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NOTICE OF EXCESS LINE PLACEMENT Village of Gowanda 27 East Main Street Gowanda, NY 140706 Consistent with the requirements of the New York Imsurance Law and Regulation 4! Village of Gowanda is hereby advised that all er a portion of the required coverages have been placed by Arthur J. Gallagher Risk Management Services, LLC with insurers not authorized to do an insurance business in New York and which are not subject to supervision by this State. Placements with unauthorized insurers can only be made under one of the following circumstances: a) A diligent effert was first made to place the required insurance with companies authorized in New York to write coverages of the kind requested; or b) NO diligent effort was required because i) the coverage qualifies as an “xport List” risk, or ii) the insured qualifies as an “Exempt Conimercial Purchaser.” Policies issued by such unauthorized insurers may not be subject to all of the regulations of the Superintendent of Financial Services pertaining to policy ferms. In the event of insolvency of the unauthorized insurers, losses will not be covered by airy New York State security fund, TOTAL COST FORM (NON TAX ALLOCATED PREMIUM TRANSACTION) In consideration of your placing my insurance as described in the policy referenced below, I agree te pay the total cost below which includes all premiums, inspection charges!) and a service fee that includes taxes, stamping fees, and (if indicated) 2 fee) for compensation in addition to commissions received, and other expenses, I further understand aud agree that all fees, inspection charges and other expenses denoted by are fully earned from the inception date of the policy and are non-refundable regardless of whether said policy is cancelled. Any policy changes which generate additional premium are subject to additional tax and stamping fee charges. Re: Policy Ne. Insurer Certain Underwriters at Lloyd's, London Policy Premium $ 2,070.00 Insurer Imposed Charges: Policy Fees ) $ 185.00 Inspection Fees () $ Total Taxable Charges $ 2,255.00 Service Fee Charges: Excess Line Tax (3.60%) $ 81.18 Stamping Fee $ 3.38 Broker Fee ( $ Inspection Fee 8 Other Expenses (specify) Service Fee $ 200.00 Total Poticy Cost $ 2,539.56 (Signature of Insured) (} = Fully earned NYSED Form: NELP/2011