HomeMy WebLinkAboutCAG2023-665 - Supplement - Alliant Insurance Services, Inc.- Request to Bind Coverage - 01/01/2024 FOR CITY OF KENT OFFICIAL USE ONLY
Sup/Mgr:
Agreement Routing Form DirAsst:
• For Approvals,Signatures and Records Management Dir/Dep:
KENT This form combines&replaces the Request for Mayor's Signature and Contract Cover (optional)
WASHINGTON Sheet forms. (Print on pink or cherry colored paper)
Originator: Department:
Ellaine Wi, Ext. 5285 Human Resources
Date Sent: Date Required:
c 12/26/2023 12/29/2023
Q Mayor or Designee to Sign. Date of Council Approval:
Q Interlocal Agreement Uploaded to Website N/A
Budclet Account Number: Grant? Yes No�✓
56701450 11751 164630
Budget?❑✓ Yes E]No Type: N/A
Vendor Name: Category:
Alliant Contract
Vendor Number: Sub-Category:
Original
0
Project Name: "Request to Bind Coverage"
cProject Details: January 1 Renewal Insurance Proposal
c
c
Basis for Selection of Contractor:
� Agreement �2 150 368 Other
GJ
*Memo to Mayor must be attached
Start Date: fl/1/2024 Termination Date: 1/1/2025
a Local Business? Yes ✓�No*If meets requirements per KCC 3.70.100,please complete"Vendor Purchase-Local Exceptions"form on Cityspace.
Business License Verification: ❑Yes In-Process F1 Exempt(KCC 5.01.045) Authorized Signer Verified
Notice required prior to disclosure?
Contract Number:
"d
YeszNo A2023-665 Comments:
1A This information will be presented to the Council of the Whole on 1/16/2024.
7
C C
a,
a
Date Received:City Attorney: 12/27/23 Date Routed:Mayor's Officl 12/27/23 ty Clerk's Office 12/28/23
adccW22373_7_20 Visit Documents.KentWA.gov to obtain copies of all agreements
rev.20221201
DocuSign Envelope ID: FBFCADFO-B686-4732-9515-9993OCC3AO5F
Request to Bind Coverage
City of Kent
We have reviewed the proposal and agree to the terms and conditions of the coverages presented. We are requesting coverage to be bound as outlined
by coverage line below:
Coverage Line Bind Coverage for
Liability Program - $25,000,000 ❑
Did you know that Alliant works with premium financing companies?Are you interested in financing your annual premium?
Yes, please provide us with a financing . . . not wish to finance our premium.
❑ ❑
This Authorization to Bind Coverage also acknowledges receipt and review of all disclaimers and disclosures, including exposures used to develop
DocuSigned by: insurance terms, contained within this proposal.
0a" b K L 12/28/2023
93E99D67ED24442...
Signature of Authorized Insured Representative Date
Mayor
Title
Dana L Ralph
Printed /Typed Name
This proposal does not constitute a binder of insurance. Binding is subject to the final carrier approval.The actual terms and conditions of the
policy will prevail.
Alliant Insurance Services, Inc. I www.alliant.com I CA License No.OC36861 Page 19