R2011-153 ACCEPTING BID AND AUTHORIZING CONTRACT WITH TRAVERLERS COMPANIES, INC.

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1 1 Account Executive: Rich Zak 1 TRAVELERS Fax Number: 651-3105383 ACCOUNT PREMIUM SUMMARY&PROVISIONAL BILL Entity Name: Decatur Public Transit Agency: A7 Gallagher State: IL 1 This notice serves as a premium summary and provisional bill. Acceptance of coverage means that payment is due on your account current 45 days from the effective date. The quoted premium contemplates full payment and no installment charge. To bind coverage: • Place a checkmark in the box next to the payment plan and lines of business to be bound; Indicate the effective date: Sign this form and fax to the underwriter named above. AGENCY BILL PAYMENT PLAN OPTIONS INSTALLMENT CHARGE SELECTION 1 Full Payment-due at inception None 2 Pay-50%due at inception,50%due at 6th month None 4 Pay-25%due at inception,25%due at 4th,7th&10th month None DIRECT BILL PAYMENT PLAN OPTIONS INSTALLMENT SELECTION 1 CHARGE Full Pay-Lump Sum None 2 Pay(50%and 1),paid in full 6 months prior to expiration. (Semi-Annually) $6.00 per installment 4 Pay-(25%and 3),paid in full 2 months prior to expiration(Quarterly Billing) $6.00 per installment 1 INSUREDS SELECTION COVERAGE: PREMIUM Check Box to Bind ....................................................................... .._._............ General Liability $ 1,963 x ......_.._..........._.._._........_....._....._._.._._.._._..................................................................... Auto Liability $ 70,301 x 1 ......................................................................................................................................... ............. Umbrella $ 73,055 x ................................_._._.._._.._._....._....................._..._.._._.._._._.._._.._._....................._._._...._ Total Premium $ 145,319 x ........._.._...._.._........_._............_._....._.._._._.._._.._._._....._.._._._.._._.._._._....._._._._.._....._._._....._._. Signature: Date: 1 1 l 1 1 1