
Building-Offi 61212 86,452 $49.99 $4,322
Parking -Priv 46622 1,000 $38.00 $38
Warehouse 68702 41,098 $14.064 $578
Land-Lessor' 45539 1 $0.00 $0
Sub-Contrac 91585 If Any $10.00 $0
In Connection With $0
Insured Construction $0
Sub-Contrac 91585c If Any $30.00 $0
Insured/Uninsured
Total $34,450
Surplus Line 3.50% $1,206
Stamping Fe 0.20% $69
Inspection Fee $500
Total $36,225

Optional Terrorism $945

Minimum Earned Premium 25% $5,004

Inspection Fee Is Fully Earned $500

Premium Audit Fully Earned


A Loss

fessional Services
son or Organization

ecret,Trademark))
oning, or Any Disease

t Prior To A Loss

Are Performing Operations

dge, Levee, Dike, Dam

To A Loss
essments

orsement
O
X
X
X
X
X
X
X
X
X
X
X

X
?
X
X
X
X

X
X
X
X
X
MAT Leasing, Inc.
General Liability Pricing Comparison
2012-2013 2012-2013 2013-2014 2013-2014
Code Exposure Rate Premium Rate Premium
Trucking/Transfer Ops 99793 $330,725 $23.77 $7,861 $23.77 $7,861
Road Resurfacing 99315 $200,000 $70.29 $14,058 $70.29 $14,058
Vacant Land 49451 64 4.40727 $282 4.40727 $282
Building-Office 61212 50,317 59.55666 $2,997 59.55666 $2,997
Parking -Private 46622 1,000 41.33098 $41 41.33098 $41
Warehouse 68702 41,098 18.393 $756 18.393 $756
Land-Lessor's Risk 45539 1 4.89696 $5 4.89696 $5
Employee Benefits Flat Charge Included $500 $500
Blanket Waiver of Subrogation Flat Charge Included $0
Blanket Additional Insured Flat Charge Included $0
Endorsements $250 $250

Total $26,750 $26,750


Surplus Lines Tax 3.50% $928.00 $936.24
Stamping Fee 0.10% $27.00 $26.75
Total $27,705 $27,713
Optional Terrorism $945 $945
Minimum & Deposit Premium (Non Auditable) $27,704.62 $27,712.60

27455 $27,712.60
$86,452

Rating 2014-2015 2014-2015 2014-2015


Classification Code Exposure Rate Premium
Trucking/Transfer Ops 99793 $330,725 $21.8541 $7,228
Road Resurfacing 99315 $200,000 $69.0987 $13,820
Vacant Land 49451 62 $4.07 $252
Building-Office Lessors Ris 61212 86,452 $60.03 $5,189
Parking -Private 46622 1,000 $40.59 $41
Warehouse 68702 41,098 $17.40284 $715
Land-Lessor's Risk 45539 1 $4.52 $5
$0
$0
$0
$0

Total $27,250
Surplus Lines Tax 3.50% $954
Stamping Fee 0.10% $27
Total $28,231

Optional Terrorism $945


MAT Leasing, Inc.
General Liability Pricing Comparison

Pricing - Original Quotation 2015-2016 2015-2016 2015-2016


Classification Code Exposure Rate Premium
Trucking/Transfer Ops 99793 $700,829 $41.982 $29,422
Road Resurfacing 99315 Included $41.982 $0
Vacant Land 49451 62 $1.45 $90
Building-Office Lessors Ris 61212 86,452 $49.99 $4,322
Parking -Private 46622 1,000 $38.00 $38
Warehouse 68702 41,098 $14.064 $578
Land-Lessor's Risk 45539 1 $0.00 $0
If Any $10.00 $0
$0
$0
If Any $30.00 $0

Total $34,450
Surplus Lines Tax 3.50% $1,206
Stamping Fee 0.10% $34
Total $35,690

Optional Terrorism $945

Pricing - REVISED Quotation 2015-2016 2015-2016 2015-2016


Classification Code Exposure Rate Premium
Trucking/Transfer Ops 99793 $595,000 $41.982 $24,979
Road Resurfacing 99315 n/a n/a n/a
Vacant Land 49451 62 $1.45 $90
Building-Office Lessors Ris 61212 86,452 $49.99 $4,322
Parking -Private 46622 1,000 $38.00 $38
Warehouse 68702 41,098 $14.064 $578
Land-Lessor's Risk 45539 1 $0.00 $0
Sub-Contractor Work 91585 If Any $10.00 $0
In Connection With $0
Insured Construction $0
Sub-Contractor Work 91585c If Any $30.00 $0
Insured/Uninsured
Total $30,007
Surplus Lines Tax 3.50% $1,050
Stamping Fee 0.20% $60
Inspection Fee $500
Total $31,617

Optional Terrorism $945

Minimum Earned Premium 25% $5,004

Inspection Fee Is Fully Earned $500

Premium Audit Fully Earned

Estimated ANNUAL Return Premium $4,073


E&O Audit
Policy Application
MAT Leasing, Inc., Etal. 1

Contractors Pollution
I. Current Carrier Nautilus Ins. Co.

II. Named Insureds MAT Waste Northwest, Inc.


M.A.T. Leasing, Inc.
Marina Cartage, Inc.
Marina Waste Transfer
MT Transit, Inc.

III. Effective Date 10/1/16

IV. Type of Policy General Liability: Occurrence Pollution: Claims Made

Each Pollution Condition Products/CO &


V. Coverage Deductible Each Pollution Condition
General Aggregate*
A. General Liability $2,500 $2,000,000 $2,000,000

B. Contractors Pollution $25,000 $5,000,000 $5,000,000

C. Contingent Transportation $25,000 $5,000,000 $5,000,000

D. Professional Liability N/A N/A N/A

* General Aggregate and Products Completed Operations Each Have There Own Separate Aggreg

VI. Deductible
A. General Liability $2,500
B. Contractors Pollution $25,000
C. Contingent Transportation $25,000

VI. Retro Active Date


A. General Liability N/A
B. Contractors Pollution 7/1/05
C. Contingent Transportation 7/1/05

VII. Defense Costs


A. General Liability Outside The Limit
B. Contractors Pollution Inside The Limit
C. Contingent Transportation Inside The Limit

VIII. Additional Coverage


A. Contingent Transportation Includes Loading or Unloading Of Property of Others
B. Site Pollution Includes Loading or Unloading Of Property of Others

IX. Additional Coverage - General Liability Includes -- See Attached


E&O Audit Quotation

Policy Application

regate*

ate Aggregate

Wrongful Delivery
Loading or Unloading Of Property of Others

2014-2015
2015-2016
X. Premium
Revenues ### ###
Rate $1.8240 $0.607
Premium $14,227 $13,739
e Limit Broker Fee $500 $500
Stampin 0.002 $33 $27.48
Tax 0.035 $1,139 $480.87
Total $15,899 $14,747

Terrorism (Optional Coverage) $550

Mimimum Earned Premium 100%

Minimum & Deposit 100%


MAT Leasing, Inc., Etal.
Site Pollution
I. Current Carrier Nautilus Ins. Co.

II. Named Insureds MAT Waste Northwest, Inc.


M.A.T. Leasing, Inc.
Marina Cartage, Inc.
Marina Waste Transfer
MT Transit, Inc.

III. Effective Date 10/1/16

IV. Claims Made Or Occurrence Claims Made

Coverage
V. Coverage Each Pollution Condition
Section Limit
A. First Party Clean-Up Costs $5,000,000 $5,000,000
B. 3rd Party Claims For Clean-Up Costs, Bodily Injury or Prop $5,000,000 $5,000,000
C. 3rd Party Claims For Non-Owned Disposal Sites Not Covered Not Covered
D. 3rd Party Claims For Contingent Transportation Not Covered Not Covered
E. Total All Pollution Conditons & Claims Limit $5,000,000

VI. Deductible Per Pollution Condition


A. First Party Clean-Up Costs $25,000
B. 3rd Party Claims For Clean-Up Costs, Bodily Injury or Property Damage $25,000
C. 3rd Party Claims For Non-Owned Disposal Sites N/A
D. 3rd Party Claims For Contingent Transportation N/A

VIII. Retro Active Date


A. First Party Clean-Up Costs 7/1/05
B. 3rd Party Claims For Clean-Up Costs, Bodily Injury or Property Damage 7/1/05
C. 3rd Party Claims For Non-Owned Disposal Sites N/A
D. 3rd Party Claims For Contingent Transportation N/A

IX. Defense Costs Inside The Limit

X. Additional Coverage Included


A. Loading or Unloading Of Property of Others
B. Contractual Liability
C. Blanket Additional Insured Applies Only When Required In A Written Contract;
D. Blanket Primary & Non Contributory Only When Required In A Written Contract;
E. Blanket Waiver of Subrogation Only When Required In A Written Contract;
F. Additional Insured City of Chicago
MAT Leasing, Inc., Etal.
Site Pollution
XII. Non-Owned Locations Coverage Retro Active Date
1 Northwest Sorting Center A, B Office 7/1/05
750 N. Kilbourn Transfer Site
Chicago, Illinois 60623

XIII. Owned Locations Coverage Retro Active Date


1 4450 S. Morgan A, B Corporate Office 7/1/05
Chicago, Illinois 60609 Maintenance Facility
Park Vehicles

2 4500 S. Morgan A, B Park Vehicles 7/1/05


Chicago, Illinois 60609

3 4335-45 S. Western Ave. A, B Lessor Risk 7/1/05


Chicago, Illinois

4 2901 W. 31st St. A, B Lessor Risk 7/1/05


Chicago, Illinois 60623

5 2005 W. 43rd St. A, B Lease Space Park Trailers 7/1/05


Chicago, Illinois

6 4010 S. Damen Ave. A, B Lease Space Park Trailers 7/1/05


Chicago, Illinois

7 4000 S. Ashland Ave. A, B Lease Space Park Trailers 7/1/05


Chicago, Illinois

8 8900 S. Chicago Ave. A, B Lease Space Park Trailers 7/1/05


Chicago, Illinois

9 1001 W. 45th St. A, B Lease Space Park Trailers 7/1/05


Chicago, Illinois

10 963 W. 37th St. A, B Lease Space Park Trailers 7/1/05


Chicago, Illinois
MAT Leasing, Inc., Etal.
Site Pollution
XIII. Owned Locations Coverage Retro Active Date
11 3022 N. Lake Shore Drive A, B Vacant Property 7/1/05
Chicago, IL 60657

12 2814, 2835 S. Lock St. A, B Vacant Property 7/1/05


Chicago, Illinois 60608

13 2814 Grady Ct. A, B Vacant Property 7/1/05


Chicago, Illinois 60609

14 2811, 2813, 2817, 2819,2821, A, B Vacant Property 7/1/05


2823, 2827, 2829, 2831,
2833 S. Grove St.
Chicago, Illinois 60608

15 2812, 2816, 2818 S. Hillock Av A, B Vacant Property 4/5/10


Chicago, Illinois 60608
E&O Audit Quotation 3C
Policy Application

2015-2016
X. Premium
Premium $15,763
Broker Fee $500
Stamping 0.002 $31.53
Tax 0.035 $551.71
Total $16,846

Terrorism (Optional Coverage) $550

ago Mimimum Earned Premium 50%

Minimum & Deposit 100%

E&O Audit Quotation


Policy Application
E&O Audit Quotation
Policy Application

XV. 3rd Party Pollution Liability: Partial List of Coverage F. Exclusions Except If Cov
A. Aircraft, Auto & Watercraft And Excluding Loading & Unloading
B. Asbestos
D. Contractual Liability
E. Damage To Your Product
F. Damage To Your Work
G. Divested Property Sold, Given Away, Donated, or Abandoned Your Location Out Of Which
H. Employment Related Practices
I. Executive Officer For Liability Arising From Your Services For Another Company Not Nam
J. Intentional Acts (Causing Injury To Another Or Non Compliance With Statutes)
K. Known Conditions
L. Lead Paint
M. Non-Designated Locations (Locations Must Be Scheduled)
N. Other Enterprises Including Parent or Affiliate Companies Not Named In The Declaration
O. PD & Clean Up Costs To Owned, Leased Property & Property In Your CCC Even If Costs
P. Punitive Damages Unless Allowable By Law
Q. Underground Storage Tanks
R. War, Nuclear Energy, Radio Active Material
S. WC & Employers Liability

XVI. Clean Up Costs Your Locs: Partial List of Coverage G. Exclusions Except If Cover
A. Aircraft, Auto & Watercraft And Excluding Loading & Unloading
B. Asbestos
D. Contractual Liability
E. Capital Expenditures
F. Damage To Your Product
G. Damage To Your Work
H. Divested Property Sold, Given Away, Donated, or Abandoned Your Location Out Of Which
I. Employment Related Practices
J. Executive Officer For Liability Arising From Your Services For Another Company Not Nam
K. Intentional Acts (Causing Injury To Another Or Non Compliance With Statutes)
L. Known Conditions
M. Lead Paint
N. Mold, Mold Spores & Fungus
O. Non-Designated Locations (Locations Must Be Scheduled)
P. Other Enterprises Including Parent or Affiliate Companies Not Named In The Declaration
Q. Underground Storage Tanks
R. War, Nuclear Energy, Radio Active Material
S. WC & Employers Liability
ept If Covered By Endorsement

t Of Which Claims Have Arsien

ny Not Named In The Declaration

Declarations
n If Costs Is To Mitigate Damage

t If Covered By Endt

t Of Which Claims Have Arsien


ny Not Named In The Declaration

Declarations
MAT Leasing, Inc., Etal. 2 E&O Audit Quotation

Excess Site & Contractors Pollution Policy Application


I. Proposed Carrier Nautilus Ins. Co.
X
II. Named Insureds X
See Attached Schedule X

III. Effective Date 10/1/15

IV. Claims Made Or Occurrence Occurrence X


X
X
V. Coverage
A. Excess Contractors Pollution
Each Pollution Condition $4,000,000
Annual Aggregate $4,000,000
B. Contingent Transportation Each Pollution Condition Included

IX. Defense Costs Inside The Limit

2015-2016
X. Premium
Revenues $22,629,166
Rate $0.910
Premium $20,592
Broker Fee $500
Stamping 0.002 $41.18
Tax 0.035 $720.72
Total $21,854

Terrorism (Optional Coverage) $824

Mimimum Earned Premium 100%

Minimum & Deposit 100%


Quotation

Application

Coverage Does Not Apply To "Claims" As A Result Of Any Negligence,

Transportation Pollution Liability


Those Sums The Insured Becomes Obligated To Pay Because of Bodily Injury, Property Damage And
Clean Up Costs Arising Out Of The Ownership, Maintenance, Use, Operation, or Entrustment To Others
Of Any Auto Owned By or Rented or Loaned To Any Insured Arising Out Of A Pollution Condition.

2013-20142014-20152015-2016
XI. Current Premium $27,250 $32,542 $32,485
Broker Fee $0 $500 $500
Stamping Fee $27 $33 $33
Tax $954 $1,139 $1,202
Total $28,231 $34,214 $34,220
lt Of Any Negligence, Act, Error, or Omission, or

amage And
ment To Others
MAT Leasing, Inc.
Umbrella
I. Proposed Carrier Rockhill Ins. Co.

II. Effective Date 10/1/16

III. Limit
A. Each Occurrence $5,000,000
B. Products & Completed Operations Aggregate $5,000,000
C. General Aggregate $5,000,000
D. Form Follow Form
E. Type Pay On Behalf
F. Defense Costs Are In Addition To The Limit of Liability

IV. Schedule of Underlying


Coverage Carrier Effective Limits
A. MAT Leasing, Inc. Etal
General Liability Indian Harbor 10/1/15-16 Each Occurrence $1,000,000
General Aggregate $5,000,000
Products & Completed Ops. Aggregate $1,000,000

B. MAT Leasing, Inc. Etal


Automobile Liability TRIP 5/1/15-16 Each Occurrence $2,000,000
Non Owned & Hired 83CSES27501 $2,000,000

C. MAT Leasing, Inc. Etal


Worker's Comp. TRIP 5/1/15-16 Bodily Injury-Each Acc $2,000,000
Employers Liability 83WNS27500 Disease - Policy Limit $2,000,000
Disease - Each Employ $2,000,000
D. Marina Express, Inc.
General Liability Kinsale 11/11/16-17 Each Occurrence $1,000,000
General Aggregate $1,000,000
Products & Completed Ops. Aggregate $1,000,000

E. Marina Express, Inc.


Automobile Liability Nat'l Fire Hartford 4/5/16-17 Each Occurrence $1,000,000
Non Owned & Hired $1,000,000

F. Marina Express, Inc.


Worker's Comp. American Interstate 4/5/16-17 Bodily Injury-Each Acc $1,000,000
Employers Liability Disease - Policy Limit $1,000,000
Disease - Each Employ $1,000,000
MAT Leasing, Inc.
Umbrella
VII. Partial List of Exclusions
A. Standard Policy Exclusions
B. Aircraft Products & Grounding
C. Auto-Uninsured & Underinsured Motorists
D. Absolute Pollution; Pollution Legal Liability
E. Asbestos
F. Contractors Limitation (Wrap Ups, Professional Liablity, CCC, Blasting, Excavation, Grading, Demolition,
G. Chromated Copper Arsenate (CCA)
H. Cross Suits Named Insured vs Named Insured
I. Care, Custody & Control Real & Personal Property
J. Designated Work
K. Directors & Officers Liability
L. Discrimination & Humiliation
M. Employment Related Practices
N. ERISA
O. Expected or Intended Bodily Injury or Property Damage
P. EIFS
Q. Entran Pipe
R. Financial Services
S. Fire Retardant Treatment
T. Foreign Liability
U. Liquor Liability
V. Lead Paint
W. Landfill & Disposal Site
X. Microbial Matter,Fungi, Bacteria
Y. Mold, Mildew, Yeast, Microbe
Z. New Entities, Non Scheduled Property
AA. Owned & Non Owned Aircraft & Watercraft
BB. Organic Pathogens
CC. Pre-Existing Damage Or Injury
DD. Professional Liability & Errors & Omissions
EE. Products Recall
FF. Property Damage To Owned Property & Damage To Your Work
GG. Property Damage To Wires, Conduits Pipes, Mains, Sewers, etc. Arising From Blasting, Excavation, Grading
HH. Punitive Damages
II. Respirable Dust
JJ. Residential Construction & Construction Defect: Home, Apt., Condo
KK. Silica
LL. Sub-Limits In Primary Policies
MM. Toxic Drywall
NN. Travel Accident
OO. Terrorism
PP. US Economic & Trade Sanctions
QQ. Unimpaired Aggregate
RR. War; Nuclear Energy
SS. Work. Comp. Statutory Coverage
2013-14 Primary
E&O Audit Application

Pollution Liability
Site Pollution Legal Colony 10/1/15-16 Not Covered
Each Occ./Aggregate
Contractors Pollutio Colony 10/1/15-16 Not Covered
Each Occ./Aggregate

D.

V. Premium $100,000
A. Wholesaler Fee $7,500
B. SL Tax $3,500
C. Stamping Fee $200
D. Total $111,200

Premium 2012 to 2013


Minimum & Deposit (Non Au $89,650
Wholesaler Fee (Peachtree S $6,700
Surplus Lines Tax 3.5% $3,138
Stamping Fee 0.1% $90
Total $99,577

VI. Subject To: Terrorism


A. Signed TRIA Form; Signed Acord App;
B. Contractors Supplemental Application-Completed & Signed
C. Copy Of Underlying Policies
D. Underlying Carriers Have A Minimum Best Rating Of A- VII
2013-14 Primary
E&O Audit Application

Demolition,

tion, Grading, Demolition


2013 to 2014
2014 TO 2015
### ###
Incl $7,500
Incl $3,500
Incl $100
### ###

$680 $734
MAT Leasing, Inc.
Excess Liability Pricing Comparison
2011-2012 2011-2012 2012-2013 2012-2013 2013-2014 2013-2014
Rockhill Ins. Great American Rockhill Ins. Great American Rockhill Ins. Great American
Limit $5,000,000 $25,000,000 $5,000,000 $25,000,000 $5,000,000 $25,000,000
xs xs xs xs xs xs
Primary $5,000,000 Primary $5,000,000 Primary $5,000,000

Premium $89,650 $115,000 $89,650 $115,000 $100,000 $120,750

Stamping Fee 0.001 $89.65 $0 $89.65 $0 $100.00 $0

ESTIMATED Taxes $ 0.035 $3,138 $0 $3,138 $0 $3,500.00 $0

Wholesaler Fee $6,700 $0 $6,700 $0 $7,500 $0

Total $99,577 $115,000 $99,577 $115,000 $111,100 $120,750

Terrorism $ 1% $1,180 $1,150 $1,180 $1,150 $0 $0

Sub-Total Including Terrorism $100,757 $116,150 $100,757 $116,150 $111,100 $120,750

Flat or Auditable

Minimum Earned Premium


mat mc
2010-2011 2010-2011
$20 $110,865 $90,291
3.1% $3,437 $2,799
1.0% $1,109 $903
$115,410 $93,993 $0 $0 $209,403

mc
2011-12 2011-12
$5 $0 $45,522 $5
3.1% $0 $1,411
1.0% $0 $455
$0 $47,388 $0 $47,388

$5 $0 $37,875 $15
3.1% $0 $1,174
1.0% $0 $379
$0 $39,428 $15 $0 $39,443
$86,816
E&O Audit
Policy Application

rican
MAT Leasing, Inc.
Umbrella
I. Proposed Carrier Great American

II. Effective Date ASAP

III. Limit
A. Excess Liability $25,000,000 xs $5,000,000
B. Form Follow Form
C. Type Pay On Behalf
D. Defense Costs Are In Addition To The Limit of Liability

IV. Schedule of Underlying


Coverage Carrier Effective Policy # Limits
A. Primary Excess Policy Each Occurrence $5,000,000
General Aggregate $5,000,000
Products Aggregate $5,000,000

Underlying
B. MAT Leasing, Inc. Etal
General Liability Indian Harbor 10/1/15-16 Each Occurrence $1,000,000
General Aggregate $5,000,000
Products & Completed Ops. Aggregate $1,000,000

C. MAT Leasing, Inc. Etal


Automobile Liability TRIP 5/1/15-16 Each Occurrence $1,000,000
Non Owned & Hired 83CSES27501 $1,000,000

D. MAT Leasing, Inc. Etal


Worker's Comp. TRIP 5/1/15-16 Bodily Injury-Each Accid $1,000,000
Employers Liability 83WNS27500 Disease - Policy Limit $1,000,000
Disease - Each Employee $1,000,000
E. Marina Express, Inc.
General Liability Kinsale 11/11/16-17 Each Occurrence $1,000,000
General Aggregate $1,000,000
Products & Completed Ops. Aggregate $1,000,000

F. Marina Express, Inc.


Automobile Liability Nat'l Fire Hartford 4/5/16-17 Each Occurrence $1,000,000
Non Owned & Hired $1,000,000

G. Marina Express, Inc.


Worker's Comp. American Interstate 4/5/16-17 Bodily Injury-Each Accid $1,000,000
Employers Liability Disease - Policy Limit $1,000,000
Disease - Each Employee $1,000,000

VI. Exclusions Follow form


A. Asbestos
B. Organic Pathogens
C. Pollution
D. Punitive Damages
E. UM/UIM
F. Landfills
Pollution Colony10/1/13 to
Each Occ./Aggregate
10/1/14 Not Covered A. MAT Leasing, Inc. Etal
Contractor Colony10/1/13 to
Each Occ./Aggregate
10/1/14 Not Covered General Li
Burlington10/1/15-16
General Aggrega
Products & Completed Ops. Aggregate

B. MAT Leasing, Inc. Etal


Automobile
Hartford 5/1/15-16
Non Owne83CSES27501

C. MAT Leasing, Inc. Etal


Worker's Hartford 5/1/15-16
Marina Express, Inc. Employers83WNS27500
Automobile Liability
Non Owned & Hired D. Marina Express, Inc.
General LiKinsale 10/1/15-16
General Aggrega
Products & Completed Ops. Aggregate

C.N.A. 2/1/12
Each Occurrence
### E. Marina Express, Inc.
### Automobile
Nat'l Fire Hartford
5/1/15-16
Non Owned & Hired

F. Marina Express, Inc.


Worker's 4/5/15-16
American Interstate
EmployersAVWCIL219396201

V. Premium
A. Wholesaler Fee
B. SL Tax
C. Stamping Fee
V. Premium 2012-20132013-20142014-2015 D. Total
Minimum & Deposit ### ### ###
Wholesaler Fee (Pea $0 $0 $0 Minimum Earned Pre
Surplus L 3.5% $0 $0 $0
Stamping 0.1% $0 $0 $0
Total ### ### ###
Terrorism $1,150 $1,208 $1,208
Each Occurrence
###
General Aggregate
###
Aggregate ###

Each Occurrence
###
###

Bodily In ###
Disease - ###
Disease - ###

Each Occurrence
###
General Aggregate
###
Aggregate ###

Each Occurrence
###
###

Bodily In ###
Disease - ###
Disease - ###

emium ###
holesaler Fee $0
$0
amping Fee $0
###

nimum Earned Premium 25%


MAT Leasing, Inc., Etal.
Property
Schedule of Locations
Loc. Location Owner-Loss Payee Occupancy Tenant GL Rating # Emp
1 4450 S. Morgan Michael Tadin Building Account Corporate Office Marina Cartage, Inc. Etal Sq. Ft. 155
Chicago, Illinois 60609 Maintenance Facility

2 750 N. Kilbourn City of Chicago Office M.A.T. Leasing, Inc. Payroll 8


Chicago, Illinois 6062 M.A.T. Leasing, Inc. Transfer Site Operates Transfer Site
As Their Interest May Appear Park Vehicles

3 2901 W. 31st Street The Amalgamated Bank of Chicago Lease Space Maerske 41,050 0
Chicago, Illinois 60623 As Trustee of Michael A. Tadin Pier Trsel
Irrevocable Family Trust Dated
6/23/98

4 3468 S. California 35th Street Partners Lease Space Hamilton Container Sq. Ft. 1
Chicago, Illinois 60616 MMT Investments, Inc.

5 4335-45 S. Western Ave Western Warehouse, Inc. Lease Space Kinsella Landscaping 41,098 7
Chicago, Illinois WP Snow

6 2005 W. 43rd St. Canadian National Leases Lease Space Park Trailers GE 20 Acres 0
Chicago, Illinois Property To MT Transit MT Directs Trucks Infinity
As Their Interest May Appear
MAT Leasing, Inc.
Property
I. Current Carrier Axis

II. Effective Date 10/1/16

III. Property Damage Total Values


A. Building Excluding Underground Piping, Flues or Drains $18,784,317
B. Personal Property; Improvements & Betterments; M&E, Inventory $1,399,995
C. EDP $275,000
D. P.P. Of Others (Excluding Property Accepted Under Shipping Document) $0
E. Leased Real Property-Contractual Responsibility To Insure $0
F. Contractor's Equipment $4,231,398

IV. Business Interruption $2,050,000


A. Extra Expense (Included In BI Limit) Included
B. Expediting Expense $100,000
C. Extended Period of Indemnity N/A
D. Ordinary Payroll N/A
E. Loss of Rents $1,986,000
F. Contingent Business Interruption-Unscheduled Locations N/A
G. Civil Authority: (1Mile) Access To Insured Locs Is Prohibited By Civil Authorit 14 Days
H. Ingress/Egress: Damage To ANY Location Within 1 Mile Preventing Ingress/E 14 Days

V. Extra Expense (Separate Limit) 40% - 80% - 100% $250,000

VI. Loss Limit Per Occurrence $25,000,000

VII. Property Damage & Time Element Perils-Special Form Including Sub-Limit
A. Collapse Including Collapse Caused By Weight of Ice, Snow, Water Covered
B. Earthquake - Annual Aggregate (4450 S. Morgan) $1,000,000
C. Flood Annual Aggregate (4450 S. Morgan) $1,000,000
D. Flood For Locations In Flood Zones B, X, A, V-(See Endt For Complete List)-E Not Covered
E. Theft of Contents Covered
F. Off Premises Power Interruption (Caused By An Insured Peril) Including Loss Covered
Damage To Overhead Transmission Lines Within 1 Mile of the Insured's Location

VIII. Equipment Breakdown $25,000,000


A. Computer Equipment $100,000
B. Data Restoration $100,000
C. Expediting Expense $100,000
D. Hazardous Substance $100,000
E. Service Interruption $100,000
MAT Leasing, Inc.
Property
IX. Additional Coverage All Scheduled Locs (Property Damage & Time El Sub-Limit
A. Accounts Receivable Including Off Premises (Loc 1 Only) $2,500
B. Architect Fees $0
C. Arson Reward $0
D. Brands & Labels $0
E. Cost of Claim Adjuster's Expense At Direction of Carrier $0
F. Civil Authority: (1Mile) Access To Insured Locs Is Prohibited By Civil Authorit 14 Days
G. Demolition & Increased Cost of Construction $100,000
H. Debris Removal $100,000
I. Electronic Vandalism $0
J. Exhibition & Trade Shows $5,000
K. Extra Expense $250,000
L. Excavation, Grading Backfilling or Filling, Paved Surfaces $0
M. Employee Tools On Premises & While On Vehicle/Premises
1) Maximum Per Item $10,000
2) Maximum Per Employee $75,000
3) Maximum Per Occurrence $250,000
N. Fences, TV Ant., Dishes, Attached Outdoor Signs Sign: $2,500
O. Fire Department Service Charge $10,000
P. Fire Protection Equipment Recharge (Additional Limit) $0
Q. Fines For False Alarms-Annual Aggregate $0
R. Fungus, Wet Rot, Dry Rot & Bacteria-Limited Coverage (Annual Aggregate) $10,000
S. Increased Cost of Construction Applies Only To Blds Insured For Replacemt C Incl. In G. & H.
T. Ingress/Egress: Damage To ANY Location Within 1 Mile Preventing Ingress/E 14 Days
U. Landscape-Sod, Shrubs & Plants (Named Peril Coverage) $250/Tree; $1,000 Agg
V. Lost Key (Master Key) Replacement of Locks $0
W. PD-Newly Acquired Premises-Business Interruption $0
X. PD-Newly Acquired/Rented Buildings (90 Day Reporting Period) $250,000
Y. PD-Newly Acquired Personal Property (90 Day Reporting Period) $100,000
Z. PD-Unscheduled Locations Off Premises(90 Day Reporting Period) $10,000
AA. PD-Underground Piping $0
BB. PD-Personal Effects Of Employees On Site Or Property of Others (Excluding T $2,500 /Loc
CC. Pollutant Clean Up & Removal (Annual Aggregate) $10,000
DD. Radioactive Contamination $0
EE. Rewards $0
FF. Trailers - Non Owned $5,000
GG. Unintentional Errors & Omissions $0
HH. Valuable Papers & Records $2,500
II. Transit $5,000
1) Your Personal Property While In Transit Within The Continental US, But Does Not Include
Personal Property of Others For Which You Are Responsible As A Carrier For Hire, As A
Shipper or Hauler. Insurance Company Will Pay For Those Shipments In The Custody Of A
Carrier Under A Shipping Document.
2) Your Interest In Shipments Sold Free On Board. When Title Passes To The Consignee
& If Consignee Refuses To Pay Because The Shipment Is Lost or Damaged, Your Insurance
Carrier Will Pay The Claim.
MAT Leasing, Inc.
Property
X. Deductible-Property Damage
A. All Perils Except As Noted Below $10,000
B. Flood $100,000
C. Earthquake $25,000
D. Coastal Wind N/A
E. Transit $10,000
F. Equipment Breakdown $10,000

XI. Deductible-Time Element


A. Business Interruption 72 Hours
B. Extra Expense 72 Hours
C. Off Premises Power Interruption Caused By Covered Perils 72 Hours
D. Equipment Breakdown 48 Hours

XII. Deductible Exceptions


A. In The Event One Loss Occurs Involving Both Property Damage & Business Interruption The Highest Ded
Coverage Applies

XIII. Loss Adjustment Bases Coinsurance Valuation


A. Building Agreed Amount Endt Replacement Cost
B. Building-4335 S. Western Ave. Agreed Amount Endt Actual Cash Value
C. Building-2901 W. 31st Agreed Amount Endt Actual Cash Value
D. Personal Property Agreed Amount Endt Replacement Cost
E. Contractors Equipment Agreed Amount Endt Actual Cash Value
F. Time Element Agreed Amount Endt Actual Loss Sustained

XIV. Valuation
A. Replacement Cost Shall Not Exceed The SMALLEST Of The Following Amounts:
1) The Cost To Repair or Replace The Covered Property, Or Any Part Thereof, With Property Of Comparable
Material & Quality;
2) The Amount Actually Expended In Repairing or Replacing The Damaged Property;
3) Insured May Take All or Any Part Of The Property At An Agreed or Appraised Value.
B. Partial Payments Will Be Based On Actual Cash Value Until The Damaged Property Is Repaired or Replac
C. Building Coverage: Insured May Elect To Rebuild At Another Site;
D. Inventory: Selling Price Less Discounts
E. Outdoor Equipment & Furniture: ACV
F. Contractors Equipment: ACV
G. Vacant Buildings: ACV

XV. Loss Payee Regarding


A. City of Chicago 750 N. Kilbourn
Dept of Procurement Services Chicago, Illinois 60623
City Hall
121 N. LaSalle St. Rm. 403
Chicago, Il. 60602

B. Wells Fargo Equipment finance, Inc. #1


1540 W. Fountainhead Parkway
Tempe, AZ 85282

C. CAT Financial Services Corp


2120 West End Ave.
Nashville, TN 37203 Per Schedule
MAT Leasing, Inc.
Property Valuation At Time Of Loss
XVI. Partial List of Exclusions Except If Covered By Endorsement
A. Asbestos Removal
B. Building (Including Contents) Left Vacant or Unoccupied Building Over 30 Days
C. Boiler & Machinery-Damage Caused By Electrical Failure, Injury or Disturbance To Electrical Appliances
or Wiring Caused By Electrical Currents Artificially Generated
D. Boiler & Machinery-Mechanical or Machinery Breakdown Including Rupture or Bursting Caused By Cent
Rupture Bursting or Operation of Pressure Relief Vessels
E. Change In Flavor or Color or Texture or Finish
F. Dampness or Dryness of Atmosphere, Change in Temperature, Smog, Shrinkage, Loss of Weight
G. Delay or Loss of Use of Market
H. Debris Removal Of Pollutants (Limited Coverage)
I. Earthen or Concrete Flow or Storage Pits or Reservoirs & Their Contents
J. Earthquake Sprinkler Leakage
K. EDP Equipment/Data: Virus And/Or Computer Manipulation
L. EDP Equipment/Data: Business Interruption & Extra Expense: Caused By Interruption Of Computer Ope
M. Increased Cost of Construction Expenses Arising From Pollutants, Fungi, Mold, etc.
N. Misappropriation, Conversion, False Pretense, Embezzlement, Dishonesty, Mysterious Disappearance
O. Mold, Moss, Mildew, Fungi, Spores, Bacterial Infestation, Chemical, Wet or Dry Rot (Limited Coverage)
P. Off Premises Power Interruption Caused By Earthquake, Flood, Windstorm, Intentional Act(s) By The Sup
To Shed Load To Maintain System Integrity, or Failure of Insured To Comply With Terms or Conditions O
Q. Faulty Workmanship, Defective Material, Design E&O
R. Flood & Earthquake (Location 4450 S. Morgan Is Covered)
S. Fines & Penalties
T. Freezing of Plumbing, Heating or Fire Protection Systems Which Have Been Unoccupied For 30 Days
U. Rust, Corrision
V. Settling, Cracking, Shrinkage, Bulging or Expansion In Foundations, Walls, Floors or Ceilings
W. Termites, Moths or Vermin,
X. Theft-No Visible Signs of Forcible Entry
Y. Vehicles Including Personal Property While In or On A Vehicle
Z. Vacant Buildings: Carrier Must Be Notified If Any Insured Building Is Vacant Over 30 Days
Z. Wear & Tear, Deterioration, Inherent Vice, Latent Defect
AA. War, Nuclear, Insurrection, Rebellion, Revolution, Civil War, Usurped Power, Government Action

XVIII. Partial List of Excluded Property Except If Covered By Endorsement


A. Animals
B. Aircraft, Watercraft, Motor Vehicles or Trailers Licensed For Road Use & The Contents Inside.
C. Bridges, Paved Surfaces, Foundations, Pilings Below The Surface.
D. Contraband
E. Contractors Equipment & Contractors Equipment That Is Loaned, Leased or Rented To Others
F. Cost of Grading, Excavation & Filling.
G. Currency, Money, Deeds, Evidence of Debt, Securities
H. Dams, Dikes, Piers, Wharves, Docks, Retaining Walls, Bulkheads, RR Beds, Ties, Tracks.
I. Electronic Data: Replacement Of Information, Facts or Computer Prgrms Stored As or On, Created or Us
J. Electronic Data: As Defined In The Policy Is Not Covered
K. Fragile Articles-Statuary, Marbles, Chinaware, Porcelains If Broken
L. Gutters & Downspouts Caused By Weight of Ice, Snow, or Sleet.
M. Jewelry, Precious Stones, Fine Art & Similar Items.
N. Land, Landscaping, Roads, Trees, Shrubs, Plants, Standing Timber, Crops, Bodies of Water.
O. Property In The Open From Wind, Rain, Hail.
P. Radio or TV Antennas, Satellite Dishes, Wiring, Masts, Fences
Q. Tools & Clothing Belonging To Employees
R. Underground & Underwater Piping, Fittings, Conduits, Drains, Flues, Underground Tanks, & Similar Ite
S. Underground Caverns, Tanks & Personal Property Contained Therein; Mines Including Coal Stock
T. Vacant Buildings (70% or More Of Rentable Space)
U. Valuable Papers
E&O Checklist Quote
Policy Application3C

Definition amend to within 1,000 feet of bld


Endt G excludes mechanical failure, electrical disturbance. Confirm this applies only to prope

Must add coverage-limit was included so a charge was made

Back Up of Sewers, Pipes & DraiThe intent was to have

IX. Warrant
Insured Is Required To Maintain The Protective Devises or Services As Noted
A. Automatic Sprinkler System Including Supervisory Services
B. Automatic Fire Alarm That Is Central Station or Reporting To A Public or Pri

If Automatic Sprinkler System Will Be Shut Down For Over 48 Hours You Mu
E&O Checklist
Policy Application

XX
XX X
XX X

XX
XX
XX

XX X
XX
XX
Need to include Fences in definition of bld.

XX
Lesser of $10,000 or 5% Limit
XX
XX

XX 0
XX 0
XX

XX 0
XX $10,000

XX

XX
X

Note: The Sub-Limits Are NOT IN ADDITION TO The Policy Limits


Note: There Must Be A Contractual Responsibility To A 3rd Party When Insu
E&O Checklist
Policy Application
$10,000
XX
XX
X
$10,000
$10,000

The Highest Deductible For Each

X
Policy says Coins-Nil do we need to add AA

The Declaration Page should be amended to include a spec

Endorsement ES 0330106 Excludes EDP


ustained Equipment Breakdown- Is EDP Equipment covered?
Equipment Breakdown- Is Production Equipment Covered?

Vehicles Including Personal Property While In or On A Veh


Of Comparable Is Theft covered
2012 CAT X4T00422 Increase limit from $269,886 to $288
Item A.1.b. Definition of Personal Property should read "wi
Item A.1.c. Definition of Personal Property of Others shoul
aired or Replaced Earthquake endorsement should be amended to include co
Need to add

Contractors Equipment Limit for Newly Acquired Property


Subsidence

is 60623
Application

rical Appliances, Devices, Fixtures,

Caused By Centrifugal Force, Nor

XX

Can coverage be added for no additional premium?

f Computer Operations

sappearance
ted Coverage)
ct(s) By The Supplying Company
or Conditions Of Any Contract

For 30 Days

er 30 Days

Action

XX
XX
XX
XX
X
XX
XX
XX Railroad or Railway Rolling Stock & Contents.
n, Created or Used From Software Refractory Lining
Crude Oil, Natural Gas or Other Minerals.
Drilling & Production Platforms.
Electrical Transmission & Distribution Lines.

XX

Amend Definition of Bld/Cts to include Fences, Antennas

s, & Similar Items XX


oal Stock

X
es only to property coverage not Equipment Breakdown

ent was to have a lower deductible on this coverage even if we have a lower limit. Typically this is not included

Services As Noted Below:

To A Public or Private Fire Co.

48 Hours You Must Notify The Insurance Company.


Limits
Party When Insuring Property of Others
to include a specific limit for each coverage or state "Included"

t covered?
uipment Covered?

e In or On A Vehicle

$269,886 to $288,276
y should read "within 1,000 feet"
y of Others should read "within 1,000 feet"
ded to include coverage for foundations, underground pipes, flues or drains

cquired Property should read $250,000


not included in the definition of Flood.
MAT Leasing, Inc.
2016-2017 Statement of Values
M&E; Inv.
Contents Loss of Bus. Extra Contractors Total Cost
Loc. Addresses Building Imp. & Bet. EDP Rents Int. Expense Equipment Values SqFt Sq Ft RC
1 4450 S. Morgan St. $5,814,814 $1,149,995 $275,000 $0 $550,000 $250,000 $0 $8,039,809 20,000 $290.74 $5,814,814
Chicago, Illinois

2 750 N. Kilbourn $8,000,000 $250,000 $0 $0 $1,500,000 $0 $0 $9,750,000 60,000 $133.33 $8,000,000


Chicago, Illinois 60623

3 4335-45 S. Western Av $2,898,700 $0 $0 $72,000 $0 $0 $0 $2,970,700 41,080 $70.56 $2,898,700


Chicago, Illinois

4 2005 W. 43rd St. $0 $0 $0 $1,608,000 $0 $0 $0 $1,608,000


Chicago, Illinois

5 2901 W. 31st St. $2,070,803 $0 $0 $306,000 $0 $0 $0 $2,376,803 Burglar & Fire Alarms-Central Stati
Chicago, Illinois 60623

7 Contractors Equipment $4,231,398 $4,231,398

Total $18,784,317 $1,399,995 $275,000 $1,986,000 $2,050,000 $250,000 $4,231,398 $28,976,710


Rate $0.1535
Annual Premium $44,471
Tax 0.035 $1,556.47
Stamping Fee 0.006 $266.82
Total $46,293.85

Terrorism $2,500
3468 S. California $0 $0 $0 $120,000 $0 $0 $0 $120,000
Chicago, Illinois
E&O Checklist
Policy Quote

al Station
MAT Leasing, Inc. E&O
Contractors Equipment Floater
I. Current Carrier Axis

II. Effective Date 10/1/15

III. Scheduled Property


A. Limit Per Occurrence $0
B. Limit Per Item Per Statement of Values
C. Rental Reimbursement
1) Per Occurrence $0
2) Annual Aggregate $0

IV. Additional Coverage Sublimits


A. Additionally Acquired SIMILAR Equipment 30 Days To Repo $50,000
B. Employee Tools On Premises & While On Vehicle
1) Maximum Per Item $10,000
2) Maximum Per Employee $75,000
3) Maximum Per Occurrence $250,000
4) Unscheduled Tools & Equipment $1,000
C. Leased, Rented or Borrowed Equipment By Insured $150,000
1) Automatic Coverage 30 Days Included
2) Per Item $150,000
3) Per Occurrence $150,000
D. Owned Equipment Loaned, Leased or Borrowed By Someone Without Insur Included
With The Permission of Insured
1) Per Item $150,000
2) Per Occurrence $150,000
E. Property of Others In Your Care, Custody & Control $150,000

V. Perils: Special Form (All Risk) Including: Sublimits


A. Flood Per Occurrence/Aggregate $1,000,000
B. Earthquake Per Occurrence/Aggregate $1,000,000
C. Theft
D. Collapse
E. Collision
F. Transit & Upset or Overturn Of Vehicle
G. Conversion/False Pretense
H. Debris Removal 25% Of The Loss
I. Pollution Clean Up & Removal No Deductible $10,000

VI. Deductible
A. Contractors Equipment Option ### Per Occurrence $10,000
B. Mechanics Tools Per Occurrence $500
C. Off Premises Portable Restroom Units Per Occurrence N/A
D. Leased, Rented or Borrowed Equipment By Insured Per Occurrence $2,500
E. Owned Equipment Loaned, Leased or Borrowed Per Occurrence $2,500
F. Rental Reimbursement Per Occurrence 24 Hrs.
MAT Leasing, Inc.
Contractors Equipment Floater
VII. Valuation-Contractors Equipment (Description & Values Have Been Reported To Carrie
A. The Least of the Following:
1) The Limit Per Item Shown In The Schedule
2) The Cost To Replace The Damaged Property With Like Kind & Quality
3) The Amount Actually Spent To Repair or Replace the Damaged Property

VIII. Valuation-Contractors Equipment (Newly Acquired Property)


A. Automatic Coverage 120 Days; Equipment is Covered For Actual Cash Value;
B. Once The Equipment is Added To The Policy Replacement Cost Coverage Applies

IX. Valuation-Mechanics Tools


A. The Least of the Following:
1) The Limit Per Item Shown In The Schedule
2) The Cost To Replace The Damaged Property With Like Kind & Quality
3) The Amount Actually Spent To Repair or Replace the Damaged Property

X. Valuation-Off Premises Portable Restroom Units


A. The Least of the Following:
1) The Limit Per Item Shown In The Schedule
2) The Cost To Replace The Damaged Property With Like Kind & Quality
3) The Amount Actually Spent To Repair or Replace the Damaged Property

XI. Valuation-Leased, Rented or Borrowed Equipment By Insured


A. The Value Agreed Upon In The Written Contract & Scheduled In The Policy
B. If Not Scheduled The Least of The Following:
1) The Limit Per Item Shown In The Schedule
2) The Cost To Replace The Damaged Property With Like Kind & Quality
3) The Amount Actually Spent To Repair or Replace the Damaged Property

XII. Valuation-Owned Equipment Loaned, Leased or Borrowed By


A. The Value Agreed Upon & Scheduled In The Policy
MAT Leasing, Inc.
Contractors Equipment Floater
XIII. Exclusions
A. Asbestos Removal
B. Building (Including Contents) Left In Vacant or Unoccupied Building Over 30 Days
C. Boiler & Machinery-Damage Caused By Electrical Failure, Injury or Disturbance To Electrical Appl
or Wiring Caused By Electrical Currents Artificially Generated
D. Boiler & Machinery-Mechanical or Machinery Breakdown Including Rupture or Bursting Caused B
Rupture Bursting or Operation of Pressure Relief Vessels
E. Change In Flavor or Color or Texture or Finish
F. Contractors Equipment While Loaned, Leased or Rented To Others.
G. Dampness or Dryness of Atmosphere, Change in Temperature, Smog, Shrinkage, Loss of Weight
H. Delay or Loss of Use of Market
I. Demolition
J. Debris Removal Of Pollutants
J. Dishonest Acts
K. Earthen or Concrete Flow or Storage Pits or Reservoirs & Their Contents
K. Earthquake
L. Misappropriation, Conversion, False Pretense, Embezzlement, Dishonesty, Mysterious Disappearance
M. Mold, Moss, Mildew, Fungi, Spores, Bacterial Infestation, Chemical, Wet or Dry Rot,
Off Premises Power Interruption Caused By Earthquake, Flood, Windstorm, Intentional Act(s) By The Sup
N. To Shed Load To Maintain System Integrity, Failure of Insured To Comply With Terms or Conditions Of An
O. Faulty Workmanship, Defective Material, Design E&O
P. Flood
Q. Fines & Penalties
R. Freezing of Plumbing, Heating or Fire Protection Systems Which Have Been Unoccupied For 30 Days
S. Rain, Snow, Ice, Sleet to Property In The Open
T. Rust, Corrision
U. Settling, Cracking, Shrinkage, Bulging or Expansion In Foundations, Walls, Floors or Ceilings
V. Termites, Moths or Vermin,

Voluntary Parting / False Pretense


Water Damage Including Leakage From Plumbing, etc.; Rain, Snow Sleet
Wear & Tear, Deterioration, Inherent Vice, Latent Defect
War, Nuclear, Insurrection, Rebellion, Revolution, Civil War, Usurped Power, Government Action
E&O Checklist
E&O ChecklistMAT Leasing
Policy Application/QuoteCurrent Policy Application

New

$1,000
$10,000
$250,000
$0
New
New
New
New

New
New
New

X
X
X

X $10,000
ted To Carrier)
X
X

X
X
X
X

appearance

t(s) By The Supplying Company


onditions Of Any Contract

For 30 Days
X
X
X
X
X
X
X
X
MAT Leasing, Inc.
Contractors Equipment Schedule
7/14/15 2016-2017

Unit # Year Make Model Type Serial # Value


1 2012 Wirtgen W220 Milling Machine 05220029 $585,000
2 2015 CAT 980M Wheel Loader TKRS00993 $465,558
3 2013 Wirtgen W150i Milling Machine 0-6130016 $365,625
4 963D 2008 CAT 963D Track Loader LCS00708 $204,750
5 PM201 2008 CAT PM201 Cold Planer PNM00243 $365,625
6 G-5 N5481 2011 CAT 140H Motor Grader APM03594 $190,000
7 G-3 1999 Fiatalis FG65C Motor Grader 79A07069 $31,200
8
9 C-13 1996 CAT 938F Front End Loader 01KM01570 $38,500
10 C-21 1999 CAT 950 G Front End Loader 3JW01417 $63,375
11 C-29 2012 CAT 962K Wheel Loader X4T00422 $263,150
12 C-30 2012 CAT 950 K Wheel Loader R4A00790 $248,265
13 C-32 2012 CAT 950 K Wheel Loader R4A00925 $248,265
14 C-33 2012 CAT 950 K Wheel Loader R4A00884 $248,265
15 C-34 2012 CAT 962K Wheel Loader JX4T00326 $248,265
16 2013 CAT 980K Wheel Loader 0W7K01627 $426,350
17 Pelican P-Series Sweeper P20435 $10,000
18 2007 Bobcat T140 Skid-Steer Loader 529311803 $17,605
19 2008 Bobcat S300 Skid-Steer Loader A5GP21534 $23,875
20 2013 Atlas S770 Bobcat ATF211615 $53,725
21 2013 Taylor TECSP 155 Hi-Lift 22995 $134,000

Sub Total $4,231,398

MAT Leasing, Inc.


Contractors Equipment Schedule
2014-2015 Deleted Equipment
Replacement ACV
Unit # Year Make Model Serial # Cost Value
32 G-1 Fiatalis 68C04528
33 G-2 Fiatalis 68C04520
34 C-14 1996 CAT 963B Track Loader 9BL02268 $47,500
35 C-14 1996 CAT 963B Track Loader 9BL02268 $42,000
36 C-18 1999 CAT 950G Front End Loader 3JW01243 $67,500
37 C-18 1999 CAT 950G Front End Loader 3JW01243 $82,500
38
39
40 C-15 1999 CAT 950G Front End Loader 3JW00983 $67,500
41 C-17 1999 CAT 950G Front End Loader 3JW01183 $67,500
42 C-19 1999 CAT 950G Front End Loader 3JW00977 $67,500
43 C-20 1999 CAT 950G Front End Loader 3JW01404 $67,500
44 C-22 1999 CAT 950 G Front End Loader 3JW01444 $67,500
45 C-24 2001 CAT 962 G Front End Loader 4PW00400 $72,500
46 Wirtgen Milling Machine 09100018 $175,000
47 980H - #2 2010 CAT 980H Wheel Loader JMS05947 $345,000
48 980H 2010 CAT 980H Wheel Loader JMS05432 $380,000

49 G-4 2001 New Holland RG 80 Motor Grader 85S06174 $36,575


50 C-31 2012 CAT 950 K Wheel Loader R4A00885 $254,630
51
52
53
54
55
56
57
58
59
60
61
62
Total Values $1,840,705

MAT Leasing, Inc.


Contractors Equipment Schedule
2014-2015 Deleted Equipment
Replacement ACV
Unit # Year Make Model Serial # Cost Value
C-16 1999 CAT 950G Front End Loader 3JW01193 $65,000
C-23 2001 CAT 962 G Front End Loader 4PW00398 $70,000

G-5 1995 CAT 140H Motor Grader 9TN00162 $100,000


Acord Annualized Pro-Rated Date Date Endt
App Rate Premium Premium Added Deleted #

4716016 $4,716,016
Annualized Pro-Rated Date Date Endt
Rate Premium Premium Added Deleted #

10/1/12 1
### 12/20/12 3,5
12/26/13
5/7/13
6/1/13 7
12/26/13

20 Deleted
MAT Leasing, Inc. 1 of 3

Equipment Breakdown
I. Current Carrier
II. Effective Date ASAP
III. Comprehensive Form Including
A. Production Equipment
B. All Boilers - Pressure Vessels
C. All Air Conditioning
D. All Refrigeration Equipment
E. All Electrical Equipment
F. All Mechanical Equipment
G. Boilers Used To Provide Steam For One or More Turbine Generators
H. Turbine & Engine Generators
I. Water Heaters; Heating Equipment Including Water Connections
J. Motors, Deep Well & Other Pumps
K. Fuel Cells or Other Alternative Electrical Generating Equipment
L. Electrical Transformers, Switchgear & Power Lines Used To Convey Electricity
M. Electrical Apparati
N. Equipment That Generates, Transmits or Utilizes Energy, Including Electronic Communications & EDP Eqmt.
O. Computer Related Equipment Including But Not Limited To: USP's, Servers, Air Conditioning Equipm
P. Equipment Which Operates Under Vacuum or Pressure, Other Than The Weight of Its Contents.

IV. Coverage Limits


A. Property Damage $0
B. Business Interruption $0
1) Ordinary Payroll Included
2) Extended Period of Indemnity Including Extended Period Due To Ordinance/Law Included
C. Extra Expense Included
D. Expediting Expenses For Tempory Repairs & To Expedite Permanent Repairs $100,000
E. Contingent Business Interruption

V. Equipment Breakdown Maximum Limit Per "Accident" $0

VI. Sub-Limits
A. Ammonia Contamination $0
B. Computer Equipment $100,000
C. Data Restoration $100,000
D. Demolition $0
E. Debris Removal $0
F. EDP/Valuable Papers: Cost To Research, Replace or Restore Lost "Data" $0
G. Hazardous Substances: Additional Cost To Repair/Replace Contaminated Property
H. Coverage Also Extends To Clean Up & Disposal Costs $0
I. Newly Acquired Locations - Must Report To Carrier Within 120 Days $0
J. New Construction, Alterations, Additions, Renovations, Repairs $0
K. Ordinance or Law-Increased Cost of Construction To Repair Damaged Portion of The Bld. $0
L. Ordinance or Law-Demolition $0
M. Ordinance or Law-Regulating Decontamination, Debris Removal, Clean Up & Disposal Costs $0
N. Service Interruption (Electrical, Waste, Refrig, Heat, AC, Gas, Internet, Telecommunication $100,000
O. Spoilage $100,000
P. Unnamed Locations $0

VII. Deductible
A. Property Damage $2,500
B. Business Interruption 24 Hr.
C. Extended Period of Restoration 5 Days
MAT Leasing, Inc. 2 of 2

Equipment Breakdown
VIII. Valuation
A. Equipment 24 Years or Newer Replacement Cost
B. Equipment 25 Years or Older Actual Cash Value

IX. Joint Loss Agreement Included

X. Covered Accidents
A. Sudden & Accidental Mechanical Breakdown Including Rupture or Bursting Caused By Centrifugal Force
B. Artificially Generated Electric Current Including Electric Arcing that Disturbs Electrical Devices
C. Explosion of Steam Boilers, Steam Pipes, Steam Engines, Steam Turbines, Electric Steam Generators,
Gas Turbine, Or Moving or Rotating Machinery Caused By Centrifugal Force or Mechanical Failure
D. An Event Inside Steam Boilers, Steam Pipes, Steam Engines, Steam Turbines That Damages Such Equipm
E. An Event Inside Hot Water Boilers or Other Water Heating Equipment That Damages Such Equipment
F. Failure of Pressure or Vaccuum Equipment
G. Bursting, Cracking or Splitting Caused By Centrifugal Force

XI. Covered Equipment


A. Boilers, Including Attached Steam, Condensate & Feedwater Piping
B. Fired or Unfired Pressure Vessels Subject To Vacuum or Internal Pressure Other Than The Static Pressure Of It
C. Computer Equipment Including Media And Peripherals

XII. Covered Equipment Definition


A. Property That Generates, Transmits, or Utilizes Energy, Including Electronic Communications & Data Processin
B. Which During Normal Usage, Operates Under Vacuum Or Pressure, Other Than The Weight Of Its Contents

XIII. Exclusions-Mechanical Breakdown Except If Specifically Endorsed To The Policy


A. Breakdown of Any Structure or Foundation
B. Breakdown of Any Boiler Setting, Insulating or Refactory Material.
C. Breakdown of a Power Shovel, Dragline, Excavator, Vehicle, Aircraft, Floating Vessel or Structure, Well
Casing, Penstock or Draft Tube.
D. Breakdown of Any Elevator, Crane, Hoist, Escalator or Conveyor, But Not Including Any Pressure Vessel
or Electrical Equipment Used With Such a Machine.
E. Breakdown of Boilers, Pressure Vessels, Machinery or Equipment Manufactured or Held For Sale By You.
F. Breakdown of Any Catalyst.
G. Combustion Explosion Including A Combustion Explosion of Any Steam Boiler or Other Fired Press. Vessel
H. Cracking Of Any Part On An Internal Combustion Gas Turbine Exposed To The Products of Combustion
I. Data: Information or Instructions Stored In Digital Code Capable of Being Processed
J. Deterioration, Rust, Corrosion, Erosion, Ear & Tear, Gradually Developing Conditions, Defects
K. Explosion of Gases or Fuel Within The Furnace of Any Covered Equipment
L. Elevator Hoist Motors That Generate Electricity Solely On An Emergency, Back Up Basis
M. Fines, Penalties or Punitive Damages
N. Fire & Smoke
O. Flood; Earthquake; Mold
P. Hydrostatic, Pneumatic or Gas Pressure Testing
Q. Leakage of Any Valve, Fitting, Shaft Seal, Gland Packing, Joint or Connection
R. Misalignment, Miscalibration, Tripping Off-Line, Or Any Condition That Can Be Corrected
S. Nuclear Hazard, War & Military Action
T. Ordinance or Law; Regulatory Body: Loss Due To Non Compliance With An Ordinance That You Were
Required To Comply With Before The Accident Occurred
U. Piping: Sewer or Underground Pipes, Vessels, or Valves or Fittings Forming A Part of A Sprinkler System
V. Water Piping That Is Not Part of A Closed Loop Used To Conduct Heat or Cooling From A Boiler or A
Refrigeration or Air Conditioning System
W. Vehicles or Equipment Mounted On A Vehicle; Spacecraft, Satellite or Mounted Equipment On Either
E&O Checklist 9/27/12

Policy Application 9/15/13 Updated

Eqmt.
Equipment

Building Damaged & The Loss Is Increased Because of An Ordinance or Law


That Requires The Demolition of A Building That Is Otherwise Repairable
X
X

X
X

ure Of Its Contents.

rocessing Equipment
ents

X
X

X
X
X

X
MAT Leasing, Inc.
Transportation / Motor Truck Cargo
I. Carrier Alterra America
II. Effective Date 5/1/14
III. Coverage
Provides Coverage For The Insured's Legal Liability For Loss To Covered Property Which Includes Prope
But Does Not Include Pharmaceuticals, Alcohol, Tobacco, & Electronics
A. While Under The Insured's Care, Custody or Control And
B. That The Insured Becomes Legally Obligated To Pay As A Common or Contract Carrier Under A Bill of La
Shipping Receipt or Contract of Carriage That Is Issued By The Insured or That Is Issued On Your

IV. Coverage
A. Any One Owned Vehicle $250,000
Means Any One Truck, Trailer, Semi Trailers, or Combination Of These Pulled
By One Power Unit Operated By You or Hired
B. In or At Scheduled Terminal, Whether In or On Cargo Carrying Vehicles or Otherw $250,000
And The Property Is In Due Course Of Transit $250,000
C. In Any One Loss, Disaster or Casualty, Either In Case of Partial Loss or Total $250,000
Loss or Salvage or Any Other Costs and Expenses or All Combined
D. In or On Any Rail Car $0
E. Mail Shipments $0
F. Federal Express (Customers Property) $0
G. Earned Freight Charges Unable To Collect Due To An Insured Peril $5,000
H. Moving Equipment $5,000

V. Perils-Special Form -All Risk Sub-Limit


Covered Causes of Loss Means YOUR Legal Liability As A Motor Carrier, Either As Imposed
By Law or Assumed By Written Contract, For Direct Physical Loss Caused By A Covered Peril
To Property Of Others Described On The Schedule While In Due Course Including:
A. Breakdown, Failure, Malfunction of Any Temperature Control System/Spoilage $10,000
B. Contract Penalty Incurred Resulting From A Covered Peril $5,000
C. Conversion, False Pretense Not Covered
D. Collision, Upset, Overturn Covered
E. Debris Removal, But Excluding Costs To Extract Pollutants, And Remove, Restore 25% Of Loss
Polluted Land or Water
F. Earthquake Covered
G. Off Board Electronics $5,000
H. On Board Electronics $5,000
I. Expediting Expenses To Repair A Transporting Vehicle, Or Expenses To Use Altern $5,000
Transportation $5,000
J. Fire, Lightning, Covered
K. Flood, Backup of Sewers, Pipes, Drains and Rising Waters While At Terminals Covered
L. Flood, Backup of Sewers, Pipes, Drains and Rising Waters While On A Vehcile Covered
M. Fraudulent Delivery or Pick-Up Not Covered
N. Loading & Unloading From or Onto A Sidewalk, Street, Loading Dock Adjacent To Covered
O. Loss of Use Not Covered
P. Mechanical Breakdown To Moving Equipment, Off & On Board Electronic Equipme Not Covered
Q. Off Premises Power Interruption While At Terminals $10,000
R. Pollution Clean Up Arising From A Covered Peril (Aggregate) $10,000
S. Returned Shipments $10,000
T. Reloading
U. Spoilage Caused By Sudden & Accidental Breakdown Or Malfunction Of Equipment Covered
V. Seizure By Law, Civil Authority, Confiscation, Destruction or Quarantine Not Covered
W. Theft Covered
X. Transportation, Collision or Upset Covered
Y. Windstorm Covered
MAT Leasing, Inc.
Transportation / Motor Truck Cargo
VI. Newly Acquired Vehicles
A. New Vehicles That Are To Be Added To The Policy Must Be Reported Within 10 Days
B. Substitute Vehicles Must Be Reported Within 24 Hours.

VII. Deductible
A. Per Occurrence All Perils Except As Noted In B $5,000
B. Theft, Vandalism & Malicious Mischief $10,000

VIII. Expenses Incurred At Time Of Loss


A. Expenses Are Included In The Limit
B. The Insurance Company Pays Reasonable Costs You Incurr To Make Necessary Repairs, Or If You Need T
Emergency Measures To Protect Covered Property From Further Damage By A Peril Insured Against If A
Against Has Already Caused A Loss To Covered Property. The Insurance Company Will NOT
Pay For Repairs To Property Which Has Not Been Damaged By An Insured Peril.

IX. Warranty
A. 24 Hour Security Guard
B. Fenced With locking Gate
C. Security Camera

X. Valuation
A. Actual Cash Value On The Date & Place Of Shipment, or
B. The Amount You Are Legally Liable Plus Cost Of Labor, Materials Or Services Arranged By The Insured.
C. Legally Liable For Is The Value Shown Set By Law, Or The Amount In The Tariff Document, Bill of Lading
Receipt or Contract of Carriage

XI. Amount Insurance Company Will Pay Will Be The Lesser Of:
A. The Amount Determined Under Valuation;
B. The Cost To Rebuild, Repair or Replace With Property Of Like Kind & Quality;
C. The Policy Limit

XII. Property Not Covered (Partial List)


A. Accounts, Bills, Deeds, Manuscripts, Mechanical Drawings, Valuable Papers of ANY Kind
B. Art & Statuary
C. Audio Or Video Equipment Designed For Entertainment
D. Contraband
E. Conveyance, Tarpaulins, Fittings or Other Eqmt Used In Connection With Any Vehicle
F. Electronic Data & Media
G. Intermodal Containers, Trailer, Or Carrying Conveyance Including Equipment Or Supplies That Are A Pa
H. Land or Water
I. Live Animals
J. Loss or Damage To Any Vehicle Unless Covered By Endorsement
K. Loss or Damage To Any Intermodal Container, Trailer or Any Other Carrying
L. Loss/Damage To Property In Storage For Which You Agreed To Store Under Warehouse Receipts or Writt
M. Loss or Damage To Any Intermodal Container, Trailer or Any Other Carrying Conveyance.
N. Money, Securities, Currency, Gold, Silver, Diamonds, Jewelry, Furs or Fine Arts
O. Precious Metals
P. Property You Transport Gratuitously
Q. Property For Which You Are Acting As A Transportation Broker
R. Property That Has Been Delivered After 72 Hours Following The Arrival Of The Property
S. Property That Has Been Delivered After 30 Days Following The Arrival Of The Property At The Terminal
T. Other Carriers
Carrier Does Not Cover Property While In The Custody Of Any Other Carrier If The Insured Has Waived
Made Unenforceable Their Right Of Subrogation
MAT Leasing, Inc.
Transportation / Motor Truck Cargo
XIII. Causes of Loss Not Covered (Partial List)
A. Standard Policy Exclusions
B. Breakdown, Failure Malfunction of Any Temperature Control System
C. Conversion, Fraudulent Delivery or Pick-Up
D. Cyber Risk
E. Delay or Loss of Market, Loss of Income or Loss of Use
F. Dishonest Acts By You, Your Employees, or Anyone Entrusted With The Property
G. Dampness or Dryness of Atmosphere; Heat or Cold
H. Dry Rot, Wet Rot
I. Fraudulent and Dishonest Acts
J. Fungi, Mold or Bacteria; Contamination, Rot, Rust Including Clean Up, Remediation, Containment or Re
K. Governmental Action
L. Hidden or Latent Defect, Insects, Vermin, Moths, Rodents or Worms
M. Insured's Liability For The Payment Of Any Fines, Assessments,Damages, etc.
N. Inventory Shortage, Mysterious Disappearance
O. Latent Defect, Gradual Deterioration
P. Loading & Unloading
Q. Loss or Damage Caused By or Resulting From Rain, Sleet, Hail, or Snow whether Driven By Wind or Not
R. Nuclear
S. Off Premises Power Interruption While At Terminals
T. Returned Shipments
U. Riots, Civil Commotion
V. Seizure By Law, Civil Authority, Confiscation, Destruction or Quarantine
W. Spoilage, Contamination, Freezing - Subject To Policy Terms
X. Theft, Robbery or Pilferage
Y. Vermin, Insects, Moths Rodents or Worms
Z. Vehicle Physical Damage
AA. Virus or Bacteria
Wear & Tear, Marring, or Scratching To Moving Equipment, Off & On Board Electronic Equipment
War & Military Action
New Current Marine Express
Policy Policy Policy

cludes Property They are hired by the ff or the steamship l


which has the equipment/truck serial num
X Legal Liability X
er A Bill of La X Excludes Any Scheduled Vehicles, Owned, Leased, or Op
ed On Your Behalf. X Loss While From The Perils Shown Below
X Insured Is Carrier
For Hire Means Lawful Goods & Merchandise of Ot
Transportation Under A Bill of Lading, Sh
$250,000 $250,000 As A Common or Contract Motor Carrier o
Motor Carrier. Such Property Is Covered W
Your CCC or In The Custody of a Connecti

$250,000 $100,000 Scheduled


$250,000 $100,000 Scheduled Under A Bill of Lading, Shipping Receipt
$200,000 As A Common or Contract Motor Carrier o
Motor Carrier. Such Property Is Covered W
Your CCC or In The Custody of a Connecti

X
X X
X
X 25% Of Loss $10,000 Wearing Apparel; Tobacco; Alcohol

X
X X
X
X X
X X
X
X
X
X Unlimited X
X X
X X
X X
X
X 25% Of Loss $1,000
$10,000 X Revenues/Current
Revenues/Current
New
Policy
VII. Valuation
A. RC(Replacement Cost)
B. ACV (Actual Cash Value)

VII. Valuation
$5,000 A. Invoice + Accrued Costs + Prepaid Charg
$10,000 B. Selling Price Clause
Insurance Carrier Will Pay Up To The Lim
under bills of lading, contracts of carriage
insured for loss or damage to lawful goods
f You Need To Take and while in the ordinary course of transit
d Against If A Peril Insured.
Will NOT VII. Valuation
The Value of the Covered Property Will Be
The Time of Loss
A. Amount of Invoice or If Not Under Invoice
of The Shipment; OR
B. The Value Shown In The Tariff Document,
of Carriage
C. But Not More Than What You Are Legally

The Value of the Property Will Be The Lea


he Insured. A. ACV (RC Less Depreciation)of Damaged P
Bill of Lading, Shipping B. Cost To Reasonably Restore That Property
C. The Cost of Replacing That Property With

IX. Valuation
A. Invoice + Accrued Costs + Prepaid Charg
B. Selling Price Clause
Insurance Carrier Will Pay Up To The Lim
Of Lading, Contracts Of Carriage Or Othe
X Damage To Lawful Goods And Merchandis
X Course Of Transit. In The Absence Of An I
X
X Loss Adjustment Provisions
Pay The Least of the Following:
Actual Adjusted Amount of Loss Less The
hat Are A Part Of Such Items Total Stated Amount Value As Scheduled L
Policy Limit
X

eipts or Written Contracts.


X
X
X X. Premium
X A. Exposure
X B. Rate
X C. Total
he Terminal X D. Surplus Lines Tax 0.041
X E. Deposit Premium
Has Waived Or Otherwise
F. Terrorism (Optional)
G. Surplus Lines Tax 0.041
New
Policy

X
nment or Re X

Wind or Not
X

X
X
X

X
X
ff or the steamship line to deliver the product. They operate under the interchange agreement
nt/truck serial number to verify MC has been approved to pick up intermodal container.

wned, Leased, or Operated By The Insured For Direct & Accidental Loss or Damage Resulting
n Below

& Merchandise of Others That You Have Accepted For


A Bill of Lading, Shipping Receipt or Contract of Carriage
act Motor Carrier or When You Trip Lease To Another
operty Is Covered While In Due Course of Transit In
stody of a Connecting Carrier.

, Shipping Receipt or Contract of Carriage


act Motor Carrier or When You Trip Lease To Another
operty Is Covered While In Due Course of Transit In
stody of a Connecting Carrier.

venues/Current ### $0.14


venues/Current ### $0.17
RC
ACV

ts + Prepaid Charges & Shipping Charges Incurred


SPC
Pay Up To The Limits Shown in the Declarations for your legal liability as a carrier,
ontracts of carriage or other shipping receipts issued by or on behalf of the
age to lawful goods and merchandise in the insured's care, custody or control,
ry course of transit. In The Absence Of An Invoice The ACV Of That Property.

ed Property Will Be Whichever of the Following Is Applicable At

Not Under Invoice, The Cash Market Value On The Date & Place

e Tariff Document, Bill of Lading, Shipment Receipt, or Contract

hat You Are Legally Liable

rty Will Be The Least of:


ation)of Damaged Property At Time of Loss
store That Property To Its Condition Before Loss
That Property With Substantially Identical Property

ts + Prepaid Charges & Shipping Charges Incurred

Pay Up To The Limits Shown In The Declarations For Your Legal Liability As A Carrier, Under Bills
f Carriage Or Other Shipping Receipts Issued By Or On Behalf Of The Insured For Loss Or
ds And Merchandise In The insured's Care, Custody Or Control, And While In The Ordinary
he Absence Of An Invoice The ACV Of That Property.

visions
ollowing:
nt of Loss Less The Deductible
alue As Scheduled Less The Deductible

###
$0.22
$9,500
$389
$9,889

$400
$16
MAT Leasing, Inc.
8/1/14 Site Pollution-Named Insureds

Loc. Named Insured Location Occupancy Tenant AST UST


1 Michael Tadin Building Account 4450 S. Morgan Corporate Office Marina Cartage, Inc. Etal 0 1
Chicago, Illinois 60609 Maintenance Facility
Park Vehicles UST-Excluded

2 Michael Tadin Building Account 4500 S. Morgan Park Vehicles Marina Cartage, Inc. Etal 0 0
Chicago, Illinois 60609

3 City of Chicago 750 N. Kilbourn Office M.A.T. Waste Northwest, Inc. 1 0


Chicago, Illinois 60623 Transfer Site M.A.T. Leasing, Inc.
Park Vehicles Operates Transfer Site
Diesel Fuel-2,000 Gal

4 35th Street Partners 3468 S. California Lease Space Hamilton Container 0 0


Chicago, Illinois 60616

5 The Amalgamated Bank of Chicago 2901 W. 31st Street Lease Space Maerske 0 0
As Trustee of Michael A. Tadin Chicago, Illinois 60623
Irrevocable Family Trust Dated
6/23/98

6 MMT Investments, Inc. 2814, 2835 S. Lock St. Vacant Land 0 0


Chicago, Illinois 60608

7 MMT Investments, Inc. 2814 Grady Ct. Vacant Land 0 0


Chicago, Illinois 60609

8 MMT Investments, Inc. 2811, 2813, 2817, 2819,2821, Vacant Land Morgan Street Development, LLC 0 0
2823, 2827, 2829, 2831, Property Will Be Sold To Building Contractor
2833 S. Grove St. Morgan Street Developmt, LLC 29 Single Family Home
Chicago, Illinois 60608 Development>

9 MMT Investments, Inc. 2812, 2816, 2818 S. Hillock Av. Vacant Land Morgan Street Development, LLC 0 0
Chicago, Illinois 60608 Property Will Be Sold To Building Contractor
Morgan Street Development, LLC Single Family Home Development>
MAT Leasing, Inc.
Site Pollution-Named Insureds

Loc. Named Insured Location Occupancy Tenant AST UST


10 Western Warehouse, Inc. 4335-45 S. Western Ave. Lease Space MP Snow; Coldparts, Inc.; 0 0
Chicago, Illinois Prinz Sales, Inc.;

11 T & B Ltd. 4000 S. Ashland Ave. Vacant Land 0 0


National Blvd. Bank & Trust U/T Chicago, Illinois
8369 Dated 7/12/89 & All Agents

12 T & B Ltd. 8900 S. Chicago Ave. Vacant Land 0 0


Lakeside Bank & Trust 10-1310 Chicago, Illinois
Dated 11/12/87

13 T & B Ltd. 2005 W. 43rd St. Lease Space Park Trailers Milestone 0 0
Chicago, Illinois

14 T & B Ltd. 4010 S. Damen Ave. Lease Space Park Trailers Milestone 0 0
T&B Also Leases Part of The Chicago, Illinois
Property From Canadian Natl RR

15 T & B Ltd. 1001 W. 45th St. Employee Parking Lot 0 0


Chicago, Illinois

16 T & B Ltd. 963 W. 37th St. Vacant Land 0 0


Chicago, Illinois

17 MMT Investments, Inc. 3022 N. Lake Shore Drive Vacant Land 0 0


Chicago, IL 60657
MAT Leasing, Inc.
Schedule of Locations
Site Pollution Liability
# # #
Loc. Owner Location Occupancy Tenant Area Empl. AST UST
1 Michael Tadin Building Account4450 S. Morgan Corporate Office Marina Cartage, Inc. Sq. Ft. 155 2 1
Marina Cartage, Inc. Chicago, Illinois 60 Maintenance Facility 25,000
Park Vehicles
UST Is Registered With The State
Fire Marshal; It Is Inspected Every
Year By Air Safe
UST Is NOT Insured

2 Michael Tadin Building Account4500 S. Morgan Park Vehicles Marina Cartage, Inc. 2 Acre 0 0 0
Chicago, Illinois 60609

3 City of Chicago 750 N. Kilbourn Office M.A.T. Leasing, Inc. Revenue 8 1 0


Chicago, Illinois 60 Transfer Station Operates Transfer Site 2,000
Park Vehicles Owned By City of Chicago Gal
Fuel

4 35th Street Partners 3468 S. California Lessor's Risk Hamilton Container Sq. Ft. 1 0 0
Chicago, Illinois 60616

5 The Amalgamated Bank of Chi 2901 W. 31st St. Lessor's Risk Pier Trsel & Hamilton ContainerSq. Ft. 1 0 0
As Trustee of Michael A. Tadin Chicago, Illinois 606 Rent Building & Yard
Irrevocable Family Trust Dated
6/23/98

6 Western Warehouse, Inc. 4335-45 S. Western A Lessor's Risk MP Snow; Coldparts, Inc.; 41,098 7 0 0
Chicago, Illinois Prinz Sales, Inc.;

7 T & B Ltd. 2005 W. 43rd St. Lease Space Railport 20 Acres 0 0 0


Chicago, Illinois Park Trailers GE
Infinity

MAT Leasing, Inc.


Schedule of Locations
Pollution Liability
# # #
Loc. Owner Location Occupancy Tenant Area Empl. AST UST
8 T & B Ltd. 8900 S. Chicago Ave. Vacant Land 5 Acres 0 0 0
Lakeside Bank & Trust 10-1310Chicago, Illinois
Dated 11/12/87

9 T & B Ltd. 4000 S. Ashland Ave. Vacant Land 20 Acres 0 0 0


National Blvd. Bank & Trust U/TChicago, Illinois
8369 Dated 7/12/89 & All Agents

10 T & B Ltd. 4010 S. Damen Ave. Lease Space Railport 4 Acres 0 0 0


Chicago, Illinois Park Trailers
T&B Also Leases Part of The
Property From Canadian Natl RR

11 T & B Ltd. 1001 W. 45th St. Lease Space GE 3/4 Acres 0 0 0


Chicago, Illinois Park Trailers

12 T & B Ltd. 963 W. 37th St. Vacant Land 2 Acres 0 0 0


Chicago, Illinois

13 T & B Ltd. 3022 N. Lake Shore D Vacant Land 2 Acres 0 0 0


Chicago, IL
MAT Leasing, Inc.
General Liability Pricing Comparison
Loc
# Location Description Code# Basis Exposure Rate Premium
I. Michael Tadin Building Account Corporate Office 46622 Sq. Ft. $1,000 $75.57 $76
Loc 1 4450 S. Morgan Marina Cartage, Inc.
Chicago, Illinois M.A.T. Leasing, Inc.
M.A.T. Leasing, Construction Inc.
MT Transit, Inc.
Marina Express, Inc.

II. Marina Cartage, Inc. Maintenance/Repair


Loc 1 4450 S. Morgan Parking - Private 46622 Sq. Ft. 28,000 40.588 $1,136
Chicago, Illinois Truckers 99793 Mechanics Payroll $92,598 $20.5900 $1,907
Additional Insured
Original Estimate>> $ 122,762
Acres 2 $125
Loc 2 3468 S. California Vacant Land-Lessors Risk 45539 Acres 7 $4.52 $32
Chicago, Illinois 60609

Hamilton Container Terrorism $99

III. M.A.T. Leasing, Inc.


Loc 1 4450 S. Morgan
Chicago, Illinois

Loc 2 750 N. Kilbourn Truckers 99793 Mechanics Payroll $205,059 $20.5900 $4,222
Chicago, Illinois 60623
Original Estimate>> $ 205,059
Lease & Operate Transfer Site Which
Is Owned By The City of Chicago

Park Vehicles

IV. M.A.T. Construction Leasing, Inc.


Loc 1 4450 S. Morgan Street or Road Construction 99315 Payroll $371,698 $55.000 $20,443
Chicago, Illinois Payroll $371,698 $4.0000 $1,487

Original Estimate>> $200,000

Total Page 1 $29,527


MAT Leasing, Inc.
General Liability Pricing Comparison
Loc
# Location Description Code# Basis Exposure Rate Premium
VI. MT Transit, Inc. Truckers 99793 Mechanics Payroll $121,415 $20.5900 $2,500
4450 S. Morgan Additional Insured $53
Chicago, Illinois
Original Estimate>> $ 232,069

VII. MMT Investments


Loc 1 2901 W. 31st St. Lessor's Risk 61212 Sq. Ft. 28,000 $55.0000 $1,540
Chicago, Illinois 60623

Loc 2 2814, 2835 S. Lock St. Vacant Land 49451 Acres 4 $4.0712 $16
Chicago, Illinois

Loc 3 2814 Grady Ct. Vacant Land 49451 Acres 1 $4.0712 $4


Chicago, Illinois 60609

Loc 4 3022 N. Lake Shore Drive Vacant Land 49451 Acres 1 $4.0712 $4
Chicago, Illinois 60657 Sq. Feet 4,304

VIII. Riverbend Real Estate, Inc. Building-Office 61212 Sq. Ft. 5,000 $55.0000 $275
Loc 1 2887, 2893, 2895 S. Hillock Ave. Property Owner Acres 4
Chicago, Illinois 60608

Loc2 2891, 2897, 1501 S. Hilock Ave. Vacant Land 49451 Acres 6 $4.0712 $24
Chicago, Illinois 60608

IX. Western Warehouse, Inc. Lessor's Risk 68702 Sq. Ft. 41,098 17.40284 $715
Loc 1 4335-45 S. Western Ave.
Chicago, Illinois

Total Page 2 $5,132


MAT Leasing, Inc.
General Liability Pricing Comparison
Loc
# Location Description Code# Basis Exposure Rate Premium
X. T & B Limited Partnership
Loc 1 2005 W. 43rd St. Lease Space Park Trailers 45539 Acres 20 $4.52355 $90
Chicago, Illinois Lessor's Risk 61212 Sq. Ft. 20,000 $55.000 $1,100

Loc 2 4010 S. Damen Ave. Lease Space Park Trailers 45539 Acres 4 $4.52355 $18
Chicago, Illinois Lessor's Risk

Loc 3 1001 W. 45th St. Lease Space Park Trailers 45539 Acres 1 $4.52355 $5
Chicago, Illinois Lessor's Risk

XI. National Blvd. Bank & Trust U/T Vacant Land 49451 Acres 20 $4.0712 $81
8369 Dated 7/12/89 & All Agents
Loc 1 4000 S. Ashland Ave.
Chicago, Illinois

XII. Lakeside Bank & Trust 10-1310 Vacant Land 49451 Acres 5 $4.0712 $20
Dated 11/12/87
Loc 1 8900 S. Chicago Ave.
Chicago, Illinois

Total Page 3 $1,315

Total Pages 1-3 $35,973


$ 91,598

$ 122,762

$ 205,059

$ 205,059

$ 559,890

$ 157,312

$ 200,000
$ 121,415

$ 121,415 $ 575,384

232069
$ 418,072

$ 449,236
$ 48,316
MAT Leasing, Inc.
Automobile Liability & Physical Damage
I. Proposed Carrier

II. Effective Date

III. Coverage & Limits Symbol


A. Bodily Injury & Property Damage 61
B. Medical Payments-Private Pass. 62
C. P.I.P 62
D. Uninsured Motorists-Bodily Injury (PPT Only) 66
E. Underinsured Motorists-Bodily Injury (PPT Only) 66
F. Hired & Non-Owned Liability 61
G. Broadened Pollution Coverage for Clean Up Costs
H. MCS 90
I. Waiver of Subrogation-Assumed Under Written Contract Prior To An Injury
J. Additional Insured-Lessors Any Auto Leased For A Perios of 6 Months or More
K. Primary & Non Contributory-Assumed Under Written Contract Prior To An Injury

IV. Deductible-Liability

V. Coverage & Limits Symbol


A. Comprehensive 62, 68
B. Collision 62, 68
C. Hired Auto Physical Damage
D. Loss of Use 63
E. Towing & Labor (PPT Only) 63
F. Rental Car Reimbursement 63
G. Transportation Expense-If Theft of Vehicle 63
H. Extra Expense To Return A Stolen Vehicle 63
I. Lease GAP (PPT Only) 63
J. Glass-Waiver of Deductible 63
K. Personal Effects (PPT Only) 63
L. Airbag-Accidental Discharge (PPT Only) 63

VI. Trailer Interchange Symbol


A. Comprehensive N/A
B. Collision N/A

VII. Deductible Per Occurrence


A. Comprehensive (No Deductible Fire or Lightning)
B. Collision
C. Hired Auto Comprehensive
D. Hired Auto Collision
1

mage
Hartford

5/1/16

Limit
$1,000,000
$5,000
Statutory
$1,000,000
$1,000,000
$1,000,000

Injury
s or More
To An Injury

$100,000

Limit
ACV
ACV
$75,000
Covered
N/A
$40/Day; $1,200 Max.
$40/Day; $1,200 Max.
$500
Covered
Covered
Covered
Covered

Limit
N/A
N/A

Amount
$5,000
$5,000
$100
$1,000
MAT Leasing, Inc. E&O A
Schedule of Vehicles
Unit # Year Make Model Serial # Garage Cost Radius Loss Payee Add. Insured
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
E&O Audit
Policy Application
MAT Leasing, Inc.
Automobile Liability & Physical Damage
2012 - 2013 Rating
Liability Liability Physical Dam.Physical Dam. Lia.&Phys.Dam.
Type of Unit # Vehicles Cost / Unit Premium Cost / Unit Premium Rate
Private Passenger 1 $445 $445 $741 $741 $1,186
Light Trucks 10 $770 $7,700 $295 $2,950 $1,065
Medium Trucks 0 $796 $0 $397 $0 $1,193
Heavy Truck 2 $1,317 $2,634 $160 $320 $1,477
Extra Heavy Truck Tractor 95 $2,110 ### $821 $77,995 $2,931
Trailers-All Other 203 $87 $17,661 $195 $39,585 $282

Extra Heavy Truck


Heavy Truck Tractor
Zone Rated Heavy Truck Tractor
Zone Rated Extra Heavy Truck Tractor

Semi-Trailers
Utility Trailers

Total 311 $5,525 ### $2,609 $121,591


Endorsements
Total
MAT Leasing, Inc.
Automobile Liability & Physical Damage
Historical Rates
2009-2010 2010-2011 2011-2012 2012-20
Lia.&Phys.Dam. # Combined # Combined # Combined
Premium Type of Unit Units Rate Premium Units Rate Premium Units Rate Premium
$1,186 Private Passenger 1 $0 1 $1,221 $1,221 1 $1,258 $1,258
$10,650 Light Trucks 10 $0 10 $1,221 $12,210 10 $1,258 $12,580
$0 Medium Trucks 1 $0 0 $1,221 $0 0 $1,258 $0
$2,954 Heavy Truck 1 $0 2 $1,273 $2,546 2 $1,311 $2,622
$278,445 Extra Heavy Truck Tractor 93 $0 95 $2,311 ### 95 $2,380 ###
$57,246 Trailers 203 $0 203 $79 $16,037 203 $81 $16,443

Extra Heavy Truck


Heavy Truck Tractor
Zone Rated Heavy Truck Tractor
Zone Rated Extra Heavy Truck Tractor

Semi-Trailers
Utility Trailers

$350,481 Total $0 ### ###


$7,184
$357,665

2008-09 2009-10 2010-112011-12 2012-13


PPT, Lt, MT 6 11 12

HT, EHT 5 2 4

Tractor 84 89 91

Trailers 178 180 202

Total 0 0 273 282 309

Private Passenger 1 $334 $334 $556 ### $890


Light Trucks 11 $578 ### $221 ### $799
Medium Trucks 0 $597 $0 $298 $0 $895
Heavy Truck 1 $988 $988 $120 ### $1,108
Extra Heavy Truck Tractor 93 $1,583 ### $616 ### $2,198
Trailers 203 $65 ### $146 ### $212
Total
Endorsements
Sub-Total
2012-20132012-2013

Rate Premium % Inc.


$1,186 $1,186 -5.7%
$1,065 $10,650 -15.3%
$1,193 $0
$1,477 $2,954 12.7%
$2,931 $278,445 23.2%
$282 $57,246 248.1%

$350,481 -100%

$890
$8,786
$0
$1,108
$204,437
$42,935
$258,155
$5,747
$263,902
MAT Leasing, Inc.
Coverage Differences
Current Proposed
I. General Liability
A. Deductible $5,000 $2,500
B. Employee Benefits Liability MC OK; All Other No $1,000,000
C. Damage To Premises Rented To You $100,000 $100,000
D. Designated Entity Exclusion Included Not Included
E. Med Pay $15,000 $1,000
F. Auditable or Non Auditable Some-Yes Non Auditable
G. Blanket Additional Insured-Written Contract MC OK; All Other No Included
H. Blanket Waiver of Subrogation Yes Yes

II. Pollution Legal & Contractors Pollution


A. On Site & Off Site Clean Up Costs 3rd Party 1st Party
B. Additional Legal Expense Coverage No $300,000
C. Definition of Bodily Injury Includes
Medical Monitoring No Yes
Shock No Yes
Emotional Distress No Yes
Mental Anguish No Yes
D. Indoor Air Quality (Microbial Matter/Legionella) $0 $50,000
E. Emergency Response $0 $250,000/$1,000,000

III. Property
Back Up of Sewers, Pipes & Drains Only 4450 S. Morgan Yes-All Locs
Collapse Only 4450 S. Morgan Yes-All Locs
Debris Removal & Demolition Only 4450 S. Morgan Yes-All Locs

GL Deductible Per Occurrence

Broadened Pollution Coverage for Clean Up Costs


MCS 90

Added
Effective Dat Policy Change Premium Savings
10/15/12 General LiabiAdded 2901 W. 31st St. Chicago, Illinois 60623

000,000
MAT Leasing, Inc.
Policy Cancellations
Annual Pro Short Annual
Coverage Carrier Effective Expiration Premium Rata Rate Penalty Min. Prem.
I. Property MAT Travelers 10/1/11 10/1/12 $20,261 $0 $0 $0

II. Property MC Indiana 5/1/11 5/1/12 $9,809 $8,820 $9,703 -$883

III. Property West. War. Indiana 4/6/12 4/6/13 $8,049 $4,401 $4,841 -$440

IV. Property MMT Admiral 3/29/11 3/29/12 $9,070 Do Not Cancel

V. Cont. Equip. MAT Zurich 10/1/10 10/1/11 $9,070 $0 $0 $0

VI. Auto MAT Zurich 10/1/10 10/1/11 ### $0 $0 $0

VII. Auto MC Indiana 5/1/11 5/1/12 ### $51,527 $56,730 -$5,203

VIII. GL MAT Zurich 10/1/10 10/1/11 $9,090 $0 $0 $0

IX. GL MC Indiana 5/1/11 5/1/12 $10,000 $4,176 $4,598 -$422

X. GL MT Zurich 10/1/10 10/1/11 $10,000 $0 $0 $0

XI. GL Mar. Exp. C.N.A. 2/1/11 2/1/12 $1,123 $745 $782 -$37

XII. GL MMT Landmark 3/29/12 3/29/13 $568 $2,984 $3,282 -$298

XIII. GL T&B Nautilus 8/1/12 8/1/13 $3,810 $668 $735 -$67

XIV. GL RiverbendInterstate 11/17/10 11/17/11 $3,627 Policy Written With Morgan

XV. Umbrella RiverbendInterstate 11/17/10 11/17/11 $3,885 Policy Written With Morgan

XVI. Umbrella T&B Scottsdale 8/1/12 8/1/13 $6,250 $2,267 $2,494 -$227
Umbrella T&B Torus Natl 8/1/12 8/1/13 $3,283 $2,267 $2,494 -$227
XVII. Umbrella MC Zurich 5/1/11 5/1/12 $45,522 $19,028 $20,931 -$1,903

XVIII. Umbrella MC Zurich 5/1/11 5/1/12 $39,239 $16,401 $18,042 -$1,641

XIX. Umbrella MAT Zurich 10/1/10 10/1/11 ### $0 $0 $0

XX. PLL MAT LC Zurich 10/1/10 10/1/11 $13,006 $0 $0 $0

XXI. PLL MAT L Zurich 4/5/10 10/1/11 $18,324 $0 $0 $0

XXII. WC MC, MAT, Ullico 1/18/11 1/18/12 ### ### ### ###
MT, MCL

XXIII. WC West. War. Ullico 4/1/11 4/1/12 $4,676 $2,338 $2,572 -$234

XXIV. Auto Mar. Exp. C.N.A. 2/1/11 2/1/12 $48,594 $0 $0 $0

XXV. Cargo Mar. Exp.Crum & F 2/1/11 2/1/12 $18,054 $0 $0 $0

XXVI. WC Mar. Exp. Ullico 1/18/11 1/18/12 $40,544 $0 $0 $0

XXVII. Auto Mar. Exp. C.N.A. 2/1/11 2/1/12 $48,594 $0 $0 $0

Totals ### ### ### ###


MAT Leasing, Inc.
Policy Cancellations
Annual Pro Short
Coverage Carrier Effective Expiration Premium Rata Rate Penalty Unearned
I. Property MAT Travelers 4/5/11 10/1/11 $15,996 $0 $0 $0

II. Property MC Indiana 5/1/11 5/1/12 $21,102 $8,820 $10,049 -$1,229 $11,053

III. Property West. War. Indiana 4/6/11 4/6/12 $9,050 $4,401 $4,865 -$464 $4,185

IV. Property MMT Admiral 3/29/11 3/29/12 $9,070 Do Not Cancel

V. Cont. Equip. MAT Zurich 10/1/10 10/1/11 $9,070 $0 $0 $0

VI. Auto MAT Zurich 10/1/10 10/1/11 ### $0 $0 $0

VII. Auto MC Indiana 5/1/11 5/1/12 ### $51,572 $58,753 -$7,181 $64,626

VIII. GL MAT Zurich 10/1/10 10/1/11 $9,090 $0 $0 $0

IX. GL MC Indiana 5/1/11 5/1/12 $10,000 $4,180 $4,762 -$582 $5,238

X. GL MT Zurich 10/1/10 10/1/11 $10,000 $0 $0 $0

XI. GL Mar. Exp. C.N.A. 2/1/11 2/1/12 $1,123 $745 $782 -$37 $341

XII. GL MMT Landmark 3/29/11 3/29/12 $5,871 $2,984 $3,272 -$288 $2,599

XIII. GL T&B Nautilus 8/1/11 8/1/12 $4,010 $668 $1,002 -$334 $3,007

XIV. GL RiverbendInterstate 11/17/10 11/17/11 $3,627 Policy Written With Morgan

XV. Umbrella RiverbendInterstate 11/17/10 11/17/11 $3,885 Policy Written With Morgan

XVI. Umbrella T&B Naut/Ohio 8/1/11 8/1/12 $13,600 $2,267 $3,400 -$1,133 $10,200

XVII. Umbrella MC Zurich 5/1/11 5/1/12 $45,522 $19,028 $21,678 -$2,650 $23,844

XVIII. Umbrella MC Zurich 5/1/11 5/1/12 $39,239 $16,401 $18,685 -$2,284 $20,553

XIX. Umbrella MAT Zurich 10/1/10 10/1/11 ### $0 $0 $0

XX. PLL MAT LC Zurich 10/1/10 10/1/11 $13,006 $0 $0 $0

XXI. PLL MAT L Zurich 4/5/10 10/1/11 $18,324 $0 $0 $0

XXII. WC MC, MAT, Ullico 1/18/11 1/18/12 ### ### ### -$6,490 $58,411
MT, MCL

XXIII. WC West. War. Ullico 4/1/11 4/1/12 $4,676 $2,338 $2,572 -$234 $2,104

XXIV. Auto Mar. Exp. C.N.A. 2/1/11 2/1/12 $48,594 $0 $0 $0

XXV. Cargo Mar. Exp.Crum & F 2/1/11 2/1/12 $18,054 $0 $0 $0

XXVI. WC Mar. Exp. Ullico 1/18/11 1/18/12 $40,544 $0 $0 $0

XXVII. Auto Mar. Exp. C.N.A. 2/1/11 2/1/12 $48,594 $0 $0 $0

Totals ### ### ### ### $206,161


Policy
Min.

$9,050

$5,871

$4,010

$13,600
arned
MAT Leasing, Inc. E&
Property Valuation At Time Of Loss
I. Coverage Valuation Coinsurance
A. Building Replacement Cost 90%
B. Personal Property Replacement Cost 90%
C. Finished Stock/Inventory Sold But Not Delivered
RC-Discounts-Unincurred Expenses 90%
D. Finished Stock/Inventory Not Sold: Replacement Cost 90%
E. Raw Stock & Stock In Process Replacement Cost 90%
F. Electronic Data Processing Equipme(Hardware) Replacement Cost 90%
G. Software Cost of Blank Media+Reasonable Cost of Restoring Data 90%
H. Contractors Equipment Actual Cash Value 100%
I. Business Interruption/Extra Expense Actual Loss Sustained 100%

II. Insured's Options At Time of Loss


A. Replacement Cost Shall Not Exceed The SMALLEST Of The Following Amounts:
1) The Cost To Repair or Replace The Covered Property, Or Any Part Thereof, With Property Of Compara
Material & Quality; If No Such Replacement Property Is Available See A.4.
2) The Amount Actually Expended In Repairing or Replacing The Damaged Property;
3) Insured May Take All or Any Part Of The Property At An Agreed or Appraised Value.
4) If The Property Cannot Be Repaired or Replaced As Noted In A.1. & A.2. The Loss Settlement Will Be
Limit/Value Reported In The Statement of Values On File With The Insurance Company;
B. If A. 1. or A. 2. Is Selected Partial Payments Will Be Based On Actual Cash Value Until The Damaged P
Repaired or Replaced Unless Option II. E. Is Exercised;
C. Building Coverage: Insured May Elect To Rebuild At Another Site;
D. Replacement Cost Applicable To Building & Contents Not Included
In The Event The Insured Elects Not To Repair or Replace The Lost, Damaged or Destroyed Property,
May Elect To Use The Proceeds of Such Loss Settlement, As Mutually Agreed Upon By The Adjuster &
Insured, And Subject To The Parameters Outlined In II.A., On Other Capital Expenditures Related To
Operations Within Two Years From The Date of Loss.
E. Inventory:
Valuation At Time of Loss Will Be Based On A Formula That Is Agreed Upon Between The Insured and
The Insurance Company Due To The Price Fluctuations of the Insured's Inventory.
F. Tank Valuations
Valuation At Time of Loss Will Be Based On A Formula That Is Agreed Upon Between The Insured and
The Insurance Company

III. Standard Policy Wording


Insurer Options At Time of Loss & Valuation of Damaged Property
A. Replacement Cost Shall Not Exceed The SMALLEST Of The Following Amounts:
1) The Limit Applicable To The Lost or Damaged Property;
2) The Cost To Repair or Replace The Covered Property, Or Any Part Thereof, With Property Of
Comparable Material & Quality, On The Same Premises & Used For The Same Purpose;
3) The Amount Actually Expended In Repairing or Replacing The Damaged Property;
B. Payment Will Be Based On Actual Cash Value Until The Damaged Property Is Repaired or Replaced;
If The Damaged Property Is Not Repaired or Replaced The Loss Settlement Will Be Based On ACV;
C. Building Coverage: Insured May NOT Elect To Rebuild At Another Site;
D. If The Damaged Property Is Not Repaired or Replaced The Loss Settlement Will Be Based On ACV;
E&O Checklist
Policy Application
Agreed Amount
Agreed Amount
Agreed Amount
Agreed Amount
Agreed Amount
Agreed Amount

Agreed Amount
Agreed Amount

Of Comparable

ent Will Be Based On The

Damaged Property Is

d Property, The Insured


e Adjuster & The
Related To The Insured's

nsured and

nsured and

Replaced;
On ACV;

On ACV;
Coinsurance Clause
Valuation Considerations
Coinsurance Clause
A policy provision requiring the insured to carry insurance equal to a specific percentage of the v
property covered. It provides for the full payment, up to the amount of the policy, of all losses if
has insurance at least equal to the specific per-centage (See Below) of the value of the property c
The loss payment is reduced proportionately if the amount of insurance falls short of the specifie

Building Coverage: 80%, 90% or 100%

Contents Coverage: 90% or 100%

Coinsurance Clause Formula

(Amount of Insurance Purchased) x (Amount of Loss) = (Amount Paid)


(Amount of Insurance Required)

Example I.
Building Construction: Concrete Block Walls & Steel Columns; Metal Deck Roof; Concrete Floor;

Estimated Cost Per Square Foot To Replace The Building: $175.00


Square Feet: 40,000
Estimated Replacement Cost of Building: $7,000,000

Replacement Cost: 100% $7,000,000

MINIMUM Amount of Insurance Required: 80%

Minimum Amount of Insurance Required In $ $5,600,000

Example Calculation

Amount of Insurance Carried $5,616,000

Amount of Loss $2,500,000

Amount Insured Collects

(Amount of Insurance Purchased) ### x (Amount of Loss) Amount Collected


(Amount Required) ###

Amount Collected ### x ### Equals $2,500,000


###

Uninsured Loss: $0
Coinsurance Clause
Valuation Considerations
Example II.

Building Construction:
Estimated Cost Per Square Foot To Replace The Building: $0.00
Square Feet: 0
Estimated Replacement Cost of Building: $0

Coinsurance Clause Formula

(Amount of Insurance Purchased) x (Amount of Loss) = (Amount Paid)


(Amount of Insurance Required)

Replacement Cost: $0

MINIMUM Amount of Insurance Required: 90%

Minimum Amount of Insurance Required In $ $0

Note: The Insured Can Carry 90% or Also 100%

Example Calculation

Amount of Insurance Carried $0

Amount of Loss $0

Amount Insured Collects

(Amount of Insurance Purchased) $0 x (amount of loss) $0


(Amount Required) $0

Amount Collected $0 x $0 Equals #DIV/0!


$0

Uninsured Loss: #DIV/0!


Coinsurance Clause
Valuation Considerations
Agreed Amount

The Agreed Amount endorsement WAIVES the Coinsurance clause. The insurance company and
must first agree on the amount of insurance on the property to qualify for the Agreed Amount en
The property insurance limits must be equal to the percentage of the Replacement Cost of the pr

Actual Cash Value

The Actual Cash Value is the value of the damaged or destroyed property less the depreciation of
property.

Replacement Cost

The Replacement Cost is the value of the damaged or destroyed property without any deduction

Loss Adjustments

At time of loss you have the option to repair or replace the damaged property on a Replacement
or if you elect not to replace the damaged property the loss will be adjusted on an Actual Cas
ntage of the value of the
f all losses if the insured
he property covered.
f the specified percentage.

ncrete Floor; Sprinklered


Non Combustible on Steel Deck on Fire Treated Supports; 84% Sprinklered
company and the insured
d Amount endorsement.
Cost of the property covered.

epreciation of the damaged

ny deduction for depreciation.

Replacement Cost bases,


an Actual Cash Value bases.
MAT Leasing, Inc.
COPE Information
Yr. Sq. # Columns Type & Year Last Updated Fire/Security
Loc Addresses Occupancy Built Feet Stories Basemt Walls Beams Floor Roof Heat Plumb Elect Alarms
1 Office & 190,000 Masonry Steel Concrete HVAC Syst. Conduit With
Plant Brick Joisted Slab Roof Mounted Circuit Breakers
For
Office &
Exposures
Right
Left
Rear
Front
Hydrants
Fire Dept. Distance

Yr. Sq. # Columns Type & Year Last Updated Fire/Security


Loc Addresses Occupancy Built Feet Stories Basemt Walls Beams Floor Roof Heat Plumb Elect Alarms
2 Warehouse 1963 190,000 1 No Masonry Steel Concrete
Joisted Slab

Exposures
Right
Left
Rear
Front
Hydrants
Fire Dept. Distance

Yr. Sq. # Columns Type & Year Last Updated Fire/Security


Loc Addresses Occupancy Built Feet Stories Basemt Walls Beams Floor Roof Heat Plumb Elect Alarms
3 4335-45 S. Western Ave. 190,000 Central Station Burglar
and Fire Alarm Systems.
Video Surveillance

Exposures
Right
Left
Rear
Front
Hydrants
Fire Dept. Distance
MAT Leasing, Inc. E&
Crime
I. Current Carrier Hartford

II. Effective Date ASAP

III. Territory
United States of America, U.S. Virgin Islands, Puerto Rico, Canada.

Limit Deductible
IV. Employee Dishonesty-Commercial Blanket Bond $150,000 $1,000
Means Only Dishonest Acts Committed By An Employee, Whether
Identified or Not, Acting Alone or In Collusion With Other Persons,
Except You or A Partner, With The Manifest Intent To:
A. Cause You To Sustain Loss; and Also
B. Obtain Financial Benefit Other Than Employee Benefits Earned In
The Normal Course of Employment, Including Salaries, Commissions,
Fees, Bonuses, Promotions, Awards, Profit Sharing, or Pensions For:
1) The Employee, or
2) Any Person or Organization Intended By The Employee To Receive
That Benefit.

V. Forgery or Alteration $150,000 $1,000


Forgery Or Alteration Of, On Or In Any Covered Instrument Including
Checks, Drafts, Promissory Notes or Similar Written Promises, Orders
or Directions To Pay A Certain Sum In Money That Are Drawn By or
Drawn Upon You; By One Acting As Your Agent.

VI. Money & Securities


Money or Securities Inside or Outside The Premises Caused By Theft,
Disappearance or Destruction.
A. Inside $0 $0
B. Outside $0 $0

VII. Computer Fraud & Wire Funds Transfer $0 $0


Loss Arising From Computer Fraud To Money, Securities.

VIII.Exclusions
A. Inventory Shortage
B. Employee Cancelled Under Prior Insurance
C. Acts of Employees, Directors or Trustees: Loss Resulting From Any
Dishonest or Criminal Act Committed By Any Of Your "Employees,
Directors or Trustees:
1) Whether Acting Alone or In Collusion With Other Persons, or
2) Whether While Performing Services For You or Otherwise.
D. Legal Expense Related To Any Legal Action
MAT Leasing, Inc.
Crime
IX. Extensions of Coverage
A. Definition of employee includes:
Any Person Employed By An Employment Contractor While That
Person Is Subject To Your Direction and Control and Performing
Services For You, But, Excluding Any Such Person While Having
Care and Custody of Property Outside The Premises.

B. 1974 ERISA
Requires Companies To Carry A Fidelity Bond Covering Plan Trustees.
The Fidelity Bond Must Be Written With A Limit of 10% of The Funds
Handled By A Trustee or Fiduciary. The Minimum Bond Limit Is $1,000
Per Plan Subject To A Maximum Limit of $500,000 Per Plan. Plans
Holding Employer Securities Are Required To Carry A Maximum Limit
of $1,000,000.
E&O Audit
Policy Application

ble
MAT Leasing, Inc.
Crime
I. Current Carrier Hartford
II. Effective Date ASAP
III. Retro Active Date 1/31/02
IV. Named Insured
A.
B.
V. Territory Worldwide
Limit Deductible
VI. Employee Theft ### $1,000
A. Loss of Money, Securities, & Other Property Which Results
From Theft By An Employee, Whether or Not Identifiable,
While Acting Alone or In collusion With Others

B. Employee Theft-Employee Benefit Plans Provision * $1,000


* The Limit of Insurance Applicable To Any Employee Benefit
Plan Shall Equal The Lesser of 10% Of The Employee Benefit
Plan Assets As Of The Beginning Of Such Employee Benefit
Plan Fiscal Year or $500,000.
C. Designated Agents As Employees:

VII. Money Orders, Counterfeit Currency $0 $0

VIII. Forgery or Alteration ### $500


A. Forgery or Alteration of checks, drafts, promissory notes or
similar written promises, orders or directions to pay a certain
sum in money that are drawn by or drawn upon you; by one
acting as your agent.
B. Mechanically Produced Signatures Will Be Treated The Same
As Handwritten Signatures
C. Covers Loss Anywhere In The World

IX. Money & Securities $0 $0


Loss of Money or Securities Inside or Outside The Premises
Caused By Theft, Disappearance or Destruction.

X. Computer Fraud & Wire Funds TransfeOptional >>>> ### $1,000


Loss Of & From Damage To Money, Securities, & Other
Property Following And Directly Related To Use of Any
Computer To Fraudulantly Cause A Transfer of That Property
From Inside The Premises or Banking Premises To A Person
Outside Those Premises To A Place Outside Those Premises

Loss of & Loss Money, Securities Through "Funds Transfer


Fraud" Resulting Directly From "Fraudulent Transfer Instructions"
Communicated To A "Financial Institution" & Instructing Such
Institution To Pay, Deliver, or Transfer Money or Securities From
Your Transfer Account
MAT Leasing, Inc.
Crime
X. Defense Costs Included In Retention

XI. Policy Extensions & Conditions


A. Extended Period To Discover Loss
1) No Later Than 60 Days From The Date of The Termination or Cancellation
B. Non Cumulation of Limit of Insurance
C. Special Limit: $5,000
1) Maximum Payable Any One Occurrence For Precious Metals, Semi-Precious Stones, Pearls, F
2) Maximum Payable Any One Occurrence For Munuscripts, Drawings, or Records of Any Kind o
The Cost of Reconstruction/Reproduction
D. Bridge Endorsement: Covers Losses That Fall Within The Extended Period of Indemnity From
The Prior Policy, But Only On An Excess Basis.
E. Employee Benefit Plans Are Insured For Loss Through Fraud or Dishonesty
F. Legal Expenses
Expenses Related To Any Legal Action Except When Related To Depositors Forgery. Depositor
Forgery Will Provide Defense In The Event You Are Sued For Refusing To Pay Any Instrument
Note In B.1 of The Policy, On The Basis That The Document Has Been Forged.

XII. Loss
In The Event More Than One Retention Amount Could Apply To The Same Loss, Only The Hig
Retention Amount Will Be Applied.

XIII. Partial List of Exclusions


A. Inventory Shortage
B. Employee Cancelled Under Prior Insurance
C. Acts of Employees, Directors or Trustees: Loss Resulting From Any Dishonest or Criminal Act
Committed By Any of Your "Employees, Directors or Trustees:
1) Whether Acting Alone or In Collusion With Other Persons, or
2) Whether While Performing Services For You or Otherwise.
This Exclusion Does Not Apply To Employee Dishonesty
D. Accounting or Arithmetical Errors or Omissions
E. Governemental Authority
F. Conversion-Voluntary Parting of Title or Possession of Property
G. Fire, Vandalism
H. Indirect Loss
I. Legal Expenses
J. Money Operated Devices
K. Nuclear, War
L. Risks Assumed In Contractual Agreements
M. Trading Losses
N. Warehouse Receipts Losses

XIV. 1974 ERISA


Requires Companies To Carry A Fidelity Bond Covering Plan Trustees. The Fidelity Bond M
Written With A Limit of 10% of The Funds Handled By A Trustee or Fiduciary. The Minimum B
Limit Is $1,000 Per Plan Subject To A Maximum Limit of $500,000 Per Plan. Plans Holding E
Securities Are Required To Carry A Maximum Limit of $1,000,000.
es, Pearls, Furs
f Any Kind or

emnity From

ry. Depositors
Instrument

Only The Highest

Criminal Act

elity Bond Must Be


e Minimum Bond
s Holding Employer
MAT Leasing, Inc.
Worker's Compensation
I. Proposed Carrier Trumbull Insurance Co.

II. Effective Date 5/1/16

III. Type of Program Guaranteed Cost

IV. Coverage A Statutory

V. Coverage B Employer's Liability


A. Bodily Injury-Each Accident $1,000,000
B. Disease - Policy Limit $1,000,000
C. Disease - Each Employee $1,000,000

VI. Foreign Voluntary Worker's Comp & EL


A. Repatriation / Any One Employee $1,000,000
B. Employer's Liability $1,000,000
C. Employees Covered US Citizens
D. Endemic Disease $1,000,000

VII. Annual Loss Aggregate $1,750,000

VIII. Deductible Each loss Event $200,000

IX. Allocated Loss Adjustment Expenses


A. Included In Deductible
B. Limited To Deductible Amounts

X. Program Options
A. Standard Deductible-Per Loss Event $200,000
B. Step Down Deductible-Per Loss Event Options # of Events
1 . Option I. 1
The Largest Loss During The Policy Term Will Be Subject To A $250,000
Deductible. All Other Losses Will Be Subject To A $150,000 Deductible.

2 . Option II. 2
The Two (2) Largest Losses During The Policy Term Will Be Subject To A
$250,000 Deductible. All Other Losses Will Be Subject To A $150,000 Deductible.

XI. Payrolls
Description Code # Payroll
Clerical 8810 $1,375,110
8742 $0
5506 $792,182
7228 $7,228
7580

Total $2,174,520
MAT Leasing, Inc.
Worker's Compensation
XI. Additional Coverage
A. Voluntary Compensation Covered
All Officers & Employees Including Volunteers Not Subject To The
WC Law Except Masters & Members of The Crew of Any Vessel

B. Other States Insurance Covered


All States Except North Dakota, Ohio, Washington, Wyoming. The Insurance
Company Must Be Notified Within 30 Days Once You Begin Work In Any State.

C. Stop Gap-Ohio, WV, WY, ND, Covered

D. USL&H (US Lonshoreman & Harbor Worker's Act) Covered

E. Blanket Waiver of Subrogation-Written Contracts Covered

F. # Days Notice of Cancellation 30 Days Except for Non-Payment

G. Unintentional Failure To Disclose Hazard

H. Notification of Change In Ownership Must Notify Carrier

I. Tentative Experience Modification

J. Tentative Rate

K. Contingent Experience Modification Endorsement

XII. Deductible Includes Loss Payments


Includes ALAE (Allocated Loss Adjustment Expense)
Included In Policy Limit
MAT Leasing, Inc.
Worker's Compensation
X. Option I. - Premium Calculation (One (1) $250,000 Deductible)
A. Estimated Payroll $8,815,449

B. PROJECTED WC Deductible Premium Rate $2.870

C. Premium $253,003

D. Expense Constant $280

E. Surcharges 1.01% $2,555

F. Terrorism 4% $3,526

G. Terrorism-CAT 1% $882

H. Total $260,246

XI. Option II. - Premium Calculation (Two (2) $250,000 Deductibles)


A. Estimated Payroll $8,815,449

B. PROJECTED WC Deductible Premium Rate $2.65

C. Premium $233,169

D. Expense Constant $280

E. Surcharges 1.01% $2,355

F. Terrorism 4% $3,526

G. Terrorism-CAT 1% $882

H. Total $240,211
MAT Leasing, Inc.
Worker's Compensation
X. Option III. - Premium Calculation ($200,000 Deductible)
A. Estimated Payroll $8,815,449

B. PROJECTED WC Deductible Premium Rate $2.895

C. Premium $255,207

D. Expense Constant $280

E. Surcharges 1.01% $2,939

F. Terrorism 4% $3,526

G. Terrorism-CAT 1% $882

H. Total $262,834

PROJECTED WC Deductible Premium Rate


The Rate Identified As The Projected WC Deductible Premium Rate Is An Average Rate Shown
Of Illustration. Individual State Rating Plans Apply. Hartford Will Endeavor To Balance To The P
Average WC Deductible Premium Rate Shown In Item IX. B.

Surcharges & Assessments Are Not Included In The Average Rate.


Marina Cartage, Inc. Etal.
Large Deductible
Program Structure Illustration

Statutory xs Unlimited
of Deductible "Basket Maximum"
"Specific Excess" Umbrella Aggregate Excess
x30,000,000
Coverage A-Statutory xs $1,000,000
Any One Accident

Employers Automobile
Liability Liability
Coverage B ###
All Claims Under The
Deductible Apply
Towards The Basket
Maximum. Once The
Claims Exceed $1,800,000
The Basket Maximum
(Aggregate Excess Insurance)
Insurance Applies
^^^^^
^^^^^
^^^^^
Deductible Deductible Deductible Claims Under The Deductible ^^^^^^^^^^^^^^^^^^^^^
$150,000/$250,000 $150,000/$250,000 $100,000 Apply Towards Bodily Injury ^^^^^^^^^^^^^^^^^^^^^
Aggregate Loss Fund ^^^^^^^^^^^^^^^^^^^^^
>>>>>>> >>>>> ^^^^^^^^^^^^^^^^^^^^^
>>>>>>> >>>>> ^^^^^^^^^^^^^^^^^^^^^
MAT Leasing, Inc.
Worker's Compensation
&
Automobile Liability
"Basket Maximum" Aggregate Excess / Clash Deductible
I. Proposed Carrier Hartford

II. Effective Date 10/1/11

III. Coverage C & AL "Basket Maximum" (Aggregate Excess Insurance)

IV. "Basket Maximum" (Aggregate Excess Insurance) $1,664,958


Is Equal To The Total Cumulative WC & AL Losses That Fall Under The
Deductible For All Claims That Occur During The Policy Period.

V. "Basket Maximum" Calculation


A. Rating Bases-Payroll $8,815,449

B. Rate Per $10 $1.8887

C. "Basket Maximum" Attachment Point $1,664,958

VI. Auditable Year End Policy Audit

VII. Clash Deductible


A. Combined Auto & WC Loss Limitation $225,000

B. Premium $7,500

C. Coverage
In The Event A Loss Occurs That Involves Both Automobile and Worker's Compensation Separa
Deductibles Will Apply Unless The Insured Purchases A Clash Deductible. The Insured Would
A $100,000 Automobile Deductible and A $250,000 WC Deductible (Assuming This Is The Larg
During The Policy Year). The Insured Would Potentially Pay Out $350,000 In Deductible Losse
The Insured Purhased The Clash Deductible The Most They would Pay Is $225,000.
tion Separate
red Would Pay
s The Largest Loss
tible Losses. If
MAT Leasing, Inc.
Worker's Compensation & Automobile Liability
Claim Management & Safety Fees & Services
I. Worker's Compensation Claim Management Fees
A. Basic Fee 10% of Paid Losses + ALAE

B. Fee Limitation 10% of Deductible Amount


1) $150,000 $15,000
2) $250,000 $25,000

II. Automobile Claim Management Fees


A. Basic Fee 10% of Paid Losses + ALAE

B. Fee Limitation 10% of Deductible Amount


1) $100,000 $10,000

C. The % Of Incurred Losses Includes U/M; Und./M; & PIP

III. Managed Care Fees


Legal Fees-Hartford Staff Medical Bill Review
Doctor Consultations Hospital Bill Review
PPO Network Utilization Review
Nurse Case Management Subrogation Fees

IV. Miscellaneous Fees


Med Records/Reports
Med Examination
Diagnostic Examinations
Laboratory
X-Ray
Reasonable & Necessary Travel

V. Safety Fees
A. # Visits 5

B. Cost Per Visit $1,400

C. Total Cost $7,000

VI. Legal Keefe, Campbell & Associates

VII. Auto Physical Damage Claims


A. Flat Fee $2,000
B. Per Claim $425
MAT Leasing, Inc.
Worker's Compensation & Automobile Liability
Claim Management & Safety Fees & Services
VI. Risk Management Systems
A. Standard Monthly Reports

B. On Line Claim Review Capabilities Including Adjuster Notes

C. Ad Hoc Reports

VII. Services
A. Claim Settlement Authority
B. Semi Annual Claim Reviews
ssociates
MAT Leasing, Inc.
Worker's Compensation
&
Automobile Liability
Security & Escrow Calculations
I. Initial Security (Letter of Credit) ###

II. Minimum Security Amount ###

III. Mid-Term Security Adjustments


A. Positive or Negative Change In Your Financial Condition
B. Acquisitions/Divestitures
C. Change In Operations
D. Higher Than Anticipated Losses

IV. Annual Security Adjustments


A. Two Months Prior To Renewal Date

B. Formula For Calculating Security Adjustments Which Will Be Adjusted To The Nea
Add Deposit & Installment Premiums
Endorsement Premiums
Miscellaneous Charges
Residual Market Loads
Returned Premium & Dividends Paid To Insured
Deductible Reimbursements Due To Loss Development of Incurred AND
Incurred But Not Reported Losses

Less Paid Premiums


Paid Endorsement Premiums
Paid Miscellaneous Charges
Paid Residual Market Loads
Paid Deductible Reimbursements
Paid-Outstanding Judgements, Settlements & Medical Bills

V. Loss Development
Multiply The Incurred Losses By The Applicable Loss Development Factor

VI. Bank Credentials


Commercial Bank Which Is Authorized To Issue Letters of Credit & Either A Member of The
Federal Reserve System or A New York State Chartered Bank (Issuing Bank). The LOC Mus
To NY Insurance Regulation 133. Hartford Must Approve Issuing Bank & LOC.

VII. Return of Security


Hartford Will Return Unused Security To Insured 5 Years After Policy Termination, Providin
Claims Have Been Closed For The Last Two Years.
MAT Leasing, Inc.
Worker's Compensation
&
Automobile Liability
Security & Escrow Calculations
VIII. Escrow Account $35,000

Hartford Will Advance Payments On Your Behalf, Therefore, This Is The Reason For Establi
The Escrow Account. Typically The Amount Is Adjusted At Renewal, But If There Are Frequ
Requests To Replenish Funds Hartford May Ask You To Increase The Amount. The Amount
The Escrow Fund Is Equal To The 3 Month Average Of Paid Losses For The Prior 12 Month
MAT Leasing, Inc.
Worker's Compensation
&
Automobile Liability
Security & Escrow Calculations

Scheduled Loss Devel.


Coverage Adjustment Date Factor
Worker's Compensation 7/30/13 1.25

7/30/14 1.20

7/30/15 1.10

7/30/16 1.10

7/30/17 1.05

To The Nearest $100,000.

Automobile Liability 7/30/13 1.30

7/30/14 1.15
rred AND
7/30/15 1.10

7/30/16 1.05

7/30/17 1.00

ember of The
The LOC Must Conform

tion, Providing All


n For Establishing
re Are Frequent
The Amount Of
or 12 Months.
MAT Leasing, Inc. E&O Audi
Worker's Compensation
Premium Comparison

2011-2012 2011-2012 2012-2013 2013-2014


I. Deductible Premium
A. Deductible $150,000/$250,000 $150,000/$250,000$150,000/$250,000$150,000/$250,000
B. Per Occurrence or Per Claim Occurrence Occurrence Occurrence Occurrence
C. Rating
Estimated Payroll (Auditable) $8,815,449 $8,815,449 $8,815,449 $8,815,449
Estimated Rate 2.87 2.645 $0.0000 $0.0000
Deposite Premium $253,003 $233,169 $0 $0
D. Terrorism $4,408 $4,408 $0 $0
E. Taxes, BBT's, RML's, Assessments $2,835 $2,635 $0 $0
F. Deductible Premium $260,246 $240,211 $0 $0

II. Minimum Premium 100% 100% 100% 100%

III. Letter of Credit

IV.

V.

VI.

VII. Claim Administration


A. Cost Per Claim-Admin.
Medical $0 $0 $0 $0
Indemnity $0 $0 $0 $0
Managed Medical $0 $0 $0 $0
Record Only $0 $0 $0 $0
WC Indemnity - Employers Liability $0 $0 $0 $0
WC Indemnity - High Exposure $0 $0 $0 $0
B. Loss Conversion Factor (LCF)(% of Incurred Claims) 10% 10% 10% 10%
E&O Audit
Policy Application

Audited
2010-2011
Payroll
$1,019,000
$239,643
$7,327,657
$168,344
$0

$8,754,644
MAT Leasing, Inc.
Worker's Compensation 2011-2012 Financial Projection
2012-2013
2013-20142014-20152015-2016
I. Program
A. Deductible $200,000 $200,000 $200,000 $200,000
B. Per Occurrence or Per Claim Occurrence Occurrence Occurrence Occurrence

II. Deductible Premium (Specific Excess) $260,246 $242,684 $242,684 $242,684

III. "Basket Maximum" Premium (Aggregate Excess) Included Included Included Included

IV. Expected Claim Management Costs $15,968 $14,945 #REF!

V. Total Estimated Insurance & Claim Management $276,215 $257,629 #REF! $242,684

VI. Loss Level Projections


A. Estimated Premium $260,246 $257,629 #REF! $242,684
B. RCowell Projected Loss Pick At Policy Inception Minimum $119,761 $119,761 $119,761 $119,761
C. Claim Management 10% $11,976 $11,976 #REF! $0
D. Total Estimated /Projected Costs $391,984 $389,366 #REF! $362,445

A. Estimated Premium & Claim Management $260,246 $242,684 $242,684 $242,684


B. RCowell Projected Loss Pick At Policy Inception Expected $159,682 $149,446 $149,446 $149,446
C. Claim Management 10% $15,968 $14,945 #REF! $0
D. Total Estimated /Projected Costs $435,897 $407,075 #REF! $392,130

A. Estimated Premium & Claim Management $260,246 $242,684 $242,684 $242,684


B. RCowell Projected Maximum Expected Losses Maximum $175,650 $163,446 $163,446 $163,446
C. Claim Management 10% $17,565 $16,345 #REF! ###
D. Total Estimated /Projected Costs $453,461 $422,475 #REF! ###
MAT Leasing, Inc.
Worker's Compensation 2011-2012 Financial Projection
Option I. Option II.
VII. Deductible Premium (Specific Excess)
A. Rating
1) Estimated Payroll (Auditable) $8,815,449
2) Composite Rate $2.870
3) Minimum & Deposite Premium $253,003
4) Terrorism $4,408
5) Taxes, BBT's, RML's, Assessments $2,835
B. Total Specific Premium $260,246

VIII. Minimum Earned Premium 100% $260,246

IX. "Basket Maximum" Calculation


A. Stop Loss Attachment Point $1,800,000
B. Estimated Payroll (Auditable) $8,815,449
C. Rate $0.000

X. Aggregate Excess"Attachment Point"


A. Estimated Payroll (Auditable) $8,815,449
B. Rate $1.8887
C. Aggregate Attachment Point $1,664,958

XI. Claim Costs Cost Estimated Projected


Type of Claim Per Claim # Claims Claim Costs
Medical 10% 15 $2 4
Indemnity 10% 14 $1 15
Record Only 10% 1 $0 2
Total Estimated Claims Cost $3

XII. Collateral Year 1 Year 2


Letter of Credit $560,000 $713,000
Escrow $40,000 $70,000
Projection
2016-2017
$200,000
Occurrence

$242,684 $3,300 Terrorism

Included

$242,684

$242,684
$119,761
$0
$362,445

$242,684
$149,446
$0
$392,130

$242,684
$163,446
###
###
Projection
Option II.

$8,815,449
$2.65
$233,169
$4,408
$2,635
$240,211

$240,211

$1,800,000
$8,815,449
$0.000

$8,815,449
$1.8887
$1,664,958

Projected
Claim Costs
$0
$2
$0
$2

Total
$1,273,000
$110,000
MAT Leasing, Inc. 1 of 4

Hartford Program Terms


Large Deductible Program
Worker's Compensation
I. Premium
A. The premium is based on an estimated annual payroll and is subject to audit at policy expiration.
B. The deductible premium is calculated by multiplying the DISCOUNTED Classification Rate x Final Audited Payroll.
C. The deductible premium is payable with a down payme 25% and # of installmen 8
D. The policy is subject to a Minimum & Deposit Premium.

II. Auditable Policy


A. Increases in payroll will increase the Deductible Premium.
B. Increases in payroll will increase the "Basket Maximum" (Aggregate Loss Fund Amount).

III. Paid Loss Program


A. The policy does not convert from paid losses to total incurred losses at anytime in the future, unless so requested by the Insu
and agreed upon by the insurance company. All claims remain open until fully closed. Claim payments only apply to current
medical bills and final disability/settlement payments (not reserved claims).
IV. Loss Payments
A. Policyholder is responsible for all loss payments up to the Deductible Amount and up to the "Basket Maximum" Final Audited

V. Letter of Credit Requirement


A. A pre-determined amount of collateral is calculated based on projected losses ( Loss Pick) for the current year. If the program
been in effect for more than one year the LOC will be adjusted for older years based on Paid Losses + Reserved Losses and a
Incurred But Not Reported (IBNR) Factor will be applied against outstanding losses. The LOC must be drawn on an approved
bank and must comply with NY Regulation 133 for letters of credit. See Security Section of This Proposal.

VI. Escrow Fund


A. A pre-determined amount of money will be held by the insurance company to pay on-going claims. The amount is calculated
on a three month average.
MAT Leasing, Inc. 2 of 4

Program Terms
Specific Excess Insurance
Worker's Compensation
VII. Specific Excess

A. Bodily Injury By Accident

Loss arising out of one loss event (accident) that exceeds the Deductible Amount will be paid by Specific Excess Insurance
If there is more than one person involved in One Accident only one deductible applies (except loss by disease).

B. Bodily Injury By Disease

All loss arising from disease to each employee that exceeds the Deductible Amount will be paid by Specific Excess
Insurance. Disease claims are subject to a separate Deductible applying to each person that is injured by disease.

C. Employer's Liability

All claims that fall under Employer's Liability are subject to a Per Claim Deductible.

D. Deductible Amount

The Deductible Amount(s) is the most you must reimburse the insurance company for indemnity and medical benefits,
damages and Allocated Loss Adjustment Expenses combined for bodily injury to one or more employees as the result of
any one accident.

The Deductible Amount(s) shown for Bodily Injury by Disease is the most you must reimburse the insurance company
for indemnity and medical benefits, damages and Allocated Loss Adjustment Expenses combined for disablement of one
employee due to Bodily Injury by Disease.
MAT Leasing, Inc. 3 of 4

Program Terms
"Basket Maximum" (Aggregate Excess Insurance)
VIII. "Basket Maximum" (Aggregate Loss Fund)
Once your reimbursement of Paid Claims that fall under the Deductible equals the "Basket Maximum" amount, you will n
required to resume making further reimbursements of the Deductible Amounts to the insurance company.

A. Is equal to the total cumulative losses that fall under the deductible for all claims that occur during the policy period.

B. The "Basket Maximum" will not be reduced if:


1. This endorsement is issued for a period of less than one year, or
2. The policy or this endorsement is cancelled.

C. How To Calculate The "Basket Maximum"

1. Estimated "Basket Maximum" Calculation At The Beginning of The Policy Term

Rate Estimated Payroll Loss Fund


### x ### Equals ###

2. Final "Basket Maximum"


### x Final Audited Payroll Equals Final "Basket Maximum" (Amount)

IX. "Basket Maximum" Attachment Point

Is equal to the final total "Basket Maximum" and is the point at which the Insurance Company begins to pay claims.
In the calculation shown above the Attachment Point is ###
MAT Leasing, Inc. 4 of 4

Program Terms
Allocated Loss Adjustment Expenses
XI. Allocated Loss Adjustment Expenses (ALAE) (Partial List) Include:

Legal & Related Expenses Loss Includes:


Reasonable Attorney Fees Prejudgment Interests
Investigation Judgment Awards
Special Investigative Unit Fees Declaratory Judgments
Court Costs Nurse Case Management Fees
Costs of Depositions Care Management Fees
Costs For Court Reporter Vocational Rehabilitation
Cost of Recorded Statements
Witness Fees & Expenses
Vendor Interface Charges Medical Care
Bond Premiums Medical Bill Review
Printing Costs Related To Trials & Appeals Hospital Bill Review
Testimony, Opinions, Appraisals, Reports, Surveys, Utilization Review
And Analysis Of Professionals & Experts. Alternative Dispute Resolution Fees
Trial & Hearing Attendance Fees Med Records/Reports
Med Examination
Diagnostic Examinations
Laboratory
Reasonable & Necessary Travel
X-Ray
Subrogation Expenses

Allocated Loss Adjustment Expenses Excludes


I. Claim Management Fee (10% of Claims)
II. Charges for the services provided under contract by third party administrators;
III. The salaries or traveling expenses of claim department employees or overhead expenses.
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Marina Cartage, Inc.
Worker's Compensation Rating
Hartford Insurance Company
2009-2010 2009-2010 2009-2010 2010-2011 2010-2011 2010-2011 2011-2012 2011-2012
State Classification Code Payroll Rate Premium Payroll Rate Premium Payroll Rate
IL. Clerical 8810 $907,741 $0.33 $2,996 $998,200 $0.35 $3,494 $1,050,000 $0.30
IL. Street & Rd. Pavin 5506 $310,538 $15.61 $48,475 $239,643 $16.86 $40,404 $250,000 $16.42
IL. Trucking 7228 $4,407,935 $13.83 $609,617 $6,634,008 $14.92 $989,794 $7,200,000 $14.37
IL. Sewage Disposal 7580 $149,403 $5.45 $8,142 $168,344 $5.88 $9,899 $176,000 $6.53
IL. Security 7720 $0 $0 $0 $0.00 $0 $140,000 $3.00
IL.
$5,775,617 $669,230 $8,040,195 $1,043,590 $8,816,000

Waiver of Subrogation 3% $20,077 0% $0 2.8%

Total Premium $689,307 $1,043,590

Employers Liability $1,000,000 2.80% $18,738 2.80% $29,221 2.80%

Total Unmodified Premium $708,046 $1,072,811

Medical Deductible Credit -1.90% -$13,453 $694,593 $0

Experience Modification 0.76 -0.24 -$166,702 $527,891 0.82 -$193,106 $879,705 0.82 ###
Modified Premium
Managed Care Credit
Credit 30% $158,367 48% $422,258 49%
Debit 0% $0 0% $0 0%
Premium $369,523 $457,446
Large Deductible Credit
arge Deductible Premium
Premium Discount 11.10% $41,017 $328,506 11.30% $51,691 $405,755 11.30% $54,661
Voluntary Compensation $250
Expense Constant $280 $280
Endorsements $946
Terrorism 2.00% ### $1,155 1.00% ### $804 1.00% ###
CAT Terrorism 5.00% ### $2,888 5.00% ### $4,020 5.00% ###
emium Before State Taxes $334,025 $410,859

State Taxes & Surcharges 1.01% $3,374 1.01% $4,150 1.01%

Total Estimated Cost $337,399 $415,009


Marina Express, Inc.
Worker's Compensation Rating

2009-2010 2009-2010 2009-2010 2010-2011 2010-2011 2010-2011 2011-2012 2011-2012


State Classification Code Payroll Rate Premium Payroll Rate Premium Payroll Rate
IL. Clerical 8810 $50,000 $0.33 $165 $20,800 $0.35 $73 $20,800 $0.30
IL. Street & Rd. Pavin 5506 $0 $0.00 $0 $0 $0.00 $0 $0 $0.00
IL. Trucking 7228 $500,000 $13.83 $69,150 $693,649 $14.92 $103,492 $693,649 $14.37
IL. Sewage Disposal 7580 $0 $0.00 $0 $0 $0.00 $0 $0 $0.00
IL. Security 7720 $0 $0.00 $0 $0 $0.00 $0 $0 $0.00
IL.
$550,000 $69,315 $714,449 $103,565 $714,449

Employers Liability $1,000,000 2.80% $1,941 2.80% $2,900 2.80%

Total Premium $71,256 $106,465

Rate Deviation Credit 0.00% $0 0.00% $0 0.00%

Total Unmodified Premium $71,256 $106,465

Experience Modification 0.76 $54,154 0.82 -$19,164 $87,301 0.82 -$18,456

Schedule Credit / Debit


Credit 0% $0 30% $26,190 30%
Debit 12% $6,499 0% $0 0%

Modified Premium $60,653 $61,111

Premium Discount 8.70% $5,277 8.70% $5,317 7.50% $4,414

Expense Constant $280 $280

Terrorism 1.00% $550,000 $55 1.00% $714,449 $71 1.00% $714,449


CAT Terrorism 5.00% $550,000 $275 5.00% $714,449 $357 5.00% $714,449
emium Before State Taxes $55,986 $56,503

State Taxes & Surcharges 1.01% $565 1.01% $571 1.01%

Total Estimated Cost $56,552 $57,074


Marina Cartage, Inc. & Marina Express, Inc.
Worker's Compensation Rating
Total Marina Cartage & Marina Express
2009-2010 2009-2010 2009-2010 2010-2011 2010-2011 2010-2011 2011-2012 2011-2012
State Classification Code Payroll Rate Premium Payroll Rate Premium Payroll Rate
IL. Clerical 8810 $957,741 $0.33 $3,161 $1,019,000 $0.35 $3,567 $1,070,800 $0.30
IL. Street & Rd. Pavin 5506 $310,538 $15.61 $48,475 $239,643 $16.86 $40,404 $250,000 $16.42
IL. Trucking 7228 $4,907,935 $13.83 $678,767 $7,327,657 $14.92 $1,093,286 $7,893,649 $14.37
IL. Sewage Disposal 7580 $149,403 $5.45 $8,142 $168,344 $5.88 $9,899 $176,000 $6.53
IL. Security 7720 $0 $0.00 $0 $0 $0.00 $0 $140,000 $3.00
IL.
$6,325,617 $738,545 $8,754,644 $1,147,155 $9,530,449

Employers Liability $1,000,000 2.80% $20,679 2.80% $32,120 2.00%

Total Premium $779,302 $1,179,276

Rate Deviation Credit 0.00% 0.00% 0.00%

Total Unmodified Premium $779,302 $1,179,276

Experience Modification 0.76 $582,045 0.82 -$212,270 $967,006 0.82

Schedule Credit / Debit


Credit 0% $158,367 30% $448,449 0%
Debit 12% $6,499 0% $0 0%

Modified Premium $430,176 $518,557

Premium Discount 7.90% $333,783 7.60% $411,072 11.20% $59,075

Expense Constant $560 $560

Terrorism 1.00% ### $1,210 1.00% ### $875 1.00% ###


CAT Terrorism 5.00% ### $3,163 5.00% ### $4,377 5.00% ###
emium Before State Taxes $390,011 $467,362

State Taxes & Surcharges 1.01% $3,939 1.01% $4,720 1.01%

Total Estimated Cost $393,951 $472,082


Marina Cartage, Inc. Etal.
Worker's Compensation
Deductible Program Rating
2009-2010 2009-2010 2009-2010 2010-2011 2010-2011 2010-2011 2011-2012 2011-2012
State Classification Code Payroll Rate Premium Payroll Rate Premium Payroll Rate
IL. Clerical 8810 $957,741 $0.33 $3,161 $1,019,000 $0.35 $3,567 $1,070,800 $0.30
IL. Street & Rd. Pavin 5506 $310,538 $15.61 $48,475 $239,643 $16.86 $40,404 $250,000 $16.42
IL. Trucking 7228 $4,907,935 $13.83 $678,767 $7,327,657 $14.92 $1,093,286 $7,893,649 $14.37
IL. Sewage Disposal 7580 $149,403 $5.45 $8,142 $168,344 $5.88 $9,899 $176,000 $6.53
IL. Security 7720 $0 $0.00 $0 $0 $0.00 $0 $140,000 $3.00
IL.
$6,325,617 $738,545 $8,754,644 $1,147,155 $9,530,449

Employers Liability 2.80% $20,679 2.80% $32,120 2.00%

Total Premium $759,225 $1,179,276

Experience Modification 0.76 $577,011 0.82 $967,006 0.82

Deductible Credit 72% $415,448 $161,563 72% $696,244 $270,762 72% $719,200

Schedule Credit / Debit


Credit 20% $32,313 $129,250 20% $54,152 $216,609 20% $55,938
Debit 0% $0 0% $0 0%

Modified Premium $129,250 $216,609

Rate Per $100 $2.04 $2.47


7/23/12 5/1/12 to 5/1/13 Rate Is $1,000 Ded

5/1/11 to 5/1/12 Rate Wa $100,000 Ded

2011-2012 2012-2013 2012-2013 2012-2013 2013-2014 2013-2014 2013-2014


Premium Payroll Rate Premium Payroll Rate Premium
$3,150 $1,050,000 $0.30 $3,150 $900,000 $0.15 $1,350
$41,050 $250,000 $16.42 $41,050 $200,000 $9.10 $18,200
$1,034,640 $7,200,000 $14.37 $1,034,640 $6,800,000 $8.91 $605,880
$11,493 $176,000 $6.53 $11,493 $300,000 $3.27 $9,810
$4,200 $140,000 $3.00 $4,200 $50,000 $2.32 $1,160

$1,094,533 $8,816,000 $1,094,533 $8,250,000 $636,400

$30,647 2.8% $30,647 2.0% $12,728

$1,125,180 $1,125,180 $649,128

$31,505 2.80% $31,505 1.40% $8,910

$1,156,685 $1,156,685 $658,038

$0 $0 $0

$948,481 0.82 ### $948,481 0.64 ### $421,144

10% $42,114
$464,756 49% $464,756 0% $0
$0 0% $0 0% $0
$483,726 $483,726 $379,030
37.531% $142,254
$236,776
$429,065 11.30% $54,661 $429,065 0.00% $0

$280 $280 $280

$882 1.00% ### $882 3.00% ### $2,475


$4,408 5.00% ### $4,408 1.00% ### $825
$434,634 $434,634 $240,356

$4,390 1.01% $4,390 1.01% $2,328

$439,024 $439,024 $242,684


2011-2012 2011-2012 2011-2012 2011-2012 2011-2012 2011-2012 2011-2012
Premium Payroll Rate Premium Payroll Rate Premium
$62 $20,800 $0.30 $62 $20,800 $0.30 $62
$0 $0 $0.00 $0 $0 $0.00 $0
$99,677 $693,649 $14.37 $99,677 $693,649 $14.37 $99,677
$0 $0 $0.00 $0 $0 $0.00 $0
$0 $0 $0.00 $0 $0 $0.00 $0

$99,740 $714,449 $99,740 $714,449 $99,740

$2,793 2.80% $2,793 2.80% $2,793

$102,532 $102,532 $102,532

$0 0.00% $0 0.00% $0

$102,532 $102,532 $102,532

$84,077 0.82 -$18,456 $84,077 0.82 -$18,456 $84,077

$25,223 30% $25,223 30% $25,223


$0 0% $0 0% $0

$58,854 $58,854 $58,854

$54,440 7.50% $4,414 $54,440 7.50% $4,414 $54,440

$280 $280 $280

$71 1.00% $714,449 $71 1.00% $714,449 $71


$357 5.00% $714,449 $357 5.00% $714,449 $357
$55,148 $55,148 $55,148

$557 1.01% $557 1.01% $557

$55,705 $55,705 $55,705


2011-2012 2011-2012 2011-2012 2011-2012 2011-2012 2011-2012 2011-2012
Premium Payroll Rate Premium Payroll Rate Premium
$3,212 $1,070,800 $0.30 $3,212 $920,800 $0.15 $1,381
$41,050 $250,000 $16.42 $41,050 $200,000 $9.10 $18,200
$1,134,317 $7,893,649 $14.37 $1,134,317 $7,493,649 $8.91 $667,684
$11,493 $176,000 $6.53 $11,493 $300,000 $3.27 $9,810
$4,200 $140,000 $3.00 $4,200 $50,000 $2.32 $1,160

$1,194,273 $9,530,449 $1,194,273 $8,964,449 $698,235

$34,298 2.00% $34,298 2.00% $11,702

$1,259,217 $1,259,217 $760,570

0.00% 0.00%

$1,259,217 $1,259,217 $760,570

$1,032,558 0.82 $1,032,558 0.82 $505,221

$489,979 0% $489,979 0% $25,223


$0 0% $0 0% $0

$542,579 $542,579 $437,883

$483,504 11.20% $59,075 $483,504 11.20% $4,414 $54,440

$560 $560 $560

$953 1.00% ### $953 1.00% ### $2,546


$4,765 5.00% ### $4,765 5.00% ### $1,182
$489,782 $489,782 $295,504

$4,947 1.01% $4,947 1.01% $2,885

$494,729 $494,729 $298,389


2011-2012 2011-2012 2011-2012 2011-2012 2011-2012 2011-2012 2011-2012
Premium Payroll Rate Premium Payroll Rate Premium
$3,212 $1,070,800 $0.30 $3,212 $920,800 $0.15 $1,381
$41,050 $250,000 $16.42 $41,050 $200,000 $9.10 $18,200
$1,134,317 $7,893,649 $14.37 $1,134,317 $7,493,649 $8.91 $667,684
$11,493 $176,000 $6.53 $11,493 $300,000 $3.27 $9,810
$4,200 $140,000 $3.00 $4,200 $50,000 $2.32 $1,160

$1,194,273 $9,530,449 $1,194,273 $8,964,449 $698,235

$23,885 2.00% $23,885 2.00% $13,965

$1,218,158 $1,218,158 $712,200

$998,890 0.82 $998,890 0.82 $584,004

$279,689 72% $719,200 $279,689 72% $420,483 $163,521

$223,751 20% $55,938 $223,751 20% $32,704 $130,817


$0 0% $0 0% $0

$223,751 $223,751 $130,817

$2.35 $2.35 $1.46


Marina Express, Inc.
Worker's Compensation
I. Proposed Carrier American Interstate

II. Effective Date 4/5/13

III. Type of Program Large Deductible

IV. Coverages
A. Coverage A Statutory

B. Coverage B Employer's Liability


1) Bodily Injury-Each Accident $1,000,000
2) Bodily Injury Disease - Each Employee $1,000,000
3) Bodily Injury Disease - Policy Limit $1,000,000

C. Foreign Voluntary Worker's Comp & EL


1) Repatriation / Any One Employee N/A
2) Employer's Liability N/A
3) Employees Covered N/A

V. Additional Coverage
A. Voluntary Compensation
All Officers & Employees Including Volunteers Not Subject To The WC Law Except Masters
& Members of The Crew of Any Vessel Are Excluded
Not Covered-Michael Tadin
B. All States Endorsement Excluding CT., HA., N.J., N.Y., N.D., OH., WA., WY. Covered
The Carrier Must Be Notified Within 30 Days Once You Begin Work In Any State.
C. USL&H (US Lonshoreman & Harbor Worker's Act) Not Covered
D. Blanket Waiver of Subrogation-Written Contracts Covered
E. Stop Gap-Ohio, WV, WY, ND, Not Covered
F. Endemic Disease Not Covered

VI. Conditional Endorsements Affecting Premium


A. Tentative Rate
B. Contingent Experience Modification Endorsement
C. State Amendatory Endorsements By State

VII. Premium Calculations


A. Policy Is Auditable Based On The Actual Payroll Generated From The
Policy Effective Date Through The Policy Expiration Date.

B. Audits
1) The Insurance Company Has 3 Years Within Which To Calculate The Audited Payroll
and Final Audited Premium.
2) The Insurance Company MAY Reclassify The Rating If The Auditor Determines That A More Appropriate Cla
Code Should Be Used Based On Job Descriptions.
3) The Insurance Company MAY Endorse The Current Policy To Reflect Correct Classification
4) The Insurance Company MAY Also Endorse The Current Policy To Reflect Actual Audited Payrolls From The
Audit. This Can Apply If Payrolls Are Higher or Lower Than The Previous Year.
Marina Express, Inc.
Worker's Compensation
VIII. Exclusions
A. Liability Assumed Under A Contract.
B. Punitive Damages
C. Bodily Injury To An Employee While Employed In Violation of Law With Your Actual
Knowledge, or The Actual Knowledge Of Any Of Your Executive Officers.
D. Bodily Injury Intentionally Caused By You.
E. Employment Practices.
F. Bodily Injury To A Master or Member Of The Crew Of Any Vessel.
G. Bodily Injury To Any Aircraft Pilot.
H. Fines or Penalties Imposed For Violation of Federal Laws.
I. Damages Payable Under The Migrant & Seasonal Agricultural Worker Protection Act.
J. Economic & Trade Sanctions
K. Foreign Voluntary Worker's Comp & EL
L. Repatriation / Any One Employee
ropriate Classification

s From The Prior Year


Marina Express, Inc.
Worker's Compensation Rating

2011-2012 2011-20122011-2012 2012-13 2012-13 2012-13 2013-14 2013-14 2013-14


State Classification Code Payroll Rate Premium Payroll Rate Premium Payroll Rate Premium
IL. Clerical 8810 $20,800 $0.30 $62 $20,800 $0.35 $73 $20,800 $0.30 $62
IL. Street & Rd. Paving 5506 $0 $0.00 $0 $0 $0.00 $0 $0 $0.00 $0
IL. Trucking 7228 ### $14.37 $99,677 ### $14.92 $103,492 $77,713 $13.38 $10,398
IL. Trucking 7229 $0 $0.00 $0 $0 $0.00 $0 $416,814 $15.66 $65,273
IL. Security 7720 $0 $0.00 $0 $0 $0.00 $0 $0 $0.00 $0
IL.
### $99,740 ### $103,565 $515,327 $75,733

Employers Liability $1,000,000 2.80% $2,793 2.80% $2,900 1.40% $1,060

Total Premium $102,532 $106,465 $76,794

Waiver of Subrogation 0.00% $0 0.00% $0 2.00% $1,515

Total Unmodified Premium $102,532 $106,465 $78,308

Experience Modification 0.82 -$18,456 $84,077 0.82 -$19,164 $87,301 0.64 -$28,191 $50,117

Schedule Credit / Debit


Credit 30% $25,223 30% $26,190 0% $0
Debit 0% $0 0% $0 15% $7,518

Modified Premium $58,854 $61,111 $57,635

Premium Discount 7.50% $4,414 $54,440 8.70% $5,317 8.70% $5,014 $52,621

Expense Constant $280 $280 $280

Terrorism 1.00% $714,449 $71 1.00% $714,449 $71 1.55% $515,327 $80
CAT Terrorism 5.00% $714,449 $357 5.00% $714,449 $357 4.65% $515,327 $240
Premium Before State Taxes $55,148 $56,503 $53,220

State Taxes & Surcharges 1.01% $557 1.01% $571 1.01% $538

Total Estimated Cost $55,705 $57,074 $53,758


Marina Express, Inc.
Worker's Compensation Rating

2009-20102009-2010 2009-2010 2010-20112010-2011 2010-2011 2011-2012 2011-2012 2011-2012


State Classification Code Payroll Rate Premium Payroll Rate Premium Payroll Rate Premium
IL. Clerical 8810 $50,000 $0.33 $165 $20,800 $0.35 $73 $20,800 $0.30 $62
IL. Street & Rd. Paving 5506 $0 $0.00 $0 $0 $0.00 $0 $0 $0.00 $0
IL. Trucking 7228 ### $13.83 $69,150 ### $14.92 $103,492 $693,649 $14.37 $99,677
IL. Sewage Disposal 7580 $0 $0.00 $0 $0 $0.00 $0 $0 $0.00 $0
IL. Security 7720 $0 $0.00 $0 $0 $0.00 $0 $0 $0.00 $0
IL.
### $69,315 ### $103,565 $714,449 $99,740

Employers Liability $1,000,000 2.80% $1,941 2.80% $2,900 2.80% $2,793

Total Premium $71,256 $106,465 $102,532

Rate Deviation Credit 0.00% $0 0.00% $0 0.00% $0

Total Unmodified Premium $71,256 $106,465 $102,532

Experience Modification 0.76 $54,154 0.82 -$19,164 $87,301 0.82 -$18,456 $84,077

Schedule Credit / Debit


Credit 0% $0 30% $26,190 30% $25,223
Debit 12% $6,499 0% $0 0% $0

Modified Premium $60,653 $61,111 $58,854

Premium Discount 8.70% $5,277 8.70% $5,317 7.50% $4,414 $54,440

Expense Constant $280 $280 $280

Terrorism 1.00% $550,000 $55 1.00% $714,449 $71 1.00% $714,449 $71
CAT Terrorism 5.00% $550,000 $275 5.00% $714,449 $357 5.00% $714,449 $357
Premium Before State Taxes $55,986 $56,503 $55,148

State Taxes & Surcharges 1.01% $565 1.01% $571 1.01% $557

Total Estimated Cost $56,552 $57,074 $55,705


Marina Cartage, Inc.
Worker's Compensation Rating
Guaranteed Cost Program
2011-2012 2011-2012 2011-2012 2012-13 2012-13
State Classific Code Payroll Rate Premium Payroll Rate
IL. Clerical 8810 $750,000 $0.30 $2,250 $998,200 $0.35
IL. Executive 5506 $76,000 $16.42 $12,479 $239,643 $16.86
IL. Trucking 7228 $3,500,000 $14.37 $502,950 $6,634,008 $14.92
IL. Sewage Di 7580 $100,000 $6.53 $6,530 $168,344 $5.88
IL. Security 7720 $0 $3.34 $0 $0 $0.00
IL.
$4,426,000 $524,209 $8,040,195

ver of Subrogation 0% $0 0%

Total Premium $524,209

mployers Liability ### 2.80% $14,678 2.80%

nmodified Premium $538,887

l Deductible Credit $0

ience Modification 0.82 -$97,000 $441,887 0.82 ###


Modified Premium
dule Credit / Debit
Credit 49% $216,525 48%
Debit 0% $0 0%

Premium $225,363

Premium Discount 8.90% $20,057 $205,305 11.30% $51,691


ntary Compensation
Expense Constant $280
Endorsements
Terrorism 1.00% ### $443 1.00% ###
CAT Terrorism 5.00% ### $2,213 5.00% ###
Before State Taxes $208,241

Taxes & Surcharges 1.01% $2,103 1.01%

otal Estimated Cost $210,344


ge, Inc.
tion Rating
Program
2012-13 2013-14 2013-14 2013-14
Premium Payroll Rate Premium
$3,494 $1,050,000 $0.30 $3,150
$40,404 $250,000 $16.64 $41,600
$989,794 $7,200,000 $14.37 ###
$9,899 $176,000 $6.53 $11,493
$0 $140,000 $3.34 $4,676

$1,043,590 $8,816,000 ###

$0 0% $0

$1,043,590 ###

$29,221 2.80% $30,676

$1,072,811 ###

$0 $0

$879,705 0.80 ### ###

$422,258 40% ###


$0 0% $0

$457,446 ###

$405,755 11.30% $61,087 ###

$280 $280

$804 1.00% ### $882


$4,020 5.00% ### $4,408
$410,859 ###

$4,150 1.01% $4,899

$415,009 ###
Marina Cartage, Inc. Etal
Worker's Compensation Rating
Audited Option I.
2010-2011 2010-2011 2010-2011 2010-2011 2010-2011 2010-2011 2011-2012 2011-2012 2011-2012
State Classification Code Payroll Rate Premium Payroll Rate Premium Payroll Rate Premium
IL. Clerical 8810 $1,019,000 $0.35 $3,567 $1,070,800 $0.35 $3,748 $1,070,800 $0.24 $2,570
IL. Street & Rd. Pavi 5506 $239,643 $16.86 $40,404 $250,000 $16.86 $42,150 $250,000 $13.56 $33,900
IL. Trucking 7228 $7,327,657 $14.92 $1,093,286 $7,893,649 $14.92 $1,177,732 $7,893,649 $11.72 $925,136
IL. Sewage Disposal 7580 $168,344 $5.88 $9,899 $176,000 $5.88 $10,349 $176,000 $5.32 $9,363
IL. Security 7720 $0 $0.00 $0 $140,000 $0.00 $0 $140,000 $2.72 $3,808
IL.
$8,754,644 $1,147,155 $9,530,449 $1,233,979 $9,530,449 $974,777

Waiver of Subrogation 0% $0 0% $0 2% $19,496

Total Premium $1,147,155 $1,233,979 $994,272

Employers Liability ### 2.80% $32,120 2.80% $34,551 2.80% $27,294

al Unmodified Premium $1,179,276 $1,268,530 $1,021,566

Deductible Credit 0.00% $0 $0 50.36% $514,461

xperience Modification 0.82 -$212,270 $967,006 0.82 ### $1,040,195 0.82 ### $323,224

Schedule Credit / Debit


Managed Care Credit 48% $464,163 48% $499,294 10% $32,322
Debit 0% $0 0% $0 0% $0

Premium $502,843 $540,901 $290,901

Premium Discount 8.10% $40,730 $462,113 8.10% $43,813 $497,088 0.00% $0 $290,901

Expense Constant $280 $280 $280

Terrorism 1.00% ### $875 1.00% ### $953 1.00% ### $953
CAT Terrorism 5.00% ### $4,377 5.00% ### $4,765 4.00% ### $3,812
um Before State Taxes $467,646 $503,087 $295,946

ate Taxes & Surcharges 1.01% $4,723 1.01% $5,081 1.01% $2,989

Total Estimated Cost $472,369 $508,168 $298,935


AVERAGE RATE $5.396 $5.332 $3.137
Marina Cartage, Inc. Etal
Worker's Compensation Rating
Audited Option II.
2010-2011 2010-2011 2010-2011 2010-2011 2010-2011 2010-2011 2011-2012 2011-2012 2011-2012
State Classification Code Payroll Rate Premium Payroll Rate Premium Payroll Rate Premium
IL. Clerical 8810 $1,019,000 $0.35 $3,567 $1,070,800 $0.35 $3,748 $1,070,800 $0.24 $2,570
IL. Street & Rd. Pavi 5506 $239,643 $16.86 $40,404 $250,000 $16.86 $42,150 $250,000 $13.56 $33,900
IL. Trucking 7228 $7,327,657 $14.92 $1,093,286 $7,893,649 $14.92 $1,177,732 $7,893,649 $11.72 $925,136
IL. Sewage Disposal 7580 $168,344 $5.88 $9,899 $176,000 $5.88 $10,349 $176,000 $5.32 $9,363
IL. Security 7720 $0 $0.00 $0 $140,000 $0.00 $0 $140,000 $2.72 $3,808
IL.
$8,754,644 $1,147,155 $9,530,449 $1,233,979 $9,530,449 $974,777

Waiver of Subrogation 0% $0 0% $0 2% $19,496

Total Premium $1,147,155 $1,233,979 $994,272

Employers Liability ### 2.80% $32,120 2.80% $34,551 2.80% $27,294

al Unmodified Premium $1,179,276 $1,268,530 $1,021,566

Deductible Credit $0 $0 53.50% $546,538

xperience Modification 0.76 0.82 -$212,270 $967,006 0.82 ### $1,040,195 0.82 ### $291,146

Schedule Credit / Debit


Managed Care Credit 47% $457,394 48% $499,294 10% $29,115
Debit 0% $0 0% $0 0% $0

Premium $509,612 $540,901 $262,032

Premium Discount 8.10% $41,279 $468,334 8.10% $43,813 $497,088 0.00% $0 $262,032
oluntary Compensation
Expense Constant $280 $280 $280
Endorsements
Terrorism 1.00% ### $875 1.00% ### $953 1.00% ### $953
CAT Terrorism 5.00% ### $4,377 5.00% ### $4,765 4.00% ### $3,812
um Before State Taxes $473,866 $503,087 $267,077

ate Taxes & Surcharges 1.01% $4,786 1.01% $5,081 1.01% $2,697

Total Estimated Cost $478,652 $508,168 $269,774


AVERAGE RATE $5.467 $5.332 $2.831
420373
57745 472082
478118
2011-20122011-2012
Payroll Rate
0.00% -31.43%
0.00% -19.57%
0.00% -21.45%
0.00% -9.52%
0.00% 0.00%

297827 290869

305880 298852
### 3.211
-41%
2011-20122011-2012
Payroll Rate
0.00% -31.43% $20,800 1019000
0.00% -19.57% $0
0.00% -21.45% $693,649 7327657
0.00% -9.52%
0.00% 0.00%

262087

269780
###
Disclosure Statements

I. Notice of Source of Income


The proposal being presented to you contains one or more sources of income to RBN & Associates.
Following are the possible sources:

A. Commission
premium quoted to you.
payments.

B. Contingent Commission
directly into the
typically based on
calendar year activity.
These payments are normally deferred until several months after the calendar year.

C. Service Fee
Service fees are paid directly by you to us. A separate disclosure statement will always be presented to
when a service fee is being charged.

We are happy to answer any questions regarding how we are paid or how any of these sources of
income are derived.

II. Notice of Non Admitted & Surplus Lines Carriers


The proposal being presented to you contains one or more coverage which are being underwritten by an
insurer who is either Non-Admitted in your state or a Surplus Lines carrier.

In the United States, states have the authority to regulate insurance companies and have controlled ins
mainly through their licensing powers. The license is a document that indicates an insurer has met the m
requirements established by state statute and is authorized to engage in the lines of business for which
applied. A surplus lines insurer is a company that underwrites risks for which insurance coverage gener
available through a company licensed in the insured's state (an admitted insurer). This business, therefo
placed with a non-admitted insurer. A non-admitted insurer is not licensed in the state, but allowed to o
accordance with excess or surplus lines provisions of state insurance laws.

protection afforded
a policyholder by the state's Insurance Guaranty Fund laws and regulations regarding non-renewals & p
increases that generally apply only to licensed insurers. The Guaranty Fund also provides additional fin
protections in the event the carrier becomes bankrupt.

While being a non-admitted carrier does not reflect any negative financial data, we are required to mak
you aware of this situation before coverage is purchased. In many instances, these insurers are highly
are listed below:
o RBN & Associates.

ill always be presented to you

of these sources of

being underwritten by an

s and have controlled insurance


s an insurer has met the minimum
nes of business for which it has
insurance coverage generally is not
er). This business, therefore, is
he state, but allowed to operate in

garding non-renewals & premium


so provides additional financial

a, we are required to make


hese insurers are highly
MAT Leasing, Inc.
Premium Payment Plan (Automobile & Worker's Compensation)
Miscellaneous MONTHLY BILL Total Escrow
Installment Deposit Surcharges Expenses Loss Payments Installment Fund Security
8/1/11 $116,148 $1,935 $0 $0 $118,083 $35,000 $650,000

9/1/11 $43,555 $726 $0 $0 $44,281 $0 $0

10/1/11 $43,555 $726 $0 $0 $44,281 $0 $0

11/1/11 $43,555 $726 $0 $0 $44,281 $0 $0

12/1/11 $43,555 $726 $0 $0 $44,281 $0 $0

1/1/12 $43,555 $726 $0 $0 $44,281 $0 $0

2/1/12 $43,555 $726 $0 $0 $44,281 $0 $0

3/1/12 $43,555 $726 $0 $0 $44,281 $0 $0

4/1/12 $43,555 $726 $0 $0 $44,281 $0 $0

Total $464,588 $7,743 $0 $0 $472,331 $35,000 $650,000

Miscellaneous Expenses & Monthly Charges Include


Claim Management Fees
Loss Control Fees
Non-Standard Loss Reports
WC Loss Based Assessments (Applicable In AL., CA., DC., GA., KS., LA., MI., PA., & S.C.)

Payment Due Time Table All Payments Are Made Directly To Hartford Insurance
Deposit Due Upon Receipt of Invoice
Via Mail Hartford Financial Services
Escrow Fund Due Upon Receipt of Invoice P.O. Box 415738
Boston, MA. 02241-5738
Loss Payments Within 10 Days of Due Date
Via Wire TransfeBank of America
Installments Within 10 Days of Due Date ABA#: 026009593
Account #: 9417518033
Security Due Within 30 Days of Effective Date Account Name: Hartford Fire Insurance

ACH Upon Request Forms Can Be Completed To Utilize A


As A Method Of Payment
General Liability Due Within 20 Days
Umbrella Due Within 20 Days
To Utilize ACH