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ACCEPTANCE OF PROPOSAL AND AUTHORIZATION TO BIND COVERAGE Please note that the retail broker does not have binding authority. Please request that American Specialty bind coverage as proposed by signing below and return this form to American Specialty Insurance & Risk Services, Inc. Coverage can only be bound in accordance with the specific terms and conditions outlined in the proposal and its appendices, including all Disclaimers. No revisions to these documents are permitted. Requested revisions must be submitted to American Specialty under separate cover for consideration. ANY REVISIONS MADE TO THESE DOCUMENTS WILL RENDER THE ACCEPTANCE SIGNATURE OF AMERICAN SPECIALTY, REPRESENTED BELOW, AS NULL AND VOID. COVERAGE IS EFFECTIVE THE DATE INDICATED OR THE DATE THIS FORM IS SIGNED, WHICHEVER IS LATER. Please eview this wowasal foraccuracy before binding. I acknowledge that I have no binding authority and that I have read and understand all the terms and conditions of this proposal for City of Santa Ana and by my signature below accept all such terms, provisions, and conditions as documented therein and represent that I have the authority to accept all terms and conditions of this proposal on behalf of City of Santa Ana. I acknowledge that I have read the Special State Required Notice included in this proposal and understand that any person who knowingly and with intent to defraud any insurance company commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I hereby confirm that I have read and understand the above notice. ** Note: 1m orfant Information re ardin TRIA Terrorism Covers e Terrorism coverage is an optional coverage. To bind this proposal of coverage, the Insured must sign and return the appropriate pages of this proposal and indicate their acceptance or rejection of terrorism coverage. If the Insured rejects coverage for certified acts of terrorism, please be aware that other acts of terrorism will also be excluded where allowed by state law. "All certificates of insurance will be administered by American Specialty Insurance & Risk Services, Inc. and no authority is granted to the retail broker or any other entity to issue any certificate of insurance. If the retail broker issues a certificate of insurance or evidence of insurance it must be according to the terms of this proposal and the insurance policy. Any request to change, endorse or modify the terms of this proposal or the Insurance policy must be submitted in writing to the insurance company for its advanced written approval and shall not be effective if communicated by means of a certificate of insurance or evidence of insurance. American Specialty Insurance & Risk Services, Inc. disclaims and undertakes no responsibility for incorrectly issued or inaccurate certificates or evidence of insurance. American Specialty will provide copies of certificates or evidence of Insurance issued by the retall broker to the respective Insurance companies only if required by such insurance company. Be advised that the insurance company(fes) may or may not review and/or approve a certificate or evidence of insurance. If retail broker provides copies of certificates or evidence of insurance to American Specialty, American Specialty will not review, analyze or otherwise comment on the accuracy, completeness or propriety of any certificate or evidence. Submission of a certificate or evidence of insurance to our office and/or the insurance company's office does not constitute approval of the certificate or evidence. ©American Specialty Insurance & Risk Services, Inc. dba A.S.I.R.S.I. Insurance Agency; American Specialty Insurance & Risk Services Agency; and, A S Insurance & Risk Services Agency (9/11/2019)