November 29, 2018 Andrew J. Casais, RMC, QPA Borough Clerk Qualified Purchasing Agent Borough of Roselle Park 1 10 East Westfield Avenue Delivery by hand Roselle Park, NJ 07204 Re: Response to Request For Proposal 2019 Borough Risk Manager Insurance Broker RFP Opening Date: November 30, 2018 Dear Mr. Casais: On behalf of BGIA, inc. and our President, Steve Edwards, I am pleased to enclose proposal, in the requested paper and digital format, to provide property and casualty insurance services to the Borough of Roselle Park, as the Borough Risk Manager and Insurance Broker. The proposal includes the requested information regarding experience, capabilities and process of working with our clients to address their risk management needs. Our office has managed the insurance needs of more than 100 public entities over the past 25 years. As the leading brokerage firm for Union County public entities, our Property/Casualty and Healthcare divisions have saved our clients more than 1.5 billion dollars. We have formed two of the largest Joint insurance Funds in the state, in response to market conditions that have threatened the budget stability of municipalities. While our proposal is specifically addressing Property and Casualty RFP for Property/ Casualty insurance, BGIA is well-equipped to offer a proposal to help with the Borough?s Health Insurance and Benefits as well. We are very pleased that our marketing and negotiating efforts last year have helped save the Borough more than $326,000 for years 2018 and 2019. efforts have also ensured a smooth membership transition to the Garden State Municipal over the past year. We look forward to reducing your municipality?s expenses further by continuing our focus on our risk management contractual obligations to Roselle Park per the GSMJIF risk management contract. We value the Borough as a client and look toward to a continued opportunity of providing top-quality risk management insurance consultant services for the Borough. If you require additional information, have any questions or require further clarification, please feel free to contact our office. We are happy to discuss or meet with your office as needed. We hope to have the opportunity of continuing to serve the needs of the Borough of Roselle Park. Thank you. Sincerely yours, Brian Erlandsen, CIC Vice President Public Entity Practice c.c. Steve Edwards, President BGIA Plaza Nine 900 Route 9 North 503 NJ 07095?1003 800.272 6771 fax 732.634.5379 . "2B?ne?ts ?95 erage Services New Jersey?s leading provider of insurance and employee bene?ts for the Public Entity sector Prepared exclusively for: Borough of Roselle Park Opening Date: November 30, 2018 Table of Contents Executive Summary Business Governmental Insurance Agency: New Jersey?s Public Entity Insurance and Employee Benefits Leader The BGIA Mission Statement The BGIA Customized Approach Information for RFP Response The BGIA Approach: Who We Are The BGIA Leadership Team Organizational Chart The BGIA Approach: Property Casualty The BGIA Approach: Doing Business With Us Client Engagement Listing References Appendices Forms Page 3 Page 5 Page 6 Page 7 Page 8 Page 10 Page 19 Page 24 Page 28 Page 31 Page 34 BGIA Business Governmental Insurance Agency Executive Summary This proposal has been prepared in response to the ?Request for Proposals (RFP) for the position of ?Risk Manager Insurance Broker, January 1, 2019 December 31, 2019? for the Borough of Roselle Park. Business Governmental Insurance Agency, Inc. (hereafter BGIA) is uniquely positioned in terms of qualifications, experience and resources to provide the scope of all the services as defined in the RFP. BGIA has been privileged to serve as the Borough?s Risk Manager/Broker since January 1, 2015. During this period, BGIA successfully negotiated a reduction last year of the originally proposed 2017 JIF rate increase. Taking advantage of the Borough?s eligibility to change JIF membership for 2018, marketed your insurance program to alternative JlFs, in addition to the incumbent JIF. As a result, BGIA delivered a major cost savings for the Borough for the 2018 and 2019 insurance program an approximately $326,000 cost reduction for the these years, along with improved (lower) deductible levels. BGIA Business 8. Governmental Insurance Agency Executive Summary (cont?d) In addition to the above successful experience, other areas which this proposal will focus on in support of our qualifications, experience and abilities are: A strong understanding of local government operations and finances as supported by our status as one of the leading providers of Insurance Risk Management Services to the public entities in New Jersey (over 60 public entity clients). Our General Approach for delivering the scope of Services as defined in the RFP. Our extensive experience in Managing Property/Casualty Insurance Programs for NJ Municipalities. The BGIA leadership team of professionals listed on our staffing plan has received recognition for its experience in the areas of government, finance, risk management and insurance law. Our capabilities in developing, implementing and delivering presentations to elected bodies throughout New Jersey, BGIA Business Governmental Insurance Agency Busrness Governmental Insurance Agency BGIA Is New Jersey?s Leading Provider of Property and Casualty Insurance, Employee Benefit Plans and Risk Management Services for Public Entities. BGIA responds to 0 Formed in 1993, BGIA assembled a team of . the specral needs of well-renowned professionals who gained wide acceptance in_the public sector marketplace due its clients with to their extensive experience In the areas of customized government, finance, risk management and . insurance law. Insurance programs, special group 0 BGIA operates as an extension of your purchasing plans organization, providing clients with technical and and expert loss administrative services in the assessment of risk 1? I and design of safety and other loss control can ro Ian sa 9 strategies. strategies. 0 We provide a team of tough negotiators with industry clout, who work year round to minimize your risks and improve your coverage with genuine bottom line savings. - BGIA delivers direct and personalized service to each client. Through effective communications, BGIA provides precise evaluation, design and implementation of programs that are optimal for your Public Entity. 0 We work diligently to build trust, with integrity the \7 cornerstone of our business philosophy and long-term relationships with our clients our goal. BGIA Business 8: Governmental insurance Agency {iks [v ?w BGIA Business Governmental Insurance Agency i if Property BI Casualty EBrokerage llilli: Employee Benefits Brokerage Services Mission Statement We will provide superior quality property and casualty insurance, employee benefit plans and risk management services to serve the specialized needs of the Public Entity sector. We will exceed customer expectations through our never?ending pursuit of product and service innovations that deliver meaningful solutions to the challenges facing our clients. We will create an organization that attracts the most qualified people, challenge and develop their individual talents and encourage their collaboration in order to drive our business forward. We will manage our human, financial and organizational resources to insure a secure business structure with profitable growth. We will maintain the principles of integrity, honesty, competence and quality in all aspects of our client and business relationships. BGIA Business Governmental Insurance Agency 5'1 The BGIA Customized Approach A three-phase approach to develop a comprehensive insurance and risk management program tailored for your Public Entity. 0 We diligently ascertain your exposures, and tolerance for risk in order to determine the scope and type of coverage suitable for your unique situation. 0 We learn your risk philosophy, as it is of paramount importance in the development of the optimal risk management strategy. and risk financing alternatives. We focus on: exposure identification, coverage review, loss control safety services Phase 1: Evaluation and Analysis of Exposure Phase 2: Program Development and implementation Phase 3: Proactive Customer Services -ln-depth review of your activities and operations 0Analysis and qualification of current exposures -Assessment of all possible op?ons - A detailed critique of strategy to review all viable alternatives - Effective marketing of your risks to the marketplace to solicit the widest variety of proposals - Thorough analysis of all options and proposals for accurate presentation to the client 'Feedback, selection, implementation and monitoring of best options 0 Rapid response to service needs - Coverage interpretation - Certificates of Insurance provided 0 Claims reporting and follow-up - Contract and policy review 0 Hold harmless agreements and other party indemnification 0 Analysis of effectiveness of coverage of others - Proactive monitoring of insurance mergers, acquisitions, and other special project needs - Collection of claims tracing data and analysis - Statistical studies, premium allocation, subrogation review and monitoring BGIA Business 8! Governmental Insurance Agency a. Information for RFP Response ?Submission Form/ Qualification Statement? (pages 8 through 11 of 26 of the HFP document) submission for the above is included in the Addendum section, using the Borough?s requested format. This section addresses] provides replies for the following questions: 1. Name and roles of the individuals who will perform the services and description of their education with projects similar to the services contained herein: 2. References and record of success of same or similar service: 3. Description of ability to provide the services in a timely fashion (including staffing, familiarity and location of key staff): 4. Cost Details, including the annual fee for primary duties and the hourly rates of the individuals who will perform services and all expenses for any work that is not included in the primary duties: BGIA Business 8: Governmental Insurance Agency a .1 Information for RFP Response Additional Information: - BGIA Principal Contact Steven Edwards President - BGIA Lead Service Contact Brian Erlandsen, CIC Vice President, Public Entity Practice - Professional Practices Neither BGIA nor any individuals assigned to this engagement are disbarred, suspended, or otherwise prohibited from professional practice by any federal, state or local agency. - Contingent Commissions BGIA does not have any agreements in place with commercial insurance carriers that result in the award of contingent commissions. 0 RFP Service Period January 1, 2019 through December 31, 2019. Required Documents All ?required documents? as outlined in the RFP are included in the Appendix section of this proposal. BGIA Business 8: Governmental insurance Agency The BGIA Approach: WHO WE ARE BGIA Provides a Broad Range of Products and Services to Meet the Unique Needs of New Jersey Public Entities BGIA has earned the trust of clients at every level of New Jersey government. 10 Business Governmental Insurance Agency, or BGIA, is a leading provider of Property Casualty Insurance, Employee Benefit Plans and Risk Management Services to the New Jersey Public Entity sector. BGIA responds to the special needs of public entities with customized insurance brokerage services, loss control and safety strategies. Formed in 1993, BGIA has grown steadily, and is now one of the largest providers for public entity insurance business in New Jersey. BGIA is one of the only agencies that works with all five levels of public entities in New Jersey: State, borough), Special County, Municipality (town, Districts and School Boards. Team of New Jersey Public Entity Experts STATE .1 COUNTY I. -- MUNICIPALITY SPECIAL Over the years, BGIA has assembled a team of professionals, with extensive experience in the areas of government, finance, risk management and insurance law. When you partner with BGIA, we operate as an extension of your organization, providing you with superior technical and administrative services in the assessment of risk and the design of safety and other loss control strategies. Our team of strong insurance negotiators with industry clout work year-round to minimize your risks, improve your coverages and obtain the lowest cost for your insurance. marketing strength is a major asset: in addition to our own substantial portfolio of clients and premium, we are affiliated with one of the country?s top 100 business insurance and risk management intermediaries, which maintains strong relationships with major insurers such as Travelers, Hartford, Safety National and many others. Our affiliation gives substantial market influence, and the BGIA team is well-positioned to use that influence to maintain the best possible programs for our clients. BGIA delivers direct and personal service to each and every client and we will work with you to ensure the proper evaluation, design and implementation of programs that are optimal for your Public Entity. Four Divisions Work Together to Meet All Your Needs The four divisions of BGIA function as a collaborative team located in our Woodbridge, NJ office, providing: Property Casualty We work diligently to Brokerage I i; build trust, with integrity the cornerstone of our Employee Benefits Brokerage Services business philosophy. 1 ~27 ?i'l . insurance Fund Services ?Based on years of experience, we have garnered a unique understanding of the public sector market. As a result, we offer a thorough analysis of the Public Entity?s assets, identify potential risk and recommend ways to protect the entity from financial loss in a cost effective manner.? Steve Edwards President, BGIA 12 i We Understand the Unique Exposures Faced . . Property&Casuaity By Public Entities and Desrgn Customized Brokerage Programs to Guard Against Losses The Property Casualty division provides comprehensive insurance to transfer the risk inherent in the operations of a Public Entity to strong third parties. We have access to the leading public entity insurance markets and work with top-rated carriers to ensure the most comprehensive coverage possible at the best possible cost, including: General Liability, Auto and Property Coverage Workers? Compensation Employment Practices Liability Professional Liability for Public Officials, Police/Law Enforcement, Firefighters, EMT/Paramedics and Educators Volunteer Accident (such as Homeland Security and Emergency Management volunteers) Environmental Liability Cyber Liability And it Employee Bene?ts BGIA Helps Public Entities Control the Cost of Employee Benefits While Maintaining the Quality Brokerage Services of Benefits Employees Want and Deserve The Employee Benefits division provides consulting services in the areas of healthcare, dental, prescription card programs, short and long term disability, group term life, 401 and other retirement plans as well as a variety of voluntary employee paid plans. A well-planned and implemented risk management strategy is paramount to reduce exposure and contain costs. 13 Our employee benefits services include: Plan design and benefits analysis Assist with healthcare Open Enrollment Act as liaison to adjudicate difficult claims Negotiate terms and competitive rates Review and monitor Stop Loss coverage for proper reimbursement where applicable Risk Management Consulting Risk Managlermt?fnm?:5 '2 . Services Help Clients Control Costs with Strategies to Reduce Exposures unwr? The Risk Management division identifies the potential for risk, analyzes the probability of occurrence, offers expert advice on how to control, avoid or reduce exposure to risks and provides monitoring tools to analyze your unique exposures. Our services include: Exposure identification Coverage review Loss control safety services Risk financing alternatives Contracts certificate review Drawing on its considerable expertise, BGIA provides a full spectrum of risk management services, including in-depth analysis of exposure and design and implementation of a complete risk management program tailored to each client?s safety, cost concerns and desired levels of acceptable risk. Our analysis helps our clients make more informed decisions about both their coverage and their loss control program needs. Our design and implementation services help them realize their goals in a timely and cost-efficient manner. Joint Insurance Fund (JIF) Services Managed by BGIA Provide Public Services Entities Alternatives for Transferring 5: Risk Joint insurance Fund (JIF) In addition to offering Brokerage and Risk Management Services, BGIA responded to a market need in 2001 when it helped organize the ?Garden State Municipal Joint Insurance Fund? (GSMJIF). BGIA and its affiliated companies developed and continue to manage the GSMJIF, which is one of the largest Joint Insurance Funds in New Jersey by population. Responding again to a market need, BGIA helped organize the ?Public Entity Joint Insurance Fund? (PEJIF), which launched on January 1, 2014, bringing the benefits of the Joint Insurance Fund mechanism to a new and distinct group of New Jersey municipalities. The experiences gained in the development and continual management of the GSMJIF and PEJIF (2014 launch) provide BGIA with an in-depth understanding of the advantages and challenges of transferring risk through traditional commercial insurance coverage or alternative arrangements such as Joint Insurance Funds BGIA serves as Broker, and limited Self Insurance Programs. Risk Manager or JIF Underwriting Manager The above Joint Insurance Funds presently comprise 48 NJ member for over 60 New Jersey munICIpaIities, With a population greater than 1,400,000. Public Entities. BGIA offers a full range of JIF Services, including: JIF Creation JIF Underwriting Management JIF Risk Management JIF Marketing Management 14 15 BGIA Is the Leading Provider of Insurance and Risk Management Services to the New Jersey Public Sector BGIA has assembled a team of insurance professionals with a strong background in the internal workings of governmental entities, both from an academic and practical level. The BGIA service team has many years of practical experience in risk identification, risk design and implementation of risk management and insurance programs for public entity clients. Each member of the BGIA Team is well-versed in the various disciplines of governmental finance, law, risk management, human resources and insurance. The BGIA service team is composed of highly trained exposure and loss control specialists with many years of practical experience in risk identification, risk design and implementation of risk management/ insurance programs for public entity clients. Our technical resources include coverage specialists who can help you with all coverage lines available for Public Entity risks. This includes the standard coverage lines of: Property, General Liability, Automobile, Boiler Machinery, Inland Marine, Crime, Public Official Bonds, Pollution Liability, Law Enforcement Liability, Workers' Compensation, Group Accident, Public Officials/ School Leaders Professional Liability and Employment Practices Liability, as well as insurance for emerging classes of risk such as Cyber insurance and Unmanned Aircraft (drone) insurance. We provide expertise, creativity, strong market relationships with insurers and a hands-on senior management team. 16 Our Business Principles and Service Philosophy We understand that we must earn our client?s trust. As your strategic advisor, we will demonstrate our dedication to helping you fulfill your organization?s objectives. We are committed to maintaining the highest level of integrity and serve as advocates for our clients? needs. As New Jersey Public Entity specialists, we offer recommendations and solutions to serve our client?s best interests. We serve as your advocate and partner providing customized, personalized service. We believe in Clear communications with our clients -- including clearly explaining our services and fees. We value client?s input to help maintain service quality. BGIA does not accept contingency compensation from insurers. The high levels of our staff?s expertise, dedication and creativity distinguishes BGIA in our industry. BGIA continually works to improve our organization through innovation, training and investing in streamlining our operations. As specialists, we leverage our vast knowledge base for our clients and deliver innovative solutions. Because we understand how economic and business changes impact our clients? risk management challenges, we can offer an insightful approach to develop insurance and risk financing alternatives. We help our clients reduce their total cost of risk. Our solutions go beyond the negotiating cost of insurance premiums. Risk assessment, risk strategy, program design, risk transfer transactions and risk control services enable clients to reduce costs. When you become a BGIA Client: From employee benefits to property casualty coverage, BGIA provides clients comprehensive I strategic planning backed by outstanding service. 17 We work with you to establish efficient and productive operating procedures including contacts, account handling protocols and day-to-day maintenance activities. Our senior staff members meet with your risk management staff to confirm objectives, determine priorities, set up communications channels and agree on strategy. We determine the extent of exposure to loss based on our analysis of your daily operations. Our analysis includes a review of current programs, analysis of potential new capacity, new program structures and potential savings. We use proven management tools which may include: Exposure Analysis including a review and assessment of the impact of Public Entity market trends on your risk management program including new products, new facilities, personnel changes, large losses, significant legislative and regulatory changes and more. End-Of-year Report to assess the past year?s activities and review its impact on future strategies to reduce costs. Benchmarking such as the annual RIMS Cost of Risk survey and our assessment of the market help you determine potential risk costs. Periodic meetings review progress on activities, discuss changing market conditions, plan renewal strategy, etc. The trust we have built through long-term underwriting relationships enables us to obtain the best terms. BGIA believes that We aggressively negotiate to minimize your insurance premiums while obtaining every client favorable terms and conditions. Our excellent underwriting relationships allow us deserves its own to obtain needed capacity for our clients from top companies at the most best deal. competitive cost and coverage terms. Underwriters respond favorably to our proposals because we provide the comprehensive underwriting information they need to enable them to offer their best terms to capture your business. The insurers we recommend must be financially strong, knowledgeable about the risks they assume, and willing and able to provide our clients long-term and short- term advantages. meet our standards for market security, solvency and our review for long-term and short-term advantages. We seek insurers who provide aggressive pricing balanced by service quality and top-notch security. Special District Since 1998, one of clients has been a cooperative effort of several member municipalities for cost-effective collection and treatment of wastewater. Our responsibilities include marketing and managing a Property/Casualty Insurance Program with annual premiums over $500,000. During our tenure as Broker we have worked with the executive management in identifying, quantifying controlling and funding the various risks facing the facility. Through this risk management process we identified the need and developed a program for environmental liability insurance. BGIA has also been able to leverage its market position to consistently deliver the most cost effective insurance program for the facility, well within budget. Also we have consulted with the facilitv. legal representatives on 18 The BGIA Leadership Team Richard Augustyn, Chief Executive Officer Mr. Augustyn is Founder and Chief Executive Officer of BGIA and has been a successful entrepreneur and business leader for over 20 years. He conceived, founded and continues to manage several highly successful ventures. His business success led to being named in 2003 NJ Biz?s Forty under Forty, which recognizes young men and women who have made outstanding contributions to their fields. Mr. Augustyn is a nationally recognized expert on alternative risk matters who has interviewed on and WABC. He is quoted in publications such as the New York Times and speaks on insurance-related topics throughout the country. Steven A. Edwards, President 19 Steve Edwards co?founded Business Governmental Insurance Agency in 1993. He also held senior positions in the governmental sector, serving on various government boards and commissions. He was finance chairman of the Union Township Board of Education, Vice Chairman of the Union County Planning Board; Governor?s Liaison and a Board of Trustee to the Public Employees Retirement System, and a member of the Union County improvement Authority. He is active in various civic and charitable causes. Stuart Migdon, CPA, CL U, Managing Director Employee Benefits Practice Stuart Migdon began his career in public accounting. He obtained a Certified Public Accountant designation and entered the financial services industry in 1984, advising clients on insurance and financial matters. For the last ten years, Mr. Migdon has specialized in health insurance and other related areas affecting both employers and employees. He joined BGIA in 1993 as the Director of Employee Benefits. Mr. Migdon graduated from Dowling College with a BA in Accounting. Francis J. Kelly, CPCU, RPLU, Senior Vice President 20 Frank Kelly brings extensive reinsurance background to BGIA. Having started his career as a casualty underwriter for Wausau Insurance Companies in 1976, He moved into reinsurance in 1981 and spent over 20 years producing and underwriting all classes of reinsurance for prominent companies. He subsequently served as a treaty reinsurance broker for a leading international firm, and as reinsurance buyer for a worldwide provider of and specialty insurance products. Mr. Kelly joined BG IA in October 2013 as Senior Vice President in the Public Entity Practice. He holds the Chartered Property and Casualty Underwriter (CPCU), Registered Professional Lines Underwriter (RPLU) and Associate in Reinsurance designations, and is a graduate of LeMoyne College with a BS in Accounting. Brian Erlandsen, CIC, Vice President Property Casualty Practice Brian Erlandsen has worked with major NYC and NJ insurance brokerage firms since his career began in 1981 and has an extensive background in public entity and large-line commercial insurance underwriting, marketing and account management. He joined BGIA in 1996. His Account experience with BGIA has included insurance and risk management services for both corporate and public sector clients and has also served as Deputy Executive Director and VP of Pool Underwriting for the Garden State Municipal Joint Insurance Fund. Mr. Erlandsen maintains the Certified Insurance Counselor professional designation. Conrad G. Cyriax Esq. Senior Claims Consultant Conrad Cyriax serves as Senior Claims Consultant for BGIA. Mr. Cyriax has a wealth of claims management experience having served as a Claims department leader at a major third-party claims administrator for over 10 years. He has handled complex litigation issues in many industry segments that relate to the Public Entity arena. Mr. Cyriax practiced law with Thacher Proffitt Wood in New York City, NY and with Riker, Danzig, Scherer, Hyland Perretti in New Jersey. He also has an extensive insurance background, having been the Claims Manager for Alexander Howden (U.S.), Prudential Reinsurance. Anthony Ven Graitis, ARM, ASP Risk Control Consultant 21 Anthony Ven Graitis serves as Senior Risk Control Consultant for Mr. Ven Graitis has a wealth of risk control management experience having served as a risk control specialist and manager at Fortune 500 companies, and most recently at the world?s leading provider of risk management services for over five years. He has managed and directly provided a full range of PEOSH-required safety training in New Jersey as Vice President of Risk Control for the Garden State Municipal JIF. Mr. Ven Graitis holds a BS in Chemical Engineering from Rutgers College of Engineering. Robert Persico Claims Consultant Robert Persico, Vice President, Claims at our affiliate Group, serves as claims consultant. Previously, Robert held a number of high level claims management positions at Cigna Reinsurance, ESIS Claims and Cigna Property and Casualty. He excels in technical claims management, improving loss dollar payout, implementing operational efficiencies, effective human resource management and building customer relationships. He has authored articles for various publications and given presentations on numerous claim management topics. Robert is a graduate of William Paterson University, with a BA in Business Administration. George Crosby, CPCU, ARM-P, ARM-E, Account Manager George Crosby has worked as an Account Executive with a regional insurance brokerage firm since his insurance career began in 2003. George joined BGIA in 2012. His Account Management experience includes both medium and large corporate clients. Mr. Crosby holds the Chartered Property Casualty (CPCU) and the Accredited Customer Service Representative (ACSR) professional designations. Mr. Crosby graduated from the New Jersey institute of Technology with a Bachelors Degree in Business and is a licensed Property Casualty Broker in the State of New Jersey. Denise Gigantino Employee Benefits Account Manager Ms. Gigantino is an Account Manager for BGIA. She brings more than 20 years experience in the employee benefits industry, specializing in large group insurance plans. Ms. Gigantino leads the employee benefits client management process including plan design, marketing, enrollment, administration, claims and financial management. Prior to joining BGIA, she held positions of increasing 22 BGIA Property and Casualty Service Team Steve Edwards President Francis Kelly Brian Erlandsen Conrad Cyriax Anthony Ven Graitis CPCU, RPLU, AFle CIC Senior Vice President ARM, ASP Sr. Vice President Vice President Senior Claims Consultant Loss Control Consultant Robert Persico George Crosby Brenda DeSantis Claims Consultant CPCU, ARM-P Administrative Assistant Account Manager 23 The BGIA Approach: PROPERTY 8: CASUALTY A Three Phase Approach Phase One: Evaluation and Analysis of Exposures Understanding a client?s risk philosophy is paramount in the development of any strategy. BGIA uses a three-phase approach to develop a comprehensive insurance and risk management program tailored specifically to each of our clients. BGIA diligently ascertains your exposures, and tolerance for risk in order to determine the scope and type of coverage suitable for your unique situation. Our objective is to deliver the best program at the most competitive cost. Because we regularly monitor both our clients? risk management records and the market trends in the insurance industry, we are able to ensure our clients have the proper protection and take advantage of savings when they are available. Phase Two: Program Development, Selection and Implementation 24 The first step of Phase Two, Program Development, involves a detailed critique of the strategy to ensure that all the viable alternatives receive proper consideration. Some of the considerations involved in the program development are: Which losses to transfer and which losses to retain The types of coverages that should be purchased Establishment of appropriate deductible levels The market availability of these coverage types Once the exposures are identified, quantified and alternative risk funding alternatives examined we will then commence the marketing and implementation phase. The second step of this phase is to prepare and deliver an effective marketing presentation to qualified insurance markets, seeking their most competitive terms to provide insurance that meets the client?s risk transfer requirements. When the markets respond, and after vigorous negotiation to achieve the best possible terms from each market, a thorough analysis of all the options is performed, a detailed report is prepared for presentation to the client and one of the proposals is selected. The final step of this phase is Program Implementation. We give this special attention because it is the most crucial step of the process. We assist our clients in communicating the program among their various constituents by visiting remote locations, attending meetings as well as developing training and information seminars. Implementation is a continuous process: Program Monitoring 25 assists clients in establishing the goals, objectives and performance measures to properly evaluate the effectiveness of risk management techniques and the overall success of the program. Once implemented, risk management programs need to be monitored as a way of ensuring the programs have achieved expected results. The program may need to be adjusted to take into account changes in legal and regulatory exposure and loss development. In addition, alternative risk management techniques may become available and be more cost effective. The monitoring, evaluation and adjustment process entails determining standards of acceptable performance, comparing actual performance with those standards. As an integral part of the monitoring process, assists in the development of corrective action plans to respond to sub-standard performance. For most of our clients, it all adds up to budget stability and certainty. Minimize variability, maximize security. As part of the process an Annual Risk Management (Stewardship) Report may be prepared for the client to provide a basis to compare actual performance with the established standards. This report is designed to be both quantitative and actionable in its recommendation for program improvements, and may include discussion of: Premiums Other costs (payroll, overhead, outside services, appraisal, salvage, independent adjusters, etc.) Losses, insured and retained Incurred losses (frequency and severity) Reserves (frequency and severity) Large and/or unusual losses and incidents (Including how they will be funded, root cause analysis and any preventative measures taken) Cases currently being litigated and potential litigation cases insurance recoveries Salvage and subrogation recoveries Other (contractual, FEMA recoveries) Loss prevention and safety activities Training and education performed Compliance with PEOSH Specific loss reduction achieved Safety Committee activities Safety inspections (internal, contracted and insurer provided) Other loss prevention activities Cost/benefit analysis of actions taken and results achieved Changes in coverage, limits, retention, companies Plans for change Anticipated changes in future periods Claims and other services Cost and performance evaluation Administration activities Phase Three: Customer Services 26 General Services Rapid response to daily service needs Coverage review Certificate of Insurance provided on request Claims reporting and follow-up Contract and policy review Review of hold harmless agreements/other party indemnification Analysis of effectiveness of coverage of others Collection of claims tracing data and analysis Statistical studies, premium allocation, subrogation review and monitoring Our analyses help our clients make more informed decisions about both their coverage and their loss control program needs. Our design and implementation services help them realize their goals in a timely and cost- efficient manner. 27 Risk Management Services In our increasingly litigious society, employer liability and workers? compensation expenses have become one of the largest controllable expenses in a Public Entity?s budget. A well-planned and implemented risk management strategy is paramount to reduce exposure and contain cost. Drawing on its considerable expertise, BGIA provides a full spectrum of risk management services, ranging from thorough analysis of exposure, through designing and implementation of a complete risk management program tailored to the Public Entity?s safety and cost concerns and desired levels of acceptable risk. SAMPLE OUTLINE: BGIA RISK MANAGEMENT ENGAGEMENT Custom Analysis of Client's Loss History Property Medical General Liability Auto Professional Liability Workers? Compensation Custom Report Evaluating Client's Current Program and Recommendations Loss Control Programs Loss Control Management Automobile Loss Control Fire Department Loss Control Law Enforcement Loss Control Park and Recreation Loss Control Public Works Loss Control School Facility Loss Control Government or School Board Leaders? Loss Control Policy Statement Safety Statement Management Participation Department Level Officials Statement of Safety Policy Safety Coordinator Responsibility Employee Responsibility Safety Rules and Regulations Safety Inspection Programs Outside Contractor Safety Inspection Program Safety Training Manual First Aid Program Accident Investigation Report and Procedure Safety Orientation Check List The BGIA Approach: DOING BUSINESS WITH US Specialized Public Entity Claim Management Helps BGIA Control Your Cost of Risk Over the past ten years, sovereign immunity laws of public entities have been strengthened in both the legislature and courts. These laws, known as Title 59, are the cornerstones of a Public Entity?s legal defense. Our team is well versed in Title 59 and based on our knowledge and experience we can reduce nuisance lawsuits, thus reduce claims and improve your record and lower insurance premium rates. 28 Based on our knowledge and experience with Title 59, BGIA can reduce nuisance lawsuits, thus reducing claims, improving your track record and lowering insurance rates. Claims occur even with the best risk management program and the outcome will often be determined by how well the claim is managed. Counties and other public entities in New Jersey enjoy certain tort immunities under N.J.S.A. 59, commonly known as the Tort Claims Act or Title 59. Because of these immunities and the required notice of tort filing (see below), public entity liability losses are not subject to the same frequency and severity development patterns as typical risks. in the vast majority of cases (employment practices and certain federal actions are excluded from these protections), two factors work to mitigate the exposure to loss for public entities: The claimant must file a tort notice within 90 days of the occurrence date or be barred from further action against the public entity. This has a direct effect on factors. Most common causes of loss (slips and falls, playground injuries, pothole claims, etc.) are subject to Title 59 protections. BGIA ensures you receive the full benefit of Title 59 immunities for every claim. Over the past 6 years, BGIA has coordinated nearly 1,000 liability claims involving Title 59 immunity. Title 59 immunities make it substantially more difficult to sue a governmental entity, when the entity has adopted procedures to take full advantage of the protection available under the Act. BGIA assists clients in developing and implementing the proper procedures by working closely with your insurer or Third Party Administrator (TPA) to be sure you receive the full benefit of the immunities available for every claim situation. BGIA has conducted training seminars in Title 59 for public entities throughout the state. Our Fee Structure BGIA will not charge a fee to your organization. Commissions for services rendered are paid by the selected insurance carriers at commission schedules set forth by the carriers or are paid by the respective Joint Insurance Fund depending on where coverage is placed. 29 Property Casualty Products and Services BGIA has broad access to the insurance marketplace. We canvas the market and select only those insurance companies that we feel are qualified to serve our clients. Paramount in the selection process is the prospective insurer?s financial strength and stability, quality of coverage, level of customer service and commitment to the New Jersey Public Entity market. The following standards and coverage are carefully considered: Financial Security and Management Monitor ratings measured by AM. Best and The company?s claims services record The company?s Loss Control Program Property Coverage . . We don?t just sell our clients Property Inland Marine insurance. We thoroughly and Machinery analyze your business and your Busmess interruption Commercial Crime exposures and put together a . . . comprehensive solution. Then Liability Coverage . . . we work to control your costs General Liability Commercial Auto Liability over time. For our clients, it all Workers? Compensation adds up to budget stability and Umbrella Liability certainty. Specialized Comprehensive Coverage Professional Liability for Public Officials and School Leaders Emergency Medical Services Liability Employment Practices Liability Law Enforcement Liability Public Official Bonds Cyber Liability Pollution Liability Liability Hull Insurance for Unmanned Aircraft (drones) 30 BGIA has relationships with, and access to many of the nation?s leading commercial insurance carriers: ACE American Insurance Admiral Insurance Co. Affiliated FM Insurance Co. Allstate Insurance Co. American Alternative Ins. Co. American Empire Surplus Lines American Guarantee Liability American Home Assurance Co. American International Co. Arch Insurance Co. Arch Specialty Insurance Co. Aspen Specialty Insurance Co. Benchmark Insurance Co. Berkley Risk Services, Inc. Burlington Insurance Co. Charter Oak Fire Ins. Co. Chubb Insurance Co. C.N.A Insurance Companies Colony National Columbia Casualty Commerce Industry Insurance Continental American Continental Casualty Co. Continental Ins. Co. of NJ Continental Western Insurance Co. CV Starr Co. Diamond State Insurance Co. Employers Reinsurance Cc. Evanston Insurance Co. Everest National Insurance Co. Executive Risk Indemnity Inc. Federal Insurance Co. Fidelity Deposit Fidelity Nat?l Insurance Co. Firemans Fund Insurance Co. First Financial Insurance Co. First Mercury Insurance Co. Gemini Insurance C0. General Star Indemnity Ins. Co. General Star National Ins. Co. Global Aerospace, Inc. Gotham Insurance Co. Granite State Insurance Co. 31 Great American Insurance Co. Greenwich Insurance Co. Hartford Insurance Co. Hartford Specialty Co. Hartford Underwriters Insurance Co. Homeland Insurance Co. Housing Auth. Risk Ret. Group Hudson Specialty Insurance Co. Illinois National Insurance Co. Illinois Union Insurance Co. Injured Workers? Ins. Fund Interstate Fire Casualty Co. Kentucky Employers Mutual Landmark Insurance Co. Lexington Insurance Co. Liberty Insurance Corporation Liberty Insurance Underwriters Liberty Mutual Insurance Co. Lloyds of London LM Insurance Corporation Madison Nat'l Surety Specialists Manufacturers Alliance Insurance Market Insurance Co. Maryland Casualty Co. Merchants Mutual Insurance Co. Midwest Employers Casualty Co. Mount Vernon Fire Insurance Co. National Casualty Co. National Continental Ins. Co. National Flood Insurance Program National Indemnity Co. National Surety Corporation National Union Fire Insurance Co. Nationwide Mutual Insurance Co. New Hampshire Insurance Co. New Jersey Casualty Insurance Co. New Jersey Manufacturers New Jersey Schools Insurance Grp. Property Casualty Northern Insurance Co. of NY Old Republic Insurance Co. Pacific Insurance Co. Ltd. Philadelphia Indem Insurance Co. Phoenix Insurance Co. Safety National Casualty Corp. Scottsdale Insurance Co. Selective Insurance Co. Seneca Insurance Co. Specialty National Insurance Co. State National Insurance Co. Statewide Insurance Fund Texas Mutual Insurance Co. Transportation Insurance Co. Travelers Insurance Group Tudor Insurance Co. United National Insurance Co. United States Liability Ins. Co. US Fidelity Guaranty US Fire Insurance Co. Virginia Surety Co. Inc. Western Surety Co. Zenith Insurance Co. Zurich American Insurance Co. BGIA Client Engagement Listing I References City of Linden Ms. Alexis Zack City Treasurer 301 Wood Avenue Linden, NJ 07036 (908) 474-8485 County of Union Ms. Claudia Martin Deputy Director Division of Personnel Management 10 Elizabethtown Plaza Elizabeth, NJ 07207 (908) 527-4289 Garden State Municipal Joint Insurance Fund Mr. Jonathan Hall Executive Director 900 Route Nine North Woodbridge, NJ 07095 (800) 446-7647 Ext 7365 Joint Meeting of Essex Union Counties Mr. Samuel McGhee Executive Director 500 South First Street Elizabeth, NJ 07202 (908) 353?1 313 Public Entity Joint Insurance Fund Mr. Jonathan Hall Executive Director 900 Route Nine North Woodbridge, NJ 07095 (800) 446-7647 Ext 7365 Borough of North Plainiield Mr. David Hollod Business Administrator 263 Somerset Street North Plainfield, NJ 07060 (908) 769-2917 32 City of Rahway Ms. Cherron Rountree Business Administrator 1 City Hall Plaza Rahway, NJ 07065 (732) 827-2001 County of Essex Mr. Timothy Walker Risk Manager Hall of Records, Room 510 465 Dr. Martin Luther King Jr. Newark, NJ 07102 (973) 621-4432 Rahway Valley Sewerage Authority Mr. James Meehan Executive Director 1050 East Hazelwood Ave. Rahway, NJ 07065 (732) 388-0868 x215 Linden Airport Mr. Paul Dudley President Route 1 Linden, NJ 07036 (908) 862-5557 Borough of Belmar Ms. Colleen Connolly Borough Administrator 601 Main Street Belmar, NJ 07719 (732) 681 -3700 x215 Township of Eastampton Mr. Eric Schubiger Business Administrator 12 Manor House Court Eastampton, NJ 08060 (609) 267-5723 Township of Union Board of Education Mr. James Damato Board Attorney/Board Secretary 2369 Morris Avenue Union, NJ 07083 (908) 851 -6400 Borough of Hillsdale Ms. Susan Witkowski Business Administrator 380 Hillsdale Avenue Hillsdale, NJ 07642 (201) 666-4800 Mercer County Improvement Authority Mr. Phil Miller Executive Director 640 South Broad Street Trenton, NJ 08650 (609)278?8080 Hamilton Township Board of Education Ms. Katie Attwood Business Administrator 90 Park Avenue Hamilton, NJ 08690 (609)631-4100 City of New Brunswick Mr. Thomas Loughlin Business Administrator 78 Bayard Street New Brunswick, NJ 08903 (732) 745?5007 Borough of Roselle Park Mr. Andrew Casais Borough Clerk 110 East Westfield Avenue Roselle Park, NJ 07204 (908) 245-6222 ext.1002 Union County Utilities Authority Thomas Brennan Deputy Executive Director/Comptroller 1499 US Highway 1North Rahway, NJ 07065 (732) 382-9400 Ext 225 33 Passaic Valley Sewerage Commission Mr. Gregory Tramontozzi, Esq. Executive Director General Counsel 600 Wilson Avenue Newark, NJ 07105 (973) 817-5700 Second River Joint Meeting Ms. Patricia Rufolo Treasurer/ Secretary 500 South First Street Union, NJ 07083 (908) 851-6400 City of Hoboken Board of Education Mr. William Moffitt Business Administrator 1115 Clinton Avenue Hoboken, NJ 07030 (201) 356-3611 Township of Union Mr. Ron Manzella Township Administrator 1976 Morris Avenue Union, NJ 07083 (908) 851-8500 Borough of Kenilworth Ms. Laura Reinertsen Borough Clerk 567 Boulevard Kenilworth, NJ 07033 (908) 276-9090 Township of Franklin Ms. Donna Vieiro Asst. Township Manager 475 Demott Lane Somerset, NJ 08875 (732) 873-2500 ext. 231 Bahway Board of Education Mr. AI DiGiorgio Business Administrator 1138 Kline Place Rahway, NJ 07065 (732) 396-1004 Forms Appendices RFP Submission Checklist form (pg 7) Submission Form/ Qualifications Statement (pgs 8-11) Statement of Ownership Disclosure (pgs 12-14) Affirmative Action Compliance Notice (pg 16) Mandatory EEO Language (pgs 17-18) Americans With Disabilities Act Acknowledgement (pg 19) Disclosure of Investments in Iran (pgs 20-21) Insurance Requirement Acknowledgement form (pg 22) Certification regarding Political Contributions (pg 23), with Political Contribution Disclosure form (page nos. as shown on Borough?s RFP) Other Documentation: 34 NJ Business Registration Certificate W-9 Form Certificate of Employee Information Report State of New Jersey Insurance Producer License Certificate of Professional Liability Insurance BOROUGH OF ROSELLE PARK SUBMISSION CHECKLIST THE FOLLOWING ITEMS, AS INDICATED BELOW SHALL BE PROVIDED Initial WITH THE RECEIPT OF SEALED SUBMISSIONS Here Completed RFP Checklist Completed Submission Form/ Quali?cation Statement Statement of Ownership Disclosure Non-Collusion Af?davit Required EEO/Af?rmative Action Evidence Signed Compliance Notice Acknowledgement of Americans with Disabilities Act Language of 1990 Disclosure of Investment Activities in Iran Insurance Requirement Acknowledgement Form Certi?cation Regarding Political Contributions New Jersey Business Registration Certi?cate of Vendor W-9 of Vendor This checklist is provided for vendor?s use in assuring compliance with required documentation; however, it does not include all submission requirements and does not relieve the vendor of the need to read and comply with the RFP. Name of Vendor: Business Governmental Insurance Agency Inc. Date: 11/28/2013 Signature: X. Print Name: Steve Edwards Title: President Page 7 of 26 BOROUGH OF ROSELLE PARK SUBMISSION FORM QUALIFICATION STATEMENT (ATTACH ADDITIONAL SHEETS AS NECESSARY, BUT DO NOT SIMPLY ATTACH VENDOR MATERIALS AND 1. Names and roles of the individuals who will perform the services and description of their education and experience with projects similar to the services contained herein: Page 8 of 26 SUBMISSION FORM QUALIFICATION STATEMENT (CONTINUED) (ATTACH ADDITIONAL SHEETS AS NECESSARY, BUT DO NOT SIMPLY ATTACH VENDOR MATERIALS AND 2. References and record of success of same or similar service: Page 9 of 26 SUBMISSION FORM QUALIFICATION STATEMENT (CONTINUED) (ATTACH ADDITIONAL SHEETS AS NECESSARY, BUT DO NOT SINIPLY ATTACH VENDOR MATERIALS AND RITE: 3. Description of ability to provide the services in a timely fashion (including staf?ng, familiarity and location of key staff): Page 10 of 26 SUBMISSION FORM QUALIFICATION STATEMENT (CONTINUED) (ATTACH ADDITIONAL SHEETS AS NECESSARY, BUT DO NOT SIMPLY ATTACH VENDOR MATERIALS AND 4. Cost details, including the annual fee for primary duties and the hourly rates of each of the individuals who will perform services, and all expenses for any work that is not included in the primary duties: As outlined in the ?The BGIA Approach: Doing Business With Us? section, BGIA does not charge a fee to the Borough for the services provided under this RFP. Compensation for services rendered are paid by the selected insurance carriers or joint insurance fund at standard commission terms. BGIA has voluntarily taken a reduced Risk Management Consultant (RMC) fee of 5% of Member assessment rather than the 7% normally paid by the current Joint Insurance Fund (GSMJIF), as was authorized by the Borough of Roselle for BGIA last year. There are no separate or hourly charges, for any services normally within the scope of this RFP. CERTIFICATION OF PROPOSAL (Sign Below) Firm: Business Governmental Insurance Agency Inc. Date: 11/28/2018 Authorized Re (Print): Steve Edwards Signamr?%?7 Title: President Telephone NO.: 800?272?6771 extension 7241 Fax NO.: Page 11 Of 26 BOROUGH OF ROSELLE PARK STATEMENT OF OWNERSHIP DISCLOSURE N.J.S.A. (P.L. 1977, c.33, as amended by P.L. 2016, c.43) THIS STATENIENT SHALL BE COMPLETED, CERTIFIED TO, AND INCLUDED WITH ALL BID AND PROPOSAL SUBMISSIONS. FAILURE TO SUBMIT THE REQUIRED INFORMATION IS CAUSE FOR AUTOMATIC REJECTION OF THE BID OR PROPOSAL. Name of Organization: Business Governmental Insurance Agency Inc. Organization Address: 900 Route 9 North, Suite 503, Woodbridge, NJ 07095 Part I Check the box that represents the type of business organization: Sole Proprietorship (skip Parts II and execute certi?cation in Part IV) nNon-Pro?t Corporation (skip Parts 11 and execute certi?cation in Part IV) For-Pro?t Corporation (any type) Limited Liability Company (LLC) a Partnership a Limited Partnership a Limited Liability Partnership (LLP) Other (be speci?c): Part II The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST ON THE NEXT PAGE IN THIS SECTION) OR a No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV) Page 12 of 26 STATEMENT OF OWNERSHIP DISCLOSURE (Continued) (Please attach additional sheets if more space is needed): Name of Individual or Business Entity Home Address (for Individuals) or Business Address Steve Edwards 191 Duane Street Apt. 1 New York, NY 10013 Richard Augustyn 513 Via Toledo, Palm Beach Gardens, FL 33418 Part DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART II If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater bene?cial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent ?ling, ownership disclosure can be met by providing links to the website(s) containing the last annual ?ling(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater bene?cial interest in the publicly traded parent entity, along with the relevant page numbers of the ?ling(s) that contain the information on each such person. Attach additional sheets if more space is needed. Website (URL) containing the last annual SEC (or foreign equivalent) ?ling Page Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 5225-242 has been listed. Attach additional sheets if more space is needed. Stockholder/Partner/Member and Home Address (for Individuals) or Business Address Corresponding Entity Listed in Part II Page 13 of 26 STATEMENT OF OWNERSHIP DISCLOSURE (Continued) Part IV Certi?cation I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certi?cation on behalf of the bidder/proposer; that the Borough of Roselle Park is relying on the information contained herein and that I am under a continuing obligation from the date of this certi?cation through the completion of any contracts with the Borough of Roselle Park to notify the Borough of Roselle Park in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certi?cationsubject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the Borough of Roselle Park to declare any contract(s) resulting from this certi?cation void and unenforceable. Full Name (Print): Steve Edwards T1t1e: President Signature: Date: I 11l28l2018 Page 14 of 26 BOROUGH OF ROSELLE PARK NON-COLLUSION AFFIDAVIT State of New Jersey County of Middlesex 1, Steve Edwards of the City of Woodbridge in the County of Middlesex and State of New Jersey full age, being duly sworn according to law on my oath depose and say that: I am President ofthe ?rm of Business 8. Governmental Insurance Agency Inc. (Title or Position) (Name of Firm) the bidder making this Proposal for the above named project, and that I executed the said proposal with full authority so to do; that said bidder has not, directly or indirectly entered into any agreement, participated in any collusion, or otherwise taken any action in restraint of competitive bidding in connection with the above named project; and that all statements contained in said proposal and in this a?idavit are true and correct, and made with full knowledge that the Borough of Roselle Park relies upon the truth of the statements contained in said proposal and in the statements contained in this af?davit in awarding the contract for the said project. I further warrant that no person or selling agency has been employed or retained to solicit or secure such contract upon an agreement or understanding for a commission, percentage, brokerage, or contingent fee, except bona ?de employees or bona ?de employees or bona tide established commercial or selling agencies maintained by Business 8; Governmental Insurance Agency Inc. (name Of contractor). Subscribed and sworn to before me this a5 2? day bar, Zita/3? . x/g' Signature Steve Edwards I I3 (Type or print name of af?ant under signature) Notary public of My Commission expires [0 TRACEY L. MURDOCH Page 15 Of26 PUBUC OF NEW JERSEY siy Commission Expires 10/30/2020 BOROUGH OF ROSELLE PARK AFFIRMATIVE ACTION COMPLIANCE NOTICE N.J.S.A. 10:5-31 and N.J.A.C. 17:27 GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE CONTRACTS This form is a summary of the success?il bidder?s requirement to comply with the requirements of N.J.S.A. 10:5?31 and N.J.A.C. 17:27-1 et seq. The successful bidder shall submit to the public agency, after noti?cation of award but prior to execution of this contract, one of the following three documents as forms of evidence: a) A photocopy of a valid letter that the contractor is operating under an existing Federally approved or sanctioned af?rmative action program (good for one year from the date of the letter); OR b) A photocopy of a Certi?cate of Employee Information Report approval, issued in accordance with N.J.A.C. 17227-4; OR 0) A photocopy of an Employee Information Report (Form AA302) provided by the Division and distributed to the public agency to be completed by the contractor in accordance with N.J.A.C. 17:27?4. The successful vendor may obtain the Af?rmative Action Employee Information Report (AA302) from the contracting unit during normal business hours. The successful vendor(s) must submit the copies of the AA302 Report to the Division of Contract Compliance and Equal Employment Opportunity in Public Contracts (Division). The Public Agency copy is submitted to the public agency, and the vendor copy is retained by the vendor. The undersigned vendor certi?es that he/she is aware of the commitment to comply with the requirements of NJ .S.A. 10:5-31 and N.J.A.C. 17:27.1 et seq. and agrees to furnish the required forms of evidence. The undersigned vendor further understands that his/her bid shall be rejected as non-responsive if said contractor fails to comply with the requirements of N.J.S.A. 10:5 -31 and N.J.A.C. 17:27 -1 et seq. overnmental Insurance Agency Inc. PRINT NAME: mes/72?? TITLE: President DATE: 11I28l2018 Page 16 of 26 BOROUGH OF ROSELLE PARK EXHIBIT A MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE N.J.S.A. 10:5-31 et seq. (PL. 1975, C. 127) N.J.A.C. 17:27 GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE CONTRACTS During the performance of this contract, the contractor agrees as follows: The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will ensure that equal employment opportunity is afforded to such applicants in recruitment and employment, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Such equal employment opportunity shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship. The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Of?cer setting forth provisions of this nondiscrimination clause. The contractor or subcontractor, Where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all quali?ed applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. The contractor or subcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting of?cer, advising the labor union of the contractor's commitments under this chapter and shall post copies of the notice in conspicuous places available to employees and applicants for employment. The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5-31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act. The contractor or subcontractor agrees to make good faith efforts to meet targeted Borough employment goals established in accordance with N.J.A.C. 17:27-5 .2. The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices. The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of ob-related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions. In conforming with the targeted employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken Page 17 of 26 EXHIBIT A MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE N.J.S.A. 10:5-31 et seq. (PL. 1975, C. 127) N.J.A.C. 17:27 GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE CONTRACTS (Continued) without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the State of New Jersey, and applicable Federal law and applicable Federal court decisions. The contractor shall submit to the public agency, after noti?cation of award but prior to execution of a goods and services contract, one of the following three documents: Letter of Federal Af?rmative Action Plan Approval Certi?cate of Employee Information Report Employee Information Report Form AA302 (electronically provided by the Division and distributed to the public agency through the Division?s website at ww.state.nj The contractor and its subcontractors shall furnish such reports or other documents to the Division of Purchase Property, CCAU, EEO Monitoring Program as may be requested by the of?ce from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of Purchase Property, CCAU, EEO Monitoring Program for conducting a compliance investigation pursuant to Subchapter 10 of the Administrative Code at N.J.A.C. 17:27. Page 18 of 26 BOROUGH OF ROSELLE PARK AMERICANS WITH DISABILITIES ACT OF 1990 Equal Opportunity for Individuals with Disability The Contractor and the Owner, do hereby agree that the provisions of Title 11 of the Americans with Disabilities Act of 1990 (the "Act") (42 US. C. 8121 01 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant there unto, are made a part of this contract. In providing any aid, bene?t, or service on behalf of the owner pursuant to this contract, the contractor agrees that the performance shall be in strict compliance with the Act. In the event that the contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the contractor shall defend the owner in any action or administrative proceeding commenced pursuant to this Act. The contractor shall indemnify, protect, and save harmless the owner, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The contractor shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the owner?s grievance procedure, the contractor agrees to abide by any decision of the owner which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the owner, or if the owner incurs any expense to cure a Violation of the ADA which has been brought pursuant to its grievance procedure, the contractor shall satisfy and discharge the same at its own expense. The owner shall, as soon as practicable after a claim has been made against it, give written notice thereof to the contractor along with full and complete particulars of the claim, If any action or administrative proceeding is brought against the owner or any of its agents, servants, and employees, the owner shall expeditiously forward or have forwarded to the contractor every demand, complaint, notice, summons, pleading, or other process received by the owner or its representatives. It is expressly agreed and understood that any approval by the owner of the services provided by the contractor pursuant to this contract will not relieve the contractor of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the owner pursuant to this paragraph. It is further agreed and understood that the owner assumes no obligation to indemnify or save harmless the contractor, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the contractor expressly understands and agrees that the provisions of this indemni?cation clause shall in no way limit the contractor?s obligations assumed in this Agreement, nor shall they be construed to relieve the contractor from any liability, nor preclude the owner from taking any other actions available to it under any other provisions of the Agreement or otherwise at law. The undersigned vendor consents to the full understanding of the forgoing Americans with Disabilities Act Language of 1990: Bidder/Vendor: Business Governmental Insurance Agency Inc. Signa?lu?p?y Full Name (Print): ve Edwards Title: President Date 11/28/2018 Page 19 of 26 BOROUGH OF ROSELLE PARK DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN PART 1: CERTIFICATION BIDDERS MUST COMPLETE PART 1 BY CHECKING EITHER BOX. Pursuant to Public Law 2012, c. 25 any person or entity that submits a bid or proposal or otherwise proposes to enter into or renew a contract must complete the certi?cation below to attest, under penalty of perjury, that neither the person or entity, nor any of its parents, subsidiaries, or af?liates, is identi?ed on the Department of Treasury?s Chapter 25 list as a person or entity engaging in investment activities in Iran. The Chapter 25 list is found on the Division?s website at Bidders must review this list prior to completing the below certi?cation. Failure to complete the certi?cation will render a bidder?s proposal non-responsive. PLEASE CHECK EITHER BOX: El I certify, pursuant to Public Law 2012, c. 25, that neither the person/entity listed above nor any of the entity?s parents, subsidiaries, or af?liates is listed on the NJ. Department of the Treasury?s list of entities determined to be engaged in prohibited activities in Iran pursuant to FL. 2012, c. 25 (?Chapter 25 List?). I ?lrther certify that I am the person listed above, or I am an of?cer or representative of the entity listed above and am authorized to make this certi?cation on its behalf. I will skip Part 2 and sign and complete the Certi?cation below. OR El I am unable to certify as above because I or the bidding entity and/or one or more of its parents, subsidiaries, or af?liates is listed on the Department?s Chapter 25 list. I will provide a detailed, accurate and precise description of the activities in Part 2 below and sign and complete the Certi?cation below. Failure to provide such will result in the proposal being rendered as non-responsive and appropriate penalties, ?nes and/or sanctions will be assessed as provided by law. PART 2 PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, accurate and precise description of the activities of the bidding person/entity, or one of its parents, subsidiaries or af?liates, engaging in the investment activities in Iran outlined above by completing the form below. (PROVIDE INFORMATION RELATIVE TO THE ABOVE QUESTIONS. PLEASE PROVIDE THOROUGH ANSWERS TO EACH QUESTION. IF YOU NEED TO MAKE ADDITIONAL ENTRIES, USE ADDITIONAL PAGES). Name: Relationship to Bidder/Vendor: Description of Activities: Duration of Engagement: Anticipated Cessation Date: Bidder/Vendor: Contact Name: Contact Phone Number: Page 20 of 26 DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN (Continued) CERTIFICATION I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I attest that I am authorized to execute this certi?cation on behalf of the below-referenced person or entity. I acknowledge that the Borough of Roselle Park is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certi?cation through the completion of contracts with the Borough of Roselle Park to notify the Borough of Roselle Park in writing of any changes to the answers or information contained herein. I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certi?cationrecognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreements(s) with the Borough of Roselle Park and that the Borough of Roselle Park at its option may declare any contract(s) resulting from this certi?cation void and unenforceable. Full Name (Print): Steve Edwards Signature Title: President Date 11/28/2018 Bidder/Vendor: Business Governmental Insurance Agency Inc. Page 21 of 26 BOROUGH OF ROSELLE PARK INSURANCE REQUIREMENTS AND ACKNOWLEDGEMENT FORM Certi?cate(s) of Insurance shall be ?led with the Borough Clerk's Of?ce upon award of contract by the governing body The minimum amount of insurance to be carried by the Professional Service Entity shall be as follows: PROFESSIONAL LIABILITY INSURANCE Limits shall be a minimum of $1,000,000.00 for each claim and $1,000,000.00 aggregate each policy period. Acknowledgement of Insurance Requirement: DATE: 11I28I2018 Steve Edwards - Pr Ident (Printed Name Title) Page 22 of 26 A ACORD CERTIFICATE OF LIABILITY INSURANCE ALBIEZ1 OP ID: GC DATE 03I011201B REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND 0R ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING AUTHORIZED certi?cate holder in lieu of such endorsement(s). IMPORTANT: If the certi?cate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certi?cate does not confer rights to the PRODUCER saga Marquis Agency on); FAX 900 Route 9 North, Suite 503 we. No. Ext) (AIC, Woodbridge, NJ 07095 AFFORDING COVERAGE NAIC INSURER A Allied World Insurance Co INSURED Business Governmental INSURER 3. Insurance Agency 900 Route 9 North Suite 503 INSURER Woodbridge, NJ 07095 INSURER INSURER INSURER COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDL SUBRI POLICY EFF POLICY EXP LTR TYPE OF INSURANCE [353 mp POLICY NUMBER UNITS GENERAL LIABILITY EACH OCCURRENCE DAMAGE TO RENTEO COMMERCIAL GENERAL LIABILITY PREMISES (Ea occurrence) CLAIMS-MADE OCCUR MED EXP (Any one person) 3 PERSONAL ADV INJURY GENERAL AGGREGATE AGGREGATE LIMIT APPLIES PER: PRODUCTS - AGG POLICY 5387' LOG 5 AUTOMOBILE LIABILITY 5 ANY AUTO BODILY INJURY (Per person) 3 ALL OWNED SCHEDULED . AUTOS AUTOS BODILY INJURY (Per aCCIdent) NON-OWNED PROPERTY DAMAGE 3 HIRED AUTOS AUTOS (PER ACCIDENT) UMBRELLA OCCUR EACH OCCURRENCE EXCESS LIAB CLAIMS-MADE AGGREGATE 3 BED I I RETENTION 3 WORKERS COMPENSATION WC STATU- 0TH- AND LIABILITY TORY LIMITS ER ANY PROPRIETORIPARTNERJEXECUTIVE E.L. EACH ACCIDENT I A (Mandatory in NH) E.L. DISEASE - EA EMPLOYEE If yes, describe under DESCRIPTION OF OPERATIONS below E.L. DISEASE - POLICY LIMIT 3 A Professional a. 0 0307-3371 03/01/2018 Per Claim 5,000,000 Aggregate 5,000,000 Evidence of Insurance DESCRIPTION OF OPERATIONS I LOCATIONS (Attach ACORD 101, Additional Remarks Schedule, If more space Is required) CERTIFICATE HOLDER CANCELLATION EVIDENC Evidence of Insurance SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE gag/KW ACORD 25 (2010/05) 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD BOROUGH OF ROSELLE PARK CERTIFICATION REGARDING POLITICAL CONTRIBUTIONS STATE OF NEW JERSEY SS. COUNTY OF Middlesex Business Governmental 1, Steve Edwards President of the Insurance Agency Inc. of Woodbridge in the County of Middlesex and the State of New Jersey, of sound mind and full age, being duly sworn according to law on my oath depose and say that: I am the President of the ?rm of Business Governmental Insurance Agency Inc. the Professional Service Entity making the submissions for the above named Service, and that I executed the said submission with full authority to do so; that said Professional Service Entity acknowledges that it is aware that the Borough of Roselle Park pursuant to Section 2-4 of the Borough Code prohibits the awarding of any public contract to any Professional Service Entity that has contributed in excess of two hundred ($200.00) dollars to a campaign committee of any Borough of Roselle Park candidate or holder of the public of?ce having ultimate responsibility for the award of the contract, or to any Borough of Roselle Park or Union County Party Committee, or to any political action committee (PAC) that is organized for the primary purpose of promoting or supporting Borough of Roselle Park municipal candidates or municipal of?ceholders, within one (1) calendar year immediately preceding the date of the contract or agreement. I ?lrther warrant that pursuant to Roselle Park Borough Section 2-4, a ?professional service provider? seeking a public contract means: an individual, including the individual?s spouse, if any, and any child living at home; person; ?rm; corporation; professional corporation; partnership; organization; or association. The de?nition of a service provider includes all principals who own one percent or more of the equity in the corporation or business trust, partners, and of?cers in the aggregate employed by the provider as well as any subsidiaries directly controlled by the service provider. I further warrant that I have reviewed Borough Code Section 2?4. I hereby certify that the foregoing statements made by me are true. I am aware that if any of the foregoing statements made by me are willfully false, I am subject to punishment for contempt of Court. Subscribed and sworn to before me this a day org/WM mg ,205 gn??ef?fessionan Name: St eEdwards 1? . . Tl?ei President (Signature of Notary) (Af?x Seal) TRACEY MURDOCH PUBLIC OF NEW JERSEY Samarium Expires 1013012025} Page 23 of 26 C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Public Agency Instructions This page provides guidance to public agencies entering into contracts with business entities that are required to ?le Political Contribution Disclosure forms with the agency. It is not intended to be provided to contractors. What follows are instructions on the use of form local units can provide to contractors that are required to disclose political contributions pursuant to N.J.S.A. (PL. 2005, c. 271, 3.2). Additional information on the process is available in Local Finance Notice 2006-1 2006.html). Please refer back to these instructions for the appropriate links, as the Local Finance Notices include links that are no longer operational. l. 2. 5. The disclosure is required for all contracts in excess of $17,500 that are not awarded pursuant to a ?fair and open? process (N.J.S.A. Due to the potential length of some contractor submissions, the public agency should consider allowing data to be submitted in electronic form spreadsheet, ?le, etc.). Submissions must be kept with the contract documents or in an appropriate computer ?le and be avaiiable for public access. The form is worded to accept this alternate submission. The text should be amended if electronic submission will not be allowed. The submission must be received from the contractor and on ?le at least 10 days prior to award of the contract. Resolutions of award should re?ect that the disclosure has been received and is on ?le. The contractor must disclose contributions made to candidate and party committees covering a wide range of public agencies, including all public agencies that have elected of?cials in the county of the public agency, state legislative positions, and various state entities. The Division of Local Government Services recommends that contractors be provided a list of the affected agencies. This will assist contractors in determining the campaign and political committees of the of?cials and candidates affected by the disclosure. a. The Division has prepared model disclosure forms for each county. They can be downloaded from the ?County PCD Forms? link on the Pay-to-Play web site at They will be updated from time-to?time as necessary. b. A public agency using these forms should edit them to properly re?ect the correct legislative district(s). As the forms are county-based, they list all legislative districts in each county. Districts that do not represent the public agency should be removed from the lists. c. Some contractors may ?nd it easier to provide a single list that covers all contributions, regardless of the county. These submissions are appropriate and should be accepted. d. The form may be used ?as?is?, subject to edits as described herein. The ?Contractor Instructions? sheet is intended to be provided with the form. It is recommended that the Instructions and the form be printed on the same piece of paper. The form notes that the Instructions are printed on the back of the form; where that is not the case, the text should be edited accordingly. f. The form is a Word document and can be edited to meet local needs, and posted for download on web sites, used as an e-mail attachment, or provided as a printed document. It is recommended that the contractor also complete a ?Stockholder Disclosure Certi?cation.? This will assist the local unit in its obligation to ensure that contractor did not make any prohibited contributions to the committees listed on the Business Entity Disclosure Certi?cation in the 12 months prior to the contract. (See Local Finance Notice 2006-7 for additional information on this obligation at 2006.html) A sample Certi?cation form is part of this package and the instruction to complete it is included in the Contractor Instructions. NOTE: This section is not applicable to Boards of Education. C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Contractor Instructions Business entities (contractors) receiving contracts from a public agency that are NOT awarded pursuant to a ?fair and open? process (de?ned at N.J.S.A. are subject to the provisions of PL. 2005, c. 271, 3.2 (N.J.S.A. This law provides that 10 days prior to the award of such a contract, the contractor shall disclose contributions to: any State, county, or municipal committee of a political party a any legislative leadership committee? 0 any continuing political committee political action committee) 0 any candidate committee of a candidate for, or holder of, an elective of?ce: 0 of the public entity awarding the contract 0 of that county in which that public entity is located 0 of another public entity within that county 0 or of a legislative district in which that public entity is located or, when the public entity is a county, of any legislative district which includes all or part of the county The disclosure must list reportable contributions to any of the committees that exceed $300 per election cycle that were made during the 12 months prior to award of the contract. See N.J.S.A. and for more details on reportable contributions. N.J.S.A. itemizes the parties from whom contributions must be disclosed when a business entity is not a natural person. This includes the following: 0 individuals with an ?interest? ownership or control of more than l0% of the pro?ts or assets of a business entity or 10% of the stock in the case of a business entity that is a corporation for pro?t 0 all principals, partners, of?cers, or directors of the business entity or their spouses any subsidiaries directly or indirectly controlled by the business entity 0 IRS Code Section 527 New Jersey based organizations, directly or indirectly controlled by the business entity and ?ling as continuing political committees, (PACS). When the business entity is a natural person, ?a contribution by that person?s spouse or child, residing therewith, shall be deemed to be a contribution by the business entity.? The contributor must be listed on the disclosure. Any business entity that fails to comply with the disclosure provisions shall be subject to a ?ne imposed by ELEC in an amount to be determined by the Commission which may be based upon the amount that the business entity failed to report. The enclosed list of agencies is provided to assist the contractor in identifying those public agencies whose elected of?cial and/or candidate campaign committees are affected by the disclosure requirement. It is the contractor?s responsibility to identify the speci?c committees to which contributions may have been made and need to be disclosed. The disclosed information may exceed the minimum requirement. The enclosed form, a content-consistent facsimile, or an electronic data ?le containing the required details (along with a signed cover sheet) may be used as the contractor?s submission and is disclosable to the public under the Open Public Records Act. The contractor must also complete the attached Stockholder Disclosure Certi?cation. This will assist the agency in meeting its obligations under the law. NOTE: This section does not apply to Board of Education contracts. N.J.S.A. ?The term "legislative leadership committee" means a committee established, authorized to be established, or designated by the President of the Senate, the Minority Leader of the Senate, the Speaker of the General Assembly or the Minority Leader of the General Assembly pursuant to section 16 of P.L.1993, 0.65 1) for the purpose of receiving contributions and making expenditures.? C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. This form or its permitted facsimile must be submitted to the local unit no later than 10 days prior to the award of the contract. Part l? Vendor Information VendorName: [?86 I A Address: ICIQQ Cl maid/1 City: I hr (?182 I State: NJ IZip: 0-:qu The undersigned being authorized to certify, hereby certi?es that the submission provided herein represents compliance with the provisions and as represented by the Instructions accompanying this form. ?y I S-?neren Strauss Vij? Fina/VJ: Printed Name Title Part II Contribution Disclosure Disclosure requirement: Pursuant to N.J.S.A. this disclosure must include all reportable political contributions (more than $300 per election cycle) over the 12 months prior to submission to the committees of the government entities listed on the form provided by the local unit. Check here if disclosure is provided in electronic form. Contributor Name Reel lent Name Dollar Amount I: Check here if the information is continued on subsequent page(s) Contributor Name Address: Business and Governmental insurance Agency 900 Route 9 North, Suite 503, Woodbridge, NJ 07095 Recipient Name Amy Boroff for BOE Good Government Committee Central Jersey Working Families PAC Giacobbe for Mayor CTE Figueiredo Delisfort Victory 2018 Committee to Elect Hickey, Alvarez, Medina Garwood Forward 2018 General Majority PAC Scotch Plains Democratic Municipal Committee CTE McElroy, Barker, Walsh Rahway Democratic Committee Mahr for Mayor CTE McElroy Pierce lliana Cheveres for BOE Victory 2018 Stephanie Goncalves for BOE EFO Charlene Bathelus Scotch Plains Victory 2018 Rahway Democratic Committee Date 11/29/17 02/13/18 03/06/18 03/15/18 03/27/18 04/04/18 04/19/18 05/22/18 06/14/18 06/21/18 06/26/18 07/02/18 09/26/18 09/26/18 10/16/18 10/16/18 10/16/18 10/16/18 10/16/18 10/16/18 Dollar Amount $1,000 $2,500 $1,000 $2,600 $5,200 $7,800 $1,500 $6,000 $2,500 $7,200 $1,000 $2,600 $1,500 $1,500 $2,600 $1,200 $2,600 $2,600 $7,800 $1,000 STOCKHOLDER DISCLOSURE CERTIFICATION Name of Business: I certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned, OR El undersigned. certify that no one stockholder owns 10% or more of the issued and outstanding stock of the Check the box that represents the type of business organization: a Partnership Corporation a Limited Partnership m?ubchapter Corporation DLimited Liability Corporation Sole Proprietorship nLimited Liability Partnership Sign and notarize the form below, and, if necessary, complete the stockholder list below. Stockholders: Home Address: i7 'Duotne SHeeJi' A?QarWi' IL New Vet/L, NV ((9013 Name {Richard Roads-h}, Name: Home Address: Lo (Eve Home Address: CD H's Ned: CT 0772 Name: Sex/en Ed Name: Home Address: Name: Home Address: Name: Home Address: Subscribed and sworr/Lbefore me this] day of 29 (Notary Puin 53;} NOTARY canvass; "190 ES SEXCOU IIYCOHHIS ONEXP: JUN am /(Af?ant) Sievm Strauss V10 ?mnC? (Print name title of affiant) (Corporate Seal) BOROUGH OF ROSELLE PARK THESE ARE SAMPLES OF THE ONLY ACCEPTABLE BUSINESS REGISTRATION CERTIFICATES. FAILURE TO POSSESS A NEW JERSEY BUSINESS REGISTRATION CERTIFICATE MAY BE CAUSE FOR REJECTION OF YOUR PROPOSAL REGARDLESS OF THE FACT THAT A COPY MAY ALREADY BE ON FILE WITH THE BOROUGH OF ROSELLE PARK mug; :A-z .. .4. a r?T'r?n STATE 0.- NEW unanSINESS REGISTRAT mu FICATE 2155'"; :5 5' FOR STATE MD CASINO 55mm! CONTRACTOR i- $0323 u. E: SI 7 22? TAXPAVER NAME: THAI. 2w 3?1} TAX REGISTRATION TEST ACCOUNT m1 . 1 STRAT ?f SEQL NUMBER 5? {g may: 2' a I ISSUANCE DRTE :15 . 3UNG . 01er i. . 1" 5 -.. (Lao! .. Cur-I In . 3: grand (v I ran. m1MJ?d?alntn us- e? 3.34:. f1? . -. Qua??nd. . .?fu STATE OF NEW JERSEY BUSINESS REGISTRATION CERTIFICATE Taxpayer Name: 1113; REG TIN Trade Name: Addams: '64? RUEBIJIKG AVE NI 03m I {funi?ram Number: Dale ?of Issuance: (Jemim- I4. Fur (Jf?cr Use Duly: 21104 I 1! HI 12813533 Page 24 of 26 a. 1n: . Harm Va. Alvin-mam} aulvn vuwv? vu ?my ??1ou STATE OF NEW JERSEY BUSINESS REGISTRATION CERTIFICATE Taxpayer Name: BUSINESS GOVERNMENTAL INSURANCE AGENCY, INC. Trade Name: Address: 900 ROUTE 9 NO STE 503 WOODBRIDGE, NJ 07095-1003 Certi?cate Number: 0951855 Effective Date: February 09, 1999 Date of Issuance: January 25, 2012 For Of?ce Use Only: 20120125105610755 Form W's (Rev. October 2018) Department of the Treasury Internal Revenue Service Business and Governmental Insurance Agency, Inc. 2 Business name/disregarded entity name, if different from above Request for Taxpayer Identification Number and Certification Go to for instructions and the latest information. 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. Give Form to the requester. Do not send to the IRS. following seven boxes. El individual/sole proprietor or Corporation single-member LLC Other (see instructions) Corporation Limited liability company. Enter the tax classification corporation, corporation, P=Partnership) Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is another LLC that is not disregarded from the owner for US. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3): Partnership Trust/estate Exempt payee code (if any) 5 code (if any) applies to accounts maintained outside the US.) 5 Address (number, street, and apt. or suite no.) See instructions. 900 Route 9 North, Suite 503 Print or type See Specific Instructions on page 3. Requester?s name and address (optional) 6 City, state, and ZIP code Woodbridge, NJ 07095 7 List account number(s) here (optional) Taxpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later. Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number Employer identification number 22-3329251 Part II Certification Under penalties of perjury, i certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: I am exempt from backup withholding, or have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or the IRS has notified me that I am no longer subject to backup withholding; and 3. I am a U.S. citizen or other U.S. person (defined below); and 4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct. Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and diviW not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later. Sign Here Uigfatgrseozf? General Instructions Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted after they were published, go to W9. Purpose of Form An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN). individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following. - Form 1099-INT (interest earned or paid) ?at? /.93 /?ton? - Form (dividends, in?ding tl?se from stocks or mutual funds) 0 Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) Form 1099-8 (stock or mutual fund sales and certain other transactions by brokers) 0 Form 1099-8 (proceeds from real estate transactions) 0 Form 1099-K (merchant card and third party network transactions) 0 Form 1098 (home mortgage interest), 1098-E (student loan interest), (tuition) - Form 1099-0 (canceled debt) - Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN. If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding, later. Cat. NO. 10231X Form W-9 (Rev. 10-201 8) LICENSE NUMBER State of New Jersey 9461867 Department of Banking and Insurance 20 West State Street This insurance license is Trenton, NJ 08625-0327 suspended provided that the fee set forth in N.J.A.C. THIS CERTIFIES THAT BUSINESS GOVERNMENTAL forth in .J.A. 11:17-25, INSURANCE AGENCY INC inaudingconuqurng education requnrements for resident individuals. AT BUSINESS ADDRESS SUITE 503 1 900 ROUTE 9 NORTH NJ 07095 licensee mailing address approximately 30 days prior to the ficense expiration date. IS DULY LICENSED WITH THE FOLLOWING LICENSE AND AUTHORITIES LICENSE TYPE LINES OF AUTHORITY EFFECTIVE DATE EXPIRATION DATE Insurance Producer LIFE ACCIDENT, HEALTH OR 06/01/2018 05/31/2020 PERSONAL CASUALTY WC do Acting Commissioner of printed: 04/25/2018 Banking and Insurance The Department maintains an informative website at Please visit this web page for vaiuable information and forms necessary to maintain compliance with licensing requirements. Department Contact Information web site: phone: (609) 292-4337 fax: (609) 984-5263 The request for any change of license information must be sent to the Department within 30 days of the change. Make any checks and/or money orders payable to: STATE OF NEW JERSEY, GENERAL TREASURY Mailing AddresszDepartment of Banking and Insurance 20 West State Street PO. Box 327 Trenton, NJ. 08625-0327