~ ~ ~~o DECEIVE O \P,TIOAr p - y : ~~ Texas Association of Counties ~p~ g g 204 < - ~'~ County Government Risk Management Pool + ~ ~1 5°' I. Name of Political Subdivision: 7~~d ~ 2. Address (No. & Street or P.O. Bol~x//): City, State, Zip: ~ Y'l~I~'~G~e Contact Name e m n7 ~'I T m/ten rS~g n E-mail Address Telephone Number: ~30 ~~9o`Z o~ o~ 3 / Fax Number: _ ~c~ llci/i'f~ ~Yt, CUm ~'so ~9~ aa~ 3. a) Population of county or applicant's political subdivision: ~S COQ cost Source: ~'C~Sl13 b) Number of employees for entire political subdivision: ~G3 Full time, including elected officials Part-time (all others except full time) Volunteers 4. Quotation is required by the following date: ~ • ~ ,Q ) 5. Desired Effective Date: l 1 " ~ ~ Retroactive Date Desired: `'~~A , / _ 6. Deductible Desired: / ~~ ~~ ~ Current Annual Premium: ~ I r 7 7. Indicate each particular Law Enforcement Office, Department, or Agency for which you are applying for coverage (Example: Sheriffs Dept., Constables' Offices, Detention Facilities) AND include County personnel and County approved volunteers and reserves under Question #B below: NOTE: The indication of entities above does not ensure coverage, such coverage being limited to the terms and definitions of the coverage document. 8. Please indicate the number of officers in each Rating Classification listed below. (Include County personnel and County approved volunteers and reserves for all Law Enforcement Departments, Agencies and Offices listed under Question #7 above.) g If any officers or\other personnel work part time, show the percentage of part time hours: 6 ~ .-- v ~" CLASS A #~ Include under this class: Only front line personnel with arrest powers who are armed and actively engaged in the prevention of crime and apprehension of criminals, including Jailers and Constables. C SS B # ~ ~ Include under this class: County Juvenile Probation Officers when paid by the County. (If only a portion `of their salary is paid by the County, advise percentage.) CLASS C # ~/Include under this class: Dispatchers, staff involved in clerical or other office work, or any auxiliary personnel- Also include prosecutors' criminal investigators and unpaid auxiliary or reserve officers. TAC LE APP NEW BUSINESS OS-01 Board Approved 09-06-00 If you have Quettiorzr regarding completion of tbir application, please contort ut at: 1-800-456-5974; Faaimile Line: 1-512-478-1426; or E-mail.• TlICPoolrCa~county.osg Please return thin completed application ta: T!!C County Government Ritk Management Paal, P. D. Box 2131, Aattin, 1'exat 78768 Rr~-~.~-zcio4 ~~~u i 1. ~ A,~ ~r,~~ ~ssr~ or cour~ > t~ ~ ~ ~ r1o. ~: %~~~ iJ ~ a?e i`' _ /~ 7 ,s ha-it ;uvcr~~e eu,ch+d:'s CunlClyz darn.tgcs or czemp ar;~ damages. However, shit •tcverage tan bs ndd::d by r.nr.,?r°: r.;uc:nc for are editicr.ai enttribukion. (~o yc,lr w,sY~ [o Induct^. endorsement fur punitive or exemplary camagcs? ~.~ Y65* _-,...._ t`d'J "iF V'Ec: a) f.tlvi.c (Emit dcsirec. __. X50;' 0., ___.__5;40s~OrJ.: or ~--~I,GtlQ,D¢~.; and b Advice if yo ~ dairc [hs {unit: ~- included wi[Fin the !units of lia..ilir/, or r r ) _,.~-~ , ,•,. -'tn add;tion to [hc Lmie; of !iai,i!1[y, {,.~~~~51 f"~\ ~• IC ;'rav:dc r!~,;aii5 of fi-inr i:w cn'or'ccn-•ert orofessiornl liability coverage o~ insurance for tl,c iasc truer` (5) years; __ _ _,_..._...~_-._...-----7- -r-- ~..~_~. _ r'•rc[ ~ ir,cU^er or Covere~,e Provider; ~ Lirni[': of ! ILhlliry D:ductlbfn I !'+•c;r:n m ~ IJ) UC;urrence err -~ (arc n ! -to) ~ - I . • i ---- ` tC) taauns h1udc `~ __- .......~~i?ll r,l~-'_~~-s~r.~,u~~:> _~!. aao, Ovo+-~f-_°i ~ ,-$c~'i ,~`'7 ~' .~- G_` ~=--- o~~ , F - -~ ~r_~.?.'-..~ ~---r__.....-'----- '---- --- --~-...~__._ i _-_ _ !r 1.x;1..., ~ ~ -. ---- ~ ~~ ~ I ! a) ~'rr.+•'d ; d^rails of a,iy Qcneral fi;~i'iry poll~y vi~ith may provide [overzge for cllc 3pp;iant: Csfrl0r: _. _r ~~... ,_-... _. _..-~ C{FEC CIIC 171iC: _J_ b) Fr.'.rJila ac[.aiix :,f any automobile liabi!iry pol!cy w!:ich miry provide coveraEc fo- ch: applicnnc - :~ ... . __... .__....-- r.Ffective ryote:'----:..-.~-. C~Kricr: .... Limier of l Is,Ci:icy _....... _.---._ ._..._:_ .._~_. 12. Sala=tion a:rc Training Procedures' s) t)cacr:br: ;.he S?rrir.~ and su'cenh~ }:rxodures in use to dccermine ezcil icG applicant`s f[ness for crrpiuymenc s::l ; rss A uf(irer.:r.; dcr,red under ~ucstion di3 of the app:ica[ien (Includ`i~ng tl-. psyehnlogica; cva~e,auor, methods °n use); ;,._ _. wr ~t , a) C?r:.•.„dbc the mirli~~•.urn cdu'~arlnral criteria a jn6 a' li :m[ muse metL fo\r sat~ried d!_ruucs: • '~.- _ ` ~.~~•-:,.:•,~ mar..... - `. ~;_L i~.t;,>r C`e r. .~c~ ."`a?.'.`..~-- ~e^Jt= ,\1:F _ ~~`^c~~- ~c ~~~'•~_ [) 4~t.<,-rir.;~ ble trlfnbmum ,,rrved by r .r:p~=rvi:or, for c.3ch law enfsrc~'n t~r~: ofii: ;+,ep;a: tme-,.c a° a~ancy far which coverage n nppfrrd: ~``!r=: `. ,.. ~:~~~L'~r~'<=`,..`~.c,\~.~1n~'\ -SC"1...... `~ ='u:':_`=. ~i`1:..~,_~~~1~~.;b~a~\ \r„~i~.~\.1._.~.--..,~_ t.. ~., :~r~y i`:v+• :^.nforceinenT offi:e-, efflcc reparGnicnt or asency for whkh co+~^ra,;e is ap~Ucd under any criminal or administTnrivc rnvestigatien? ___ YC-S* _ i~ _ ,iCJ *1^r 'YES, provide de:ads or ciresnucances which are unprivileged public information: in I: q;arr{.:I; ';eren!ien Facilitic;: _ I :r!rr.: "' F:->v. many t.+c~lic:rs. 'are a} uly'n~ tc.r coverage: -- _ i;. Fo° ~:Irh r,occd aGovc. (:rov;dr_ the fo!Ic,wirg hforn~atian. (ir more than one, provide ttlic inf~rm:rion ceparac^!y 1.'.C C]~ y 7y ~TCaG!1 n+(:.'lt of GF~nilr3r.:` Siq C,°. t: ~: _ '.~ ' ~ ~ _ ~ N~ ,~^~ I I:~Jinr.^, tl[e tyr:c of this fnei'icy: _ f'I: ~ __.Med V iti __.l.ork Up Tc,nporary xCacrncy Correctional Center .___fr~u^,ii3 UC~:CnCi;:n Center __ 3ooe Carr,; ,(ocher; _--_--_. ... ,._-- '2. i;,;sitai InfannaroM.~,~~Number of Cclis; ,~~.. C:apac':y of Each <~eil:~ ~`~ 3. 1'r.;vi::,r ~~ ~~Sc~ce AuCwrized ~aoacrcy-~'~,~'),~_ r'.vera~e Qa3Iy' POpUlacinr,: ~~~^~ ,__ ~ I~ ;: is fa:iiicy ::.rn. nc'y ir. cornoliance wl•_h the sclr:dard•. and/er requirerne.ncs of the slate cerufica;ion "_y wcr thi:. fn _ility ;euampic: l"exas Cort,nision on ii Standard.)? ~ _._ YES ,.__ NC,!+ '' li= h3 d3, :ndic;,.ar scci~n:: b.:ing wkcn co Sting ct fr hadiicy into cemp;iantc: 5. f; ;.' i; 1:~ciliry opr:'Iting unr.cr any variancet __- YES" - i y_ NC) +iY YE5 prn~:iciz artach;nr.n[. of ~pprov~+u vat; ar cc 5. t, r+r; ;,;',~ ~~ rc;;r,ic~n Grcifi,ies or F+•u~rams under any c^urt ordcr.d moni~erin~ or s:r,~crvi.Sir~n? _, __,__ Y4S' . __~ fJ;; ''iir YtS, provide dc:u,iL•: ~ ~ ,, ~ _ ;~ i~,...n , :gyn.,. I r 13. ~12aS:: ir..,c;,[c If ycu ;.aruripace in any of t`!e fo8ow;ng and provide the name(s); Indicate here if r;,nr, „____, __, ,!AN-2~'-20U~ THU 1? ; !2 A"I TX RSSN OF COUNi~fE:'~ ~~;a~ tJ~i. 5'.?478=~~ 42F~ ?, G4 i _, i` them have beer no :uch claims or cults, Indicate rlerc: ~_„_~ ', [)ttc of i t7a:c vl ~ Narure of Grim C1's'~^.i ~ Vn:.'~.dC~.nC I ~ ~:.x- ~ y11i/I ~Y~~ L__ __ "__ __. ~-- 1... Current ~ Loss I Staves '• Reeerves ` _ ~ Tccai Paid -' 1j~(iidudl+lg 1~xpenses) __ ~ S i ..__~__.._ F-----_._., g _ ~ ~ ~ _ i . ~- ~ _ _.,___ ^.__~...! _.._ t ~ ~ ~~. .... i $ V _.. _---- .. _~_~_~ L-1-.---~ ._ S1 1'i e' :e provide da4zilG r f tihe clnims sunimr.rized aocve ay attxhm`~nc c•i a compfe:c''ir~dlrcdual Claim Data Reporr," for each. l,i;' , ,t. I`% Art yr i:, ot• is any member cl your staff, now aware or have any knovv,odge w''~ac.~evcr a` any circumstances, occurrenees, lads or J ~ t:v^_ is .a`;ic4i arc likely to b~ a bnsi, of a claim ei:ner now or in tn_ iucure! __.._.. `'FS" _~- . Flo 'iF `t'c"S, cani~lctc an "indivi.'.ual Claim Data Fteoort" for each. 'i 'lc,ta ciue:Cir:ns in dsis aCpGeation seek inForn>sdnn from applicant which may be uses by the Fooi in processing the appti:adon or in ;ca:.ini; c4.vcraRc ncc!i:- of p~lickat zuodivisicnz, The questicnt pcsed, or ary wording of c'r~c application, should nat and rnly not 6c r.'ird upon 6r nnpiica:u as F,avir,~; ri implicztion that there e:a,;cs coo=_rogc Yor any paracu'ar r_laim, or class of claim., whenev;:r made. Thr: pri,'vi,~on; of eov;:ra~r. arc iG~:rtEG in chC issued Cav¢rage Document, Including (aecle,ra:ions and any er•dorsements, f,ravided to a covered p;:'Icicci subdivalon, 1°diC ac:c;.r nr,tlce that any covetzgc which may be Issued veil; apply on a "r't,AIM~ MAD= n.asi5," and that any failure to answer any •.r,p!ieacior F:i>rtion or question fully and accurac~ly roropramise;. eoveragr' provided by chc Focf tv the applicant parsuant to c'~o terms ~? il(^ C::vu-:,Fc Uocun^ent. may.-.._-~~-~-. _ ~~ „,:,mot-. - ---_ .~ =t . _~_.,. _..._ ._ .. "Tic;c _ ..- -._._.._~_ _~... c~t,•: _/~-3f_ ~3 .r.. ~ ~-Z'ounia 11,3F.. (c-• pia>fEintj o~i~.~Gl of ch: ~c Gciu~n~ ~ ~- . "_P:iN(; 7i•IIS FORM Das:S NOT t31t~lD 'fHE APPLICANT POUTlCAL SUBDIYISiUN DR 7HE FOOL TU CO""PLETE THE CO'dEOAGE, ".{'i:'icatf;ri ;Host be si[;;ied and dated by the County Jajg;, for applicable presiding of'ic~al) co be cons;tiered For quoantivn. ?LEA.Sc SEND THIS APPLICATION T'O; 7AC C{~L'NT1' Gt~VERr,!~~iENT RISK MAh!AGEMENT POOL T.O. POXtl3i AUSTIN, TEXAS 7871,8 TEXAS vVATTS: (9~0) 456.59%4 F.aX• (5 i 2j 178 i'f?b ~xww.courry.org ilk ....1 ~ ~•'" ~ ^'~ - e ___. / _ t. a i e non ncv. r. Isn~;t:: cc : ; ; I " •: /1~ Provf:~e Haim hist., r; (insured and/or uninsured) for rer las':5 years. Include any claims ar soles n;ade cr brou;hc ^Rainu die aprlica^,~ o; n,a;.:inse. ary offici::lc o~ ^_mp(oyces, which may be believed [a have faliCr, wichi~'. the scrpe of clvi covera~_ and iC been in effect. RECE~~~ O `pt 1 O~y O - - ,~ ~ Texas Association of Counties JAPE 0 $ 2QQ~ a ~ County Government Risk Management Pool +~1 SaY Name of Political Subdivision: I. Does the applicant's county population mandate creation of a County Bail Bond Board? (Note: A county population of 110,000 or more mandates creation of a County Bail Bond Board, per TEX. REV. CIV. STAT. Art. 2372p-3, part of Title 44.) YES No 2. Has the county created a County Bail Bond Board? YES ~~ No 7AC LE ADDENDUM -BAIL BOND BOARDS I2-00 Board Approved II-28-00 ~ECEti~E s Member Name: _ \ ~~ Name of Mutual Aid Agreement or Task Force: ~~ ~~~ ~~~~ ~.v~~<~ic ~ ~`~~~~ ~~Z ~~~~~~C Texas Political Subdivisions participating in the above are: ~Z ~ ~E- L~~ S --, •, ~~~cZ.~F ~L`~`~ ~~~~ ~~~ - ~ - ~ -~ <~ G 7AC LE OTHER JURISDICTIONS LISTING 09-00 O Owrd Approved 09-06-00 O``pTION O g f1 Texas Association of Counties ~A~ 0 $ X004 0 O County Government Risk Management Pool ~ fi31 5~ ti RECEiYEE 13. Please indicate if you participate in any of the following and provide the name(s): Indicate here if none: Task Force (Law Enforcement) *If checked, list Task Force name and other participating Texas Political Subdivisions: Mutual Aid Agreement *If checked, list names of other participating Texas Political Subdivisions: 14. Describe the policies relating to private or off-duty employment, (including "moonlighting" for other employers), and note whether it must be approved by a supervisor, for each law enforcement office, department or agency for which coverage is applied: I S. Is any law enforcement officer, office, department or agency for which coverage is applied under any criminal or administrative investigation? YES* NO *IF YES, provide details or circumstances which are unprivileged public information: 1~ I6. Regarding Detention Facilities: a. Indicate how many facilities are applying for coverage: _~ b. For each noted above, provide the following information. (If more than one, provide this information separately for each by attachment of separate sheets): Name: I. Indicate the type of this Facility: -Max _Med -Min -Lock Up -Temporary ~Quvenile Detention Center -Boot Camp -(other)- County Correctional Center 2. Physical Information: Number of Cells: ~ ~ l Capacity of Each Cell: 1 3. Provide: State Authorized Capacity: ~ 1 Average Daily Population: _~J 4. Is this facility currently in compliance with the standards and/or requirements of the state certification agency over this facility (example: Texas Commission on Jail Standards)? / YES NO* *IF NO, indicate actions being taken to bring this facility into compliance: 5. Is this facility operating under any variance? YES* / NO *IF YES, provide attachmenC of approved variances. 17. Are any detention facilities or programs under any court ordered monitoring or supervision? YES* / NO *IF YES, provide details: RE~F11iER TAC LE APP NEW BUSINESS OS-01 ~~"' O ~ aOO4 Board Approved 09-06-00 CNA EX.ESS AND SELECT Detail Loas Run/Rerr Co. Juvrnile LAW JWP CLAIM DETAIL ANALYSIS Carr D ALL Select Period: As o£: Activity Yeriod: Printed: 06/11/2003 page: 1 State 0 ALL 01/01/1997 - 06/11/2003 06/I1/2003 06/11J2002 - 06/11/2003 Agent 0 ALL Selected by: Claims With Incurred from: Insd 0 ALL DATE REPORTED -$9,999,999 thzu $99,999,999 Leg/Oth: YES Recover YES Proc D££: ALL ALL CLAIMS IN DATE REPO RTED ORDER POR CALENDAR YEARS 97 Zafo-Daly: YHS Late-Rpt: YES Maint-Only: YES ~HistSumm: N/A Claim Sts Carrier Losa Reported Entry Deaied Closed Reop ea Paid ia --- ------TOTALS AS OF: 06/11/2003-------- No No Date Late Hate Date Date Date Pay Period Paid Reserve Lacurred Open Closed Claims Claimants Pay Period Paid Reserve Incurred TOTALS: 0 D 0 0 Sod Inj: p_p0 Legal: 0.00 Other: 0.00 Adjust: O.OD Prop Dmg: __________ _ 0.00 _ TOTALS: 0.00 __________ ___________ ___________ 0.00 0.00 0.00 Sub ro Eet Totals: Subro Recov Totals: Subro Recov Totals: 1 Deduct Reo ov Totals: Deduct Potential Totals: NET: D.00 RECIFEY~E3 JaN 0 8 2004 CNA EXCESS AND SELECT Detail Losa Run/Kerr Co. Juvenile LAW JWP CLAIM DETAIL ANALYSIS Carr 0 ALL Select Period: As of: Activity Period: Printed: 06/11/2003 Page: 1 State 0 ALL 01/01/1997 - 06/11/2003 06/11/Z003 06/11/2002 - 06/11/2003 Agent 0 ALL Selected by: Claims With Incurred from: Inad 0 ALL DATE REPORTED -$9,999,999 thru $99,999,999 Leg/0th: YES Recovg: yE5 Proc Off: ALL ALL CLAIMS IN DATE REPORTED ORDER FOA CALENDAR YEARS 97 Info-Only: YES Late-Rpt: YES Maint-Only: YES +EistSumm: N/A Claim S te Carrier Loae P.eported Entry Deaied ______ Closed Reopea Paid ia ---------TOTALS AS OP: 06/I1/2003-------- Nv Nv Date Date Date Date Date Date Pay Period Paid Reserve Incurred Open Closed Claims Claimants Pay Period Paid Reserve Incurred TOTALS: 0 0 0 0 Bod Inj: 0.00 Legal: 0.00 Other: 0.00 Adjust: 0.00 Prof fig: ___________ ___ 0.00 ___ TOTALS: 0.00 _____ ___________ ___________ 0.00 D_DO 0.00 Subro Est Totals: Subro Recov Totals: Subro!Recov Totals: Deduct.Recvv Totals: _____ Deduct Potential Totals: ____________________________________________________ _____________________ NET: 0.00 CNA EXCESS AND SELECT Detail Loss Rua/Rerr Co. .juvenile LAW JWF CLAIM DETAIL ANALYSIS Carr ALL Select Period: As of: Activity Period: Printed: 06/11/2003 Page: 2 State ALL 01/01/1997 - 06/12/2003 06/11/2003 06/11/2002 - 06/11/2003 Agent ALL Selected by: Claims With Incurred from: Iasd ALL DATE REPORTED -$9,999,999 thru $99,999,999 Leg/Oth: YES Recovs: YES Proc Off: ALL ALL CLAIMS IN DATE REPORTED ORDER POR CALENDAR YEARS 97 Info-Only: YES Late-Rpt: YES Maint-Only: YES *Hie tSUmm: N/A Claim Sts Carrier Lose Reported Entry Denied Cloned Reopen Paid ia --- ------TOTALS AS OP: 06/11/2003-------- No No Date Date Date Date Date Date Pay Period Paid Reserve Incurred Open Closed Claims Claimants Pay Period Paid Reserve Incurred TOTALS: 0 0 0 0 Bod Inj: 0.00 0.00 0.00 0.00 Legal: 0.00 0.00 0.00 0-00 Other: 0.00 0.00 0.00 0.00 Adjust: 0.00 0.00 0.00 0.00 Prop Dmg: 0.00 ___________ _ 0.00 0.00 0.00 __________ __ _ TOTALS: 0.00 __ ______ ___________ 0.00 0.OD 0.00 Sabra Est Totals: 0.00 Sub ro Recov Totals: 0.00 Subro Recov Totals: i]-p0 ~ Deduct Recov Totals: O,pp _____ ___________________________________ Deduct Potential Totals: x].00 _________________________ _____________ NET: ].DO NO CLAIMS PODND FOR REPORTI CNA E%CESS AND SELECT Detail Lose Run/Rerr County S.D. LAW JWP CLAIM DETAIL ANALYSIS Carr 1 Columbia Caaual Select Period: As of: Activity Period: Printed: 06/11/2003 Page: 1 State 42 THXAS 01/01/1997 - 06/11/2003 06/11/2003~D6/11/2002 - 06/11/2003 Agent 155 Furman Ina Agea Selected by: Claims With Incurred from: Znsd 856 Rerr County SD DATE REPORTED -$9,999,999 thru $99,999,999 Leg/0th: YES Recover: YES Proc Off : ALL ALL CLAIMS ZN DATE REPORTED ORDER FOR CALHNDAR YEARS 97 Info-Only: YES Late-Rpt: YES Maint-Only: YES iAistSumm: N/A Claim Sts Carrier Lose Reported Entry Denied Closed Reopen Paid in ---------TOTALS AS OP: 06/11/2003-------- No No Date Date Date Date Date Date Pay Period Paid Reserve Sncurred ER650 C 01/30/98 04/06/98 04/09/98 05/20/98 Loaa: 97 SBIZURE Deac: WRONGFUL SEIZURE OP AUTO Claimant: POZS E~.L, CARLA Totals: 0.00 0.00 0.00 0.00 Deduct Recov: 0.00 Deduct Remaining: 0.00 Subro Recov: Subro Recov: 0.00 Subro Estimated: 0.00 ---CLAIM Si7iR~ARY--- Totals: 0.00 ____________ ___ O.OC 0.00 _________ ____________ 0.00 _ NHTc _ __________ 0.00 ' ER1098 C 08/07/98 1D/01/98 11/02/99 02/01/00 02/01/00 Lose: 75 JAIL CONDITIONS Deac: JAIL CONDITIONS/ INJ RELIEF Claimant: CORNELIUS, ROBBY Adjust: O.OD 263.50 0.00 263.6( Totals: 0.00 263.50 0.00 363.5( Deduct Recov: 0.0( Deduct Remaining: 263.5( Subro Recov: Subro Recov: 0. 0( Snbro Estimated: 0,0( ---CLAIM SUMMARY--- Totals: 0.00 263.50 0.00 p, 0( NET: 0.01 BR3808 C 06/27/96 10/01/98 11/16/99 06/11/02 Loss: BS FALSE ARREST Deac: FALSE ARRHST Claimant: WHEEI-.DCA/ 355, SCOTT fi Legal: 0.00 5023.74 0.00 5023. 7~ Adjust: 0.00 916.50 0.00 916. 5~ Totals: 0.00 5940.24 0.00 5940-2 Deduct Recov: 5023.7 Deduct Remaining: 916.5 Subro Recov: Subro Recov: 0.0 Sub ro Bstimated: 0.0 ---CLAIM SUMMARY--- Totals: 0.00 ____________ ___ 5940.24 0.00 _________ ____________ 0.0 ___________ NET: O.Of CNA EXCHSS AND SELHCT Detail Loss Run/K err County S.D. LAW JWF CLAIM DETAIL ANALYSIS Carr 1 Columbia Casual Select Period: As of: Activity Period: Printed: D6/I1/2 003 Page: 2 State 42 TEXAS 01/01/1997 - 06/11/2003 06/11/2003 06/11/2002 - 06/11/2003 Agent 155 Purman Ins Agen Selected by: Claims With Incurred from: Insd 856 Kerr County SD DATE REPORTED -$9,999,999 thru $99,999,999 Leg/0th: YES Recova: YES Proc Off : ALL ALL CLAIMS ZN DATE REPORTED ORDER FOR CALENDAR YEARS 97 Info-Only: YES Late-Rpt: YES Maint-Only: YES { HistSumm: N/A Claim Sts Carrier Loss Reported Entry Denied Closed Reopen Paid in TOTALS AS OP: 06/1 1/2003-------- No No Date Date Date Date Date Date Pay period Paid Reserve Incurred ER854 C 06/17/98 10/O 1/98 10/22/96 DB/D1/DO Loss: 91 MED DHPRIVATIObE Desc: MSD DEP/ SLZP ~ FALL Claimant: NICOI~AS, ALBERT Adjust: 0.00 542.50 0.00 542.50 Totals: 0.00 542.50 0.00 542.50 Deduct Recov: 0.00 Deduct Remaining: 542.50 Subro Recov: Subro Recov: 0.00 Subro Estimated; O.p0 ---CLAIM SUMMARY--- Totals: 0.00 ____________ ___ 542.50 0.00 _________ ____________ 0.00 _______ NHT _____ : 0.00 HR3964 C 06/06/98 06/28/00 06/29/00 05/08/02 04/10/02 Loss: 91 MED DEPRIVATION Desc: MED DEPRIVATION/ SAIL CONDITIONS Claimant: CULL7.PORD, GRAHAM Legal: 0.00 42765.58 0.00 42765.5E Adjust: O. OD 250.00 0.00 250.0( Totals: O.DD 43015.58 0.00 43015.5E Deduct Recov: 6000.0( Deduct Remaining: 0.0( Subro Recov: Subro Recov: 0. 0( Subro Ss timated: 0. O( ---~CLAZM SIIFMARY--- Totals: 0.00 43015.58 O.OD 37015.5E NET : 37015.5E CNA EXCESS AND SELECT Detail Loss Run/Aerr Covnty S.D. LAW JWP CLAIM DETAIL ANaLY52E Carr 1 Columbia Casual Select Period: As of: Activity Period: Printed: 06/11J2903 Page: State 42 TEXAS 01/01/1997 - 06/11/2003 06/11/2D03 06/11/2002 - 06/11/2003 Agent 155 Furman Zns Agen Selected by: Claims With Incurred from: Insd 856 Rerr County SD DATE REPORTED -$9,999,999 thru $99,999,999 Leg/Oth: YES Recovs: YES Proc Off : ALL ALL CLAIMS IN DATE REPORTED ORDER POR CALENDAR YEAP.S 97 Info-Only: YHS Late-Rpt: YES Maint-Only: YES +RiatSumm: N/A Claim Sts Carrier Loss Reported Entry Denied Closed Reopen Paid ia --- ------TOTALS AS OF: 06/11/2003-------~ No Na Date Date Date Date Date Date Pay Period Paid Reserve Incu-red Open Closed Claims Claimants Yay Period Paid Reserve Incur=ed TOTALS: 0 5 5 5 Hod Inj: 0.00 0. 0~7 0.00 0. O( Leal: 0.00 47789.32 0.00 47789.3: Other: 0.00 0.00 0.00 0.0f Adjust= 0.00 1972.57 0.00 1972.51 Prap Dmg: D.00 ___________ _ 0.00 0.00 0.01 __________ ___________ ___________ TOTALS: 0.00 49761.82 0.00 49761.8: Subro Est Totals: 0.0t Sub ro Recov Totals: 0.00 Sub ro Recov Totals: 0.01 Deduct Recov Totals: 11023.7• Deduct Potential Totals: 1722.51 NET: 37015.51 __________________ CNA BXCESS AND SELS CT Detail Losa Rua/Bert County S.D. LAW SWY CLAIM DETAIL ANALYSSS Carr 2 Continental Cas Select Period: As of: Activity Period: Printed: 06/11f 2003 Page: 4 State 42 TEXAS 01/01/1997 - 06/11/2003 06/11/2(103 06/11/2002 - 06/11/2003 Agent 155 FIIRMAN INSIIRANC Selected by: Claims With Zacuzred from: Inad 85fi RERR COIINTY SHE DATE REPORTED -$9,999,999 thru $99,949,999 Leg/0th: YES Recover: YES Proc Oft : ALL ALL CLAIMS ZN DATE REPORTED OADEA POR CALENDAR YEARS 47 Snfo-Only: YES Late-Rp t: YES Maint-Only: YES *HistSua®: N/A Claim Sts Carrier Loas Reported Entry Denied Closed Reopen Paid ia ---- -----TOTALS AS OP: 06/11/2003-------- No No Date Date Date Date Date Date Pay Period Paid Reserve Incurred %R3825 C 11/24/98 10/01/99 12/20/99 (13/05/02 Loss: BS FALSE ARREST Desc: PALSS ARREST & I MPRISONMENT Claimant: SEIDBR, MARA Leqal: 0.00 17142.80 O.OD 17142.80 Adjust: 0.00 1150.00 0.0(1 1150.00 Totals: 0.00 18292.80 0.00 18292.80 Deduct Recov: 5000.00 DeduC[ Remaining: 0.00 Subro Recov: Subro Recov: 0.00 Subro Estimated: O.DO -- -CLAIM SDMMARY--- Totaln: 0.00 ____________ __ 18292. Hf1 0.00 __________ ____________ _ 13292.80 ___________ NET: 13292.80 EA3946 C 12/01/99 06J05/OD O6jO6j00 OS/15/O1 D4/16/O1 Losa: 85 PALSE ARREST Desc: FALSE ARREST/ STRIP SEARCR Claimant: O'NEAL, PAIII,A Adjust: (1.00 1150.00 0.00 1'_50.(10 Totala: O.OD 1150.00 0.00 1150.00 ' Deduct Recov: D.OC Deduct Remaining: I150.OC Subro Recov: ~ Subro Recov: D.OC Subro Estimated: D.OC Claimant: O'NERL, IINANOWN Totals: 0.00 0.00 0.0(1 0.0C Deduct Recov: 0.0C Deduct Remaining: O.OC Subro Recov: Subro Recov: Subro Estimated: 0. O( - --CLAIM SUMMARY--- Totals: 0.00 1150.00 0-00 D AC NET: D. 0( CNA EXCESS AND SELECT Detail Loas Run/Eerr County S.D. LAW .7WP CLAIM DBTAIL ANALYSIS Carr 2 Continental Cas Select Period: As o£: Activity Period: Printed: 06/11/2003 Page: 5 State 42 TEXAS 01/01/1997 - 06/11/2003 06/11/2003 06/11/2002 - 06/11/2003 Agent 155 PVRMAN INSURANC Selected by: Claims With Incurred from: Iasd 856 RERR COUNTY SHE DATE REPORTED -$9,999,999 thru $99,999,999 Leg/0th: YES Recovs: YES Proc Dff : ALL ALL CLAIMS 1N DATE REPORTED ORDER FOR CALENDAR YEARS 97 Into-Dnly: YES Late-Rpt: yE5 Maint-Only: YES ~IiistSumm; N/A ________ Claim s___- -______________________ _ Sts Carrier Loss Reported Entry Denied Closed Reopen Paid in ---------TOTALS AS OF: 06/11/2(103-------- No No Date Date Date Date Date Date Pay Period Paid Reserve Incurred EIC3959 C 03/24/99 06/20/00 06/21/00 06/03/02 Loss: 93 NEGLIGENCE Desc: NEGL INJURY TO DETAINEE Claimant: WHESLOCK/ 354, SCOTT Legal: 0.00 2434.13 0.00 2934.13 Adjust: 0.(10 250.00 0.00 :50.00 Totals: 0.00 3184.13 0.00 3184.13 Deduct Recov: 2?34. 13 Deduct Remaining: :50.00 Subro Recov: Subro Recov: 0.00 Subro Ss timated: 0.00 ---CLAIM SUMFfARY--- Totals: 0.(10 3184.13 0.00 0.00 NET: 0.00 EX5515 C 07/20/00 01/19/01 01/22/01 12/12/02 Loss: 85 FALSB ARREST Desc: FALSE ARREST/ MED DEPRIVATION Claimant: BARTON, PAUL Legal: 125.00 125.00 0.00 I25.OC Adjust: 0.00 1150.00 0.00 1ZS0. OC Totals: 125.00 1275.00 0.00 1°75.00 Deduct Recov: I25.OC Deduct Remaining: IISO.OC Subro Recov: Subro Recov: 0.0( Snbro Estimated: 0. OC ---CLAIM SIIPR3ARY--- Totals: 125.00 1275.OFl 0.00 O. Of NBT: 0.0[ ER5520 C 12/02/98 01/25/01 01/29/01 12/14/01 Loss: 91 MED DEPRIVATION Desc: MEDICAL DEPRIVATION Claimant: NORRI S, WILLIE Legal: 0.00 2814.20 0.00 2E19. 2( Adjust: 0.00 250.0(1 0-00 X50. D( Totals: 0.00 3064.2(1 0.00 3064.2( Deduct Recov: 2E14. 2[ Deduct Remaining: X50. 0( Subro Recov: Subro Recov: 0. 0( Subro Estimated: D. O( ---CLASH SLJHR4ARY--- Totals: O.DO 3064.20 O.OD D.00 NET: 0.00 CNA ESCCESS AND SELECT Detail Lose Run/&err County S.D. LAW .7VTF CLAIM DETAIL ANALYSZS Carr 2 Continental Cas Select Period: Aa of: Activity Period: Punted: 06/11J2003 Page: 6 State 42 TEXAS 01/01/1997 - 06/11/2003 06/11/2003 06/11/2002 - 06/11/2003 Agent 155 FURMAN INSURANC Selected by: Claims With Incurred from: Inad 856 REAR COUNTY SHE DATE RBPORTED -$9,999,999 thru $99,999,999 Leg/0th: YES Recover: YES Proc Off: ALL ALL CLAIMS IN -ATE REPORTED ORDER FOR CALENDAR YEARS 97 Info-Only: YES Late-Rp t: Y85 Mant-Only: YES "RiatSUam~: NfA Claim Sta Carrier Loss Reported Entry Denied Closed Reopen Paid in --TOTALS AS OF: 06/11/2003-------- No No Date Date Date Date Date Date Pay Period Paid Reserve IACUrred 8105560 O 02/26/00 03/08/01 03/09/01 Loss: BS FALSE ARREST Desc: FALSE ARREST/ MAL PROS Claimant: SHLBLDS, HAROLD Bod Inj: 0.00 0.00 75000.00 75000.00 Legal: 37229.19 fi7468.39 17531.fi1 85000.00 Adjust: 0.00 1150.00 0.00 17:50.00 Totals: 37229.19 68618.39 92531.61 161150.00 peduct Recov: 5000.00 Deduct Remaining: 0.00 Subro Recov: Subro Recov: 0.00 Subro Ea timated: 0.00 --- CLAIM SUMMARY--- Totals: 37229.19 68618.39 92531.61 156150.00 NET: 156250.00 EX5622 O O1/YB/O1 05/16/01 OS/31/D1 Lose: 93 NEGLIGENCH Deac: JAIL PREMISES LIABLLITY/ CDNTUSI claimant: MATTHEWS, NAT1iAN Bod Znj: 0.00 0.00 5000.00 5000.00 Legal: 812.50 812.50 9187.50 20000.00 Adjust: 0.00 1150. 0(d 0.00 1150.00 Totals: 812.50 1962.50 14167.50 16150.00 Deduct Recov: 0.00 Deduct Remaining: 10000.00 Subro Recov: 9ubro Recov: 0.00 Subro Estimated: 0.00 -- -CLAIM SiJM14AAY--- Totals: 812.50 1962.SU 14167.50 6150.00 NST: 6150.00 CNA EXCESS AND SELECT Detail Loas Run/Aerr County S.D- LAW JWP CLAIM DETAIL ANA_.YSIS Carr 2 Continental Cas Select Period: Aa o£: Activity Period: Printed: 06/11/2003 Paqe: 7 State 42 TEXAS 01/01/1997 - 06/11/2003 06/11/2003 06/11/2002 - 06/11/2003 Agent Iaad 155 PLTRMAN INSIIRANC Selected by: B56 KERR COUNTY SHE DATE REPORTED Claims With Incurred £rom: -$9,999,999 thru $99,999,999 Leg/0th: YES Recovs: YES Proc Off: ALL ALL CLAIMS IN DATE REPORTED ORDER POR CALENDAR YEARS 97 Info-Only: YSS Late-Rp t: YES Maiat-Only: YES *His tSuam: NJA Claim Sts Carrier Loae Reported Entry Denied Closed Reopen Paid in ---------TOTALS AS OP: 06/11/2003-------- No No Date Date Date Date Date Date Pay Period Paid Reserve Incurred ER5774 C OB/10/00 12/14/01 01/02/02 01/22/02 Loss: 120 WRONGFUL TERMIN Desc: PLAINTIFF ALLEGE S WRONGFUL TERMI Claimant: ASHLEa, LORI Adjua t: 0.00 250.00 0.00 250.00 Totals: D.DD zsD.Do D.oD 25o.Do Deduct Recov: 0.00 Dedtrct Remaining: 250.00 Subro Recov: Subro Recov: 0.00 Subro Bs timated: 0.00 ---CLAIM SIIl4IAAY--- Totals: 0.00 ____________ ___ 250.001 0.00 _________ ____________ _ 0.00 ___________ NET: 0.00 ERB810 O 07/24/02 07/24/02 02/06/03 Lose: 93 NEGLIGENCE Deac: INMATE INSURED ASSISTING INSD Claimant: BONER, DUSTY Legal: 0.00 0.00' 10000.00 10000.00 Adjust: 575.00 575.00 575.00 1150.00 To tale: 575.00 575.00. 10575.00 11150.00 Deduct Recov: 0.00 Deduct Remaining: 10000.00 Subro Recov: Subro Recov: D.OG Subro Estimated: O. OC Cl aimaat: MCCAL:L, RZCHAAD Totals: 0.00 0.00 0.00 D.OC Deduct Recov: O.OC Deduct Remaining: 0.0C Subro Recov: Subro Recov: Subro Estimated: 0.0( ---CLAIM SUMMARY___ Totals: 575.p0 575.00 10575.00 1750.0( NET: 1150.0( CNA EXCESS AND SBLECT Detail Lose Run/&err County S.D. LAW JWP CLASH DETAIL ANALYSIS Carr 2 Continental Cas Select Period: Ae o£: Activity Period: Printed: D6j11J2D03 Page: B State 42 TEXAS 01/01/1997 - 06/11/2003 06/11/2003 06/11/2002 - 06/11/2003 Agent 155 PVRMAN INSURANC Selected by: Claims With Incurred from: Insd 056 ICHRR COUNTY SHE DATE REPORTED -$9,999,999 thru $99,999,999 Leg/Oth: YES Recovs: YES Proc Of £: ALL ALL CLAIMS IN DATE REPORTED ORDER POR CALENDAR YHARS 47 Info-Only: YES Late-Rpt: YES Maiat-Only: YES *FIistSumm: N/A Claim Sts Carrier Loss Reported Entry Denied Closed Reopen Paid in ---------TOTALS AS OF: 06/11/20D3-------- No No Date Date Date Date Date Date Pay Period Paid Reserve Incurred ER8776 O 07/26/02 12/17/02 01/21/03 Loss: 1D0 SBX W/ZNMATH Deac: RAPEJ GUARD ON INMATE Claimant: RARDEMON, BRANDI Legal: D.00 0.00 25000.00 25000.00 Adjust: 250.00 250.00 0.00 250.00 Totals: 250.00 250.00 25000.00 25250.00 Deduct Recov: 0.00 Deduct Remaining: 10000.00 Subro Recov: Sub ro Recov: O.OD Subro Estimated: O.DO -- -CLASH Si7lfffARY--- Totals: 250.00 I 250.OD 25000.00 15250.00 NET: 15250.00 CNA EACESS AND SELECT Detail Loss Run/Kerr Covnty S.D. LAW JWF CLAIM DETAIL ANALYSIS Carr 2 Continental Ca9 Select Period: Ae of: Activity Period: Pr_in ted: 06/11/2003 Page: 9 State 42 THXAS 01/01/1997 - 06/11/2003 06/11/2003 06/11/2002 - 06/11/2003 Aqent 155 PIIRMAN INSURA27C Selected by: Claims With Incurred from: Inad 856 KERB COUNTY SHE DATE REPORTED -$9,999,999 tbru $99,999,999 Leg/Oth: YES Recava: YES Proc Off : ALL ALL CLAIMS IN DATE REPORTED ORDER FOR CALENDAR YEARS 97 Info-Only: YES Late-Rp t: YES Maiat-Only: YES +HistSumm: N/A Claim Sts Carrier Loss Reported Entry Denied Closed Reopen Paid in ---- ________ ______ -----TOTALS AS OF: 06/11/2003-------- No No Date Date Date Date Date Date Pay Period Paid Reserve Incurred Open Closed Claims Claiman to Pay Period _ ________________ Paid Reserve Incurred TOTALS: 4 6 10 12 Hod Inj: 0.00 0.0f1 80000.00 80000.00 Legal: 38166.69 91297.02 61719.11 153016.13 Other: 0.00 0.00 0.00 0.00 Adjust: 625.00 7325.0(1 575.00 7900.00 Prop Dmg: 0.00 ----------- -- O.DO 0.00 o.DD --------- -- TOTALS: 38991.69 --------- ----------- 98622.0^. 142294.11 240916.13 Suhro Hst Totals: O.OC Subr o Recov Totals: 0.00 Subro Recov Totals: O.OC ~ Deduct Recov Totals: 15873.33 ______ D ___________________________________ educt Potential Totals: 33CISD.OC __________________________ _ _ _________ NET: 191992.8C CNA EXCESS AND SELECT Detail Loss RunJR err County S.D. LAW JWP CLAIM DETAiL AN9LYSI: Carr ALL Select Period: As of: Activity Period: Printed: 06/11/2003 Page: 11 State ALL 01/01/1997 - 06/11/2003 06/11/2003 06/11/2002 - 06/11/2003 Agent ALL Selected by: Claims With Incurred Prom: iaad ALL DATE REPDRT73D -$9,999,999 thru $99,999,999 Leg/Oth: YES Recover: YES Proc Off: ALL ALL CLAIMS IN DATE REPORTED ORDER POR CALENDAR YEARS 97 Info-Only: YES Late-Rpt: YES Maiat-Only: YES *EiatSUmm: N/A Claim Sts Carrier Loss Reported Bntry Denied Closed Reopen Paid ia --- ------TOTALS AS OF: 06/11/2003-------- No No Date Date Date Dale Date Date Pay Period Paid Reserve Incurred Open Closed Claims Claimants Pay Period Paid Reserve Incurred TOTALS: 4 11 15 17 Bod Inj: 0.00 0.00 80000.00 80000.0[ Legal: 38166.69 139086.34 61719.11 200805-4~ Other: 0.00 O.OD D-00 0.0C Adjust: 825.00 9297.50 575.D0 9872.5[ Prop Dmg: 0.00 ___________ _ 0.00 0.00 D-OC _ TOTALS: 38991.69 __ _______ ___________ ___________ 148383-84 142294.11 290677.95 Subro Eat Tota18: 0.00 Subro Recov Totals: 0.00 Subro Recov Totals: 0.00 ~ Deduct Recov Totals: 26897.07 _____ ___________________________________ Deduct Potential Totals: 34^. 72-50 _____________________ _________________ NET: 229008.38 **+ END OP REPORT +*•