National Casualty Company Scottsdale Indemnity Company
Home Office: Madison, Wisconsin Home Office: One Nationwide Plaza
Adm. Office: 8877 North Gainey Center Drive Columbus, Ohio 43215
Scottsdale, Arizona 85258 Adm. Office: 8877 North Gainey Center Drive
Scottsdale Insurance Company Scottsdale, Arizona 85258
Home Office: One Nationwide Plaza Scottsdale Surplus Lines Insurance Company
Columbus, Ohio 43215 Adm. Office: 8877 North Gainey Center Drive
Adm. Office: 8877 North Gainey Center Drive Scottsdale, Arizona 85258
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Applicant Information Section
New Renewal of Policy Number: _________________________________________________________________________
A. APPLICANT INFORMATION
1. Legal Name of Public Entity: ________________________________________________________________________________________
2. Mailing Address: ____________________________________________________________________________________________________
Street City State Zip Code
3. Street Address: _____________________________________________________________________________________________________
County _______________________________________________________________________________________
4. Phone ( ) ________________ Fax ( ) ___________________ E-Mail: ______________________________________________
5. Population Served: ________________________________________ Seasonal Population:________________________________
6. Type of Public Entity: City/Town/Village County Township Borough Other (fully describe)
7. Date quote is needed: _____________________ Bid Date: ____________________ Effective Date: ______________________
8. Specimen policies needed as part of bid specifications? .............................................................................. Yes No
If a bid, please attach a copy of the bid specifications.
B. SUBMITTING AGENCY
All agents participating in this program must comply with their state licensing requirements.
1. Agency: ____________________________________________________________________________________________________________
2. Producer’s Name: __________________________________________________________________________________________________
3. Mailing Address: ____________________________________________________________________________________________________
4. Phone ( ) ______________________________________________ Fax ( ) _______________________________________________
5. Agent Name and License Number (Applicable to Florida Agents Only): ______________________________________________
6. Licensed Agent (Applicable in Iowa Only): ___________________________________________________________________________
7. Are you the incumbent agent?....................................................................................................................... Yes No
C. LOSS HISTORY (include insured and uninsured losses)
1. Five (5) years' company loss runs, valued within the past six months, must be attached for all coverages requested.
(Law Enforcement requires seven (7) years' loss runs.) You can request this data from your agent or insurer.
PE-APP-GEN-GA (9-03) Page 1 of 1
2. For the following lines of business, complete the following table and attach a complete description of any and all
losses (paid or reserved).
Incurred No. of
Line of Business Policy Year Premium Company Deductible
Losses Claims
To
To
Property To
To
To
To
To
Inland Marine To
To
To
To
To
Crime To
To
To
To
To
General Liability To
To
To
To
To
Automobile Liability To
To
To
To
To
Automobile
To
Physical Damage
To
To
To
To
Umbrella/Excess To
To
To
PE-APP-GEN-GA (9-03) Page 2 of 2
Incurred No. of
Line of Business Policy Year Premium Company Deductible
Losses Claims
To
To
Law Enforcement To
To
To
To
To
Public Officials To
To
To
To
To
Employment
To
Practices
To
To
To
To
Emergency
To
Dispatchers
To
To
To
To
Firefighters
To
Professional
To
To
3. Has any claim been made, or is any claim now pending against the public entity or any person in his/her
capacity as an official or employee of the public entity? ............................................................................... Yes No
If yes, give details including the nature of the complaint and the current status.
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
4. Does any official or employee have knowledge of any losses, claims, litigation, or incident which may give
rise to a claim?............................................................................................................................................... Yes No
If yes:
a) Give details including the nature of the incident and current status; and
b) Confirm that the incident has been reported to current carrier ............................................................... Confirmed
PE-APP-GEN-GA (9-03) Page 3 of 3
D. GENERAL INFORMATION
1. Financial Information: Please provide actual amounts from all sources for the last three (3) years: _______________
Surplus (+)/Deficit (-) Provide an explanation Accumulated
Year Revenue Expenditures
for any significant surplus or deficit. Surplus
PLEASE ATTACH MOST RECENT ENTIRE BUDGET AND INDICATE: ADOPTED TENTATIVE
2. Bond Information:
a. What is amount of outstanding bonds? __________________________________ ....................... No Bonds Outstanding
b. What is your latest bond rating (Moody’s or Standard & Poor’s)? Rating ______________ ......... No Current Rating
c. Has your public entity been in default on principal or interest on any bond? ......................................... Yes No
If yes, explain: __________________________________________________________________________________________________
3. Coverages Requested:
Property, Inland Marine and Crime Law Enforcement Liability
Commercial General Liability Employment Practices Liability
Public Officials Liability Commercial Automobile
Emergency Dispatchers Liability (stand alone) Commercial Umbrella / Excess Liability
Firefighters Professional Liability (stand alone)
4. Current coverage information:
Expiration Policy Occurrence / Retro
Coverage Company Name Premium Deductible
Date Limits Claims Made Date
Property
Earthquake
Flood
Inland Marine
Crime
General
Liability
Public
Officials
Emergency
Dispatchers
Firefighters
Professional
Law
Enforcement
Employment
Practices
Equipment
Breakdown
Automobile
Excess/
Umbrella
PE-APP-GEN-GA (9-03) Page 4 of 4
Has any such insurance been cancelled, declined or nonrenewed in the last five (5) years?...................... Yes No
(Not applicable to Missouri applicants.)
If yes, explain: ______________________________________________________________________________________________________
E. RISK MANAGEMENT ANALYSIS
1. Contact for loss control inspection and/or mailings: __________________________________________________________________
Title: ______________________________ Phone ( ) __________________________ Fax ( ) ____________________________
2. a. Does the entity have a safety/loss control program?.............................................................................. Yes No
b. Are there regular safety/loss control meetings conducted?.................................................................... Yes No
If yes, how often? _______________________________________________________________________________________________
c. Does the entity have an accident investigation program? ...................................................................... Yes No
d. Are all premises periodically inspected for safety?................................................................................. Yes No
Frequency? ____________________________________________________________________________________________________
e. Is there a formal written program for preventative maintenance? .......................................................... Yes No
Frequency? ____________________________________________________________________________________________________
Buildings?................................................................................................................................................ Yes No
Equipment? ............................................................................................................................................. Yes No
3. Briefly describe terrorism preparedness: ____________________________________________________________________________
4. Does your entity have someone charged with the responsibility of risk management?................................ Yes No
If yes, full-time part-time
If part-time, who performs this function? _____________________________________________________________________________
5. Is the entity in compliance with the federally mandated Americans With Disabilities Act (ADA)? ................ Yes No
6. Do you fund or supply personnel to any commission, board, authority, administrative department or
other similar unit that is independently operated or not directly operated by you?................................ Yes No
If yes, please list (on a separate attachment) all those for which you desire coverage as additional in-
sured(s) and provide a brief description of the relationship.
7. What is the largest city within a twenty-five (25) mile radius of your entity? ______________ Population:_______________
F. AUTHORIZED ENTITY REPRESENTATIVE
Your designee to report claims and receive notices: _____________________________________________________________________
Name: _______________________________________________________ Title: ___________________________________________________
PE-APP-GEN-GA (9-03) Page 5 of 5
G. ENTITY’S ATTESTATION AND FRAUD WARNING
NEW YORK AUTOMOBILE FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for
commercial insurance or a statement of claim for any commercial or personal insurance benefits containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any
person who, in connection with such application or claim, knowingly makes or knowingly assists, abets, solicits or con-
spires with another to make a false report of the theft, destruction, damage or conversion of any motor vehicle to a law
enforcement agency, the department of motor vehicles or an insurance company, commits a fraudulent insurance act,
which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the value of the sub-
ject motor vehicle or stated claim for each violation.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information, or conceals for the purpose of misleading, in-
formation concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be
subject to civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
FRAUD WARNING:
Any person who knowingly and with intent to defraud any insurance company or other person files an application for in-
surance or statement of claim containing any materially false information or conceals for the purpose of misleading, infor-
mation concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such
person to criminal and civil penalties.
The undersigned declares that to the best of his/her knowledge, the information set forth in this application is true and
complete.
______________________________________________________________ ___________________________ _______________________
Signature of Authorized Public Official Title Date
PE-APP-GEN-GA (9-03) Page 6 of 6
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
Scottsdale, Arizona 85258
Scottsdale Insurance Company
Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza
Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215
Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Employment Practices Liability (Claims Made) Section
Please attach a separate page for answers requiring explanations.
Legal Name of Public Entity: ____________________________________________________ Effective Date: ______________________
A. COVERAGE REQUESTED
1. Limit of Liability: Each Wrongful Act: $___________________________ Annual Aggregate: $ _______________________
2. Deductible Requested: $ ____________________ or
SIR Requested: $ ____________________ With LAE Included in Retention Without LAE in Retention
TPA Name, Address, Telephone, and Facsimile: ____________________________________________________________________
3. Extended Employment Practices Liability Coverage Options: ________________________________________________________
a. Back Wages? .......................................................................................................................................... Yes No
Limits (per wrongful act): ________________________________________________________________________________________
b. Mental Anguish? ..................................................................................................................................... Yes No
c. Non-Monetary Defense (Indemnity coverage)? ...................................................................................... Yes No
Limits (per wrongful act/per policy period): ______________________________________________________________________
d. Non-Monetary Defense (Company provides defense)? ......................................................................... Yes No
Limits (per wrongful act/per policy period): ______________________________________________________________________
4. Consent to Settle Coverage Option?............................................................................................................. Yes No
B. EMPLOYEE INFORMATION
1. Number of Employees
Full-time Part-time Seasonal
No. of Employees
a. The following questions will assist in obtaining a proper employee count:
1) If volunteers are covered by your state’s workers compensation laws, include in employee count.
2) If elected or appointed officials are paid employees, include in employee count.
3) If seasonal employees are included in employee count, how many months during the year are
they utilized? _______________________________________________________________________________________________
b. How many of these employees are:
1) School employees?_________________________________________________________________________________________
2) Law enforcement employees? ______________________________________________________________________________
3) Fire department employees?________________________________________________________________________________
PE-APP-EP-GA (2-03) Page 1 of 1
2. Total Number of Employees:
1 Year Prior 2 Years Prior 3 Years Prior
Total No. of Employees
3. Total number of employees terminated in the past three years:
1 Year Prior 2 Years Prior 3 Years Prior
Total No. of Employees
4. Total number of employees who left voluntarily over the past three years:
1 Year Prior 2 Years Prior 3 Years Prior
Total No. of Employees
5. Have there been any layoffs of employees or reductions in service? ........................................................... Yes No
If yes, please explain: _______________________________________________________________________________________________
6. Do you have any plans to lay off 5% or more of employees within the next 24 months? ..................................... Yes No
a. Do you have a formal reduction in force policy? ..................................................................................... Yes No
b. Has this policy been reviewed by legal counsel? ................................................................................... Yes No
7. Have you had a strike, slowdown or other employee disruption? ................................................................. Yes No
If yes, please explain: _______________________________________________________________________________________________
C. POLICIES AND PROCEDURES
1. Do you have an employee handbook or manual?......................................................................................... Yes No
a. If yes: __________________________________________________________________________________________________________
(1) Does every employee receive a copy? ............................................................................................ Yes No
(2) Do you get written acknowledgement that employees have received the handbook? .................... Yes No
(3) Has it been reviewed by legal counsel? ........................................................................................... Yes No
(4) What is the date of the last review by legal counsel? ________________________________________________________
b. If no, how do you communicate your employment policies and procedures to employees? _______________________
________________________________________________________________________________________________________________
2. a. Do you follow formal written procedures, and do all supervisory personnel receive training in the procedures for
each of the following areas?
Written Supervisory Written Supervisory
Procedures Training Procedures Training
Americans With Performance
Yes No Yes No Yes No Yes No
Disabilities Act? Reviews?
Progressive Discipli-
Discrimination? Yes No Yes No Yes No Yes No
nary Program?
Disputes or Salary
Yes No Yes No Yes No Yes No
Grievances? Administration?
Employee Hiring? Yes No Yes No Sexual Harassment? Yes No Yes No
Handling
Yes No Yes No Termination? Yes No Yes No
Complaints?
Page 2 of 2
PE-APP-EP-GA (2-03)
Written Supervisory Written Supervisory
Procedures Training Procedures Training
Time off policies &
Interviews? Yes No Yes No Yes No Yes No
FMLA?
Pre-Termination
Yes No Yes No
Hearings?
b. Have the procedures been reviewed by legal counsel? ......................................................................... Yes No
c. What is the date of the last review by legal counsel? ____________________________________________________________
3. Are grievance procedures communicated to all personnel upon hiring? ...................................................... Yes No
4. Are signed acknowledgements of training required? .................................................................................... Yes No
D. UNDERWRITING INFORMATION
1. Do you have a human resources department? ............................................................................................. Yes No
If yes, total number of staff?_________________________________________________________________________________________
If no, explain how the function is handled. ___________________________________________________________________________
2. Are formal written job descriptions in place for all positions?........................................................................ Yes No
3. Do you have a formal, standardized employment application?..................................................................... Yes No
a. Has it been reviewed by legal counsel?.................................................................................................. Yes No
b. If no application is used, how do you recruit new employees? ____________________________________________________
4. Do you use a psychological test to screen applicants, to promote employees or for the purpose of con-
tinuing employment?...................................................................................................................................... Yes No
If yes: ______________________________________________________________________________________________________________
a. Is it administered to everyone? ............................................................................................................... Yes No
If no, please explain: ____________________________________________________________________________________________
b. Are results reviewed by a person trained in this field? ........................................................................... Yes No
c. Is the person being tested interviewed by a psychologist/psychiatrist? ................................................. Yes No
5. Do you provide a written performance evaluation for all employees?........................................................... Yes No
If yes, how often? ___________________________________________________________________________________________________
6. Do you require advice from a human resource person or qualified legal counsel prior to terminating an
employee? ..................................................................................................................................................... Yes No
7. Are you currently required to comply with any judicial or administrative agreement, order, decree or
judgment relating to employment? ................................................................................................................ Yes No
If yes:
1) attach a copy; and
2) explain the actions taken by the insured to bring into compliance.
8. Has there been continuous claims made coverage for the past five years?................................................. Yes No
If no, please explain: ________________________________________________________________________________________________
Page 3 of 3
PE-APP-EP-GA (2-03)
E. LOSS HISTORY
In the last five years:
1. Has any person, former employee, volunteer or job applicant made a claim or alleged unfair or improper
treatment regarding hiring, remuneration, advancement or termination? ..................................................... Yes No
If yes, provide a detailed narrative.
2. Have you had any disputes involving integration, segregation, discrimination or violation of civil rights
including sexual harassment or the Americans With Disabilities Act (ADA)? ............................................... Yes No
If yes, provide a detailed narrative.
3. How many Equal Employment Opportunity Commission and State Human Rights Commission claims or complaints
have been filed against the entity? __________________________________________________________________________________
ATTACH A LOG OF ALL SUCH CLAIMS OR COMPLAINTS.
Page 4 of 4
PE-APP-EP-GA (2-03)
National Casualty Company Scottsdale Indemnity Company
Home Office: 902 Ann Street Suite A Home Office: One Nationwide Plaza
Madison, Wisconsin 53713-2404 Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Law Enforcement Liability Section
Please attach a separate page for answers requiring explanations.
Legal Name of Public Entity: __________________________________________________ Effective Date: _____________________
A. COVERAGE REQUESTED
1. Limit of Liability: ____________________________________________________________________________________________________
Each person: $ ____________________ Each wrongful act $ __________________ Annual aggregate $________________
2. Coverage desired: Occurrence Claims Made
3. Deductible requested: $ ___________________ ; or
SIR Requested: $ ___________________ With LAE Included in Retention Without LAE in Retention
TPA Name, Address, Telephone, and Facsimile: ____________________________________________________________________
4. Consent to Settle Coverage Option?............................................................................................................. Yes No
5. Name of law enforcement department(s) or agency(ies) to be covered: ______________________________________________
B. EMPLOYEE CLASSIFICATION
1. Total number of law enforcement agency employees, including clerical: _____________________________________________
2. Provide number of employees for each type listed:
Type of Employee No. Type of Employee No.
Sheriff/chief; chief/deputy/deputy chief Full-time detectives
Personnel with rank of sergeant or higher Full-time investigators
Full-time personnel with regular street/road
Jail administrators
duties
Police Dogs (patrol and attack dogs only)
(Please provide training certificates for dogs
and handlers)
Page 1 of 1
PE-APP-LAW-GA (8-02)
C. DEPARTMENT POLICIES AND PROCEDURES
1. Do you have written policies governing the following law enforcement operations?
Policy Description Date of last revision
Use of deadly force............................................................................................. Yes No
Use of non-deadly force...................................................................................... Yes No
Use of force reports ............................................................................................ Yes No
Vehicle “hot pursuit”............................................................................................ Yes No
Motor vehicle stops & searches.......................................................................... Yes No
Firearms & less than lethal weapons.................................................................. Yes No
Domestic violence............................................................................................... Yes No
Searches............................................................................................................. Yes No
Custodial interrogation/detention........................................................................ Yes No
Service of warrant............................................................................................... Yes No
Transportation of prisoners................................................................................. Yes No
Handling of intoxicated individuals ..................................................................... Yes No
Communicable diseases..................................................................................... Yes No
Medical treatment ............................................................................................... Yes No
"Moonlighting" ..................................................................................................... Yes No
2 Are policies and procedures distributed to all personnel? ................................................................................... Yes No
3. Are policies and procedures reviewed annually by competent legal counsel? ................................................. Yes No
4. Are policies and procedures reviewed periodically with personnel as part of formal training? ..................... Yes No
5. Do you require use of force reports to be filed? ............................................................................................ Yes No
If yes, are they followed up on?..................................................................................................................... Yes No
D. EDUCATION AND TRAINING
1. Identify the background checks required prior to hiring:
a. Motor vehicle records.............................................................................................................................. Yes No
b. Psychological testing............................................................................................................................... Yes No
c. Educational verification ........................................................................................................................... Yes No
d. Criminal investigation .............................................................................................................................. Yes No
e. Reference check ..................................................................................................................................... Yes No
f. Employment history check ...................................................................................................................... Yes No
g. Other ....................................................................................................................................................... Yes No
Please Explain: _________________________________________________________________________________________________
2. Minimum educational requirement for hiring officers?
High School Some College College Graduate Other (please explain): ___________________
3. What law enforcement training is required of armed street officers? __________________________________________________
Formal Academy............................................................................................................................................ Yes No
Number of Academy Hours: ___________
Other (explain): _____________________________________________________________________________________________________
Page 2 of 2
PE-APP-LAW-GA (8-02)
4. Is formal training required before armed and assigned street duty?............................................................. Yes No
If no, verify officer is not armed or is accompanied by trained personnel ..................................................... Confirmed
5. How often must officer re-qualify with: service revolver? ____________________ personal weapon? __________________
6. What training do part time/reserve/auxiliary officers receive?.................................................................................. N/A
Explain: ____________________________________________________________________________________________________________
7. Do you have an annual minimum in-service training update? ...................................................................... Yes No
Number of Hours? __________________________________________________________________________________________________
8. If there is a seasonal population change, are there borrowed officers?............................................ Yes No N/A
If yes, are they trained in your agency’s policies and procedures?............................................................... Yes No
9. Do all officers receive training in:
First aid? ........................................................................................................................................................ Yes No
Vehicular operations? .................................................................................................................................... Yes No
CPR? ............................................................................................................................................................. Yes No
10. Is all training documented on a training log?................................................................................................. Yes No
11. Are officers trained and qualified before using?
Baton? ..................................................................................................................................... Yes No Not Used
Control holds?.......................................................................................................................... Yes No Not Used
Mace/Chemicals? .................................................................................................................... Yes No Not Used
Stun guns?............................................................................................................................... Yes No Not Used
E. EMERGENCY DISPATCH
1. Are incoming calls to dispatchers recorded?................................................................................................. Yes No
If yes, how long are tapes maintained? ______________________________________________________________________________
2. Describe the training program for dispatchers: _______________________________________________________________________
3. Do you dispatch for other entities? ................................................................................................................ Yes No
If yes:
a. For what entities do you perform emergency dispatching duties? ________________________________________________
b. What is the total population served? ____________________________________________________________________________
F. GENERAL UNDERWRITING INFORMATION
1. a. Are you:
1) Contracting law enforcement services to any other public or private entity? ........................................... Yes No
2) A party to any mutual aid or reciprocal agreement? ................................................................................. Yes No
3) A party to a drug task force or SWAT team agreement?.......................................................................... Yes No
If yes, how many officers are assigned to drug task force? ___________________ SWAT team?____________________
b. If 1), 2), or 3) above is yes:
1) Are the agreements reviewed by legal counsel? ...................................................................................... Yes No
2) Do you require your agency to be named as an additional insured for any work contracted to others? Yes No
2. a. Do you authorize employee “moonlighting”?.................................................................................................... Yes No
b. Confirm no “moonlighting” in bars and taverns: ................................................................ Confirmed Not Confirmed
Page 3 of 3
PE-APP-LAW-GA (8-02)
3. Are you accredited by any professional organizations?.......................................................................................... Yes No
If yes:
a) What organization(s)? _______________________________________________________________________________________________
b) Please provide certificate(s).
4. Do you subscribe to LETN?........................................................................................................................... Yes No
If yes, please provide certificate.
5. Has there been continuous claims made coverage for the past five years?................................................. Yes No
If no, please explain: ________________________________________________________________________________________________
G. JAIL OPERATIONS
* Explain all “no” responses to questions marked with an asterisk on a separate piece of paper.
1. Do you operate a: Jail? Holding cell? Detention cell? Other? No lockup facility?
2. Attach copies of the last state corrections official’s inspection report, fire inspector’s report and depart-
ment of health inspection report. ........................................................................................................................... None
3. Facilities:
a. Date constructed: _______________________________________________________________________________________________
b. Date renovated: ________________________________________________________________________________________________
c. Number of cells: ________________________________________________________________________________________________
d. State certified capacity: _________________________________________________________________________________________
e. Average number of daily inmates: _______________________________________________________________________________
f. Average length of stay: _________________________________________________________________________________________
g. Smoke detectors n jail area?................................................................................................................... Yes No
h. Walk-throughs every 30 minutes? .......................................................................................................... Yes No
i. Are there audio/video systems?.............................................................................................................. Yes No
If yes:
1) Booking area.............................................................................................................. Audio Video None
2) Cell area .................................................................................................................... Audio Video None
3) Sally port.................................................................................................................... Audio Video None
4. Any suicides or suicide attempts in the last five years? ................................................................................ Yes No
If yes, explain and provide details for prevention of future suicides. __________________________________________________
5. In the past three years have there been any (Check all that apply, and explain preventative measures):
Fatalities Assaults which required hospitalization Sexual Assault None
6. Are all jailers required to maintain a jail log to document incidents, action taken, and identify witnesses?.. Yes No
If yes, how long is log retained? _____________________________________________________________________________________
7. Is the facility under a court order or consent decree? ................................................................................... Yes No
If yes:
1) Attach copy with any modifications; and
2) Explain the actions taken by the insured to bring the facility into compliance.
8. Do you have a separate facility for juvenile detainees?*............................................................................... Yes No
Page 4 of 4
PE-APP-LAW-GA (8-02)
9. Jailers
a. Number of jailers per shift: Day__________________ Evening ____________________ Night_____________________
b. Are full-time jailers on duty 24 hours per day?........................................................................................ Yes No
c. Are part-time jailers utilized?................................................................................................................... Yes No
1) If yes, what percentage of time?...................................................................................................... __________ %
Explain: ____________________________________________________________________________________________________
2) Are part time jailers subject to the same selection and training requirements as full time jailers ... Yes No
d. Does dispatcher also act as jailer? ......................................................................................................... Yes No
If yes, what training is required? ________________________________________________________________________________
e. Minimum educational requirement for hiring jailers?
High School Some College College Graduate Other (please explain): ___________________
f. What training of jailers/matrons/detention guards is required before assignment?
Formal Academy ..................................................................................................................................... Yes No
Number of academy hours: ________
Other (explain): _________________________________________________________________________________________________
1) Is training required prior to assignment for all jail officers? ....................................................................... Yes No
2) Are policies and procedures reviewed periodically with jail personnel as part of formal training? .......... Yes No
10. Do you have written policies governing jail operations? ......................................................................................... Yes No
Policy Description Date of last revision
Intake screening of inmates/detainees ...................................................................... Yes No
Strip searches............................................................................................................. Yes No
Medical treatment/sick call ......................................................................................... Yes No
Storage and administration of medication ................................................................. Yes No
Suicide ID guidelines.................................................................................................. Yes No
Use of deadly force..................................................................................................... Yes No
Use of non-deadly force ............................................................................................. Yes No
Use of force reports .................................................................................................... Yes No
Handling of intoxicated individuals............................................................................. Yes No
Is jail evacuation posted through the facility .............................................................. Yes No
Key control and security............................................................................................. Yes No
Restraints.................................................................................................................... Yes No
Visual observation of inmates/detainees ................................................................... Yes No
Inmate transportation ................................................................................................. Yes No
Discipline procedures ................................................................................................. Yes No
Handling persons with communicable diseases ....................................................... Yes No
*Grievance procedure for inmate complaints ........................................................ Yes No
a Are policies and procedures distributed to all personnel? ............................................................................... Yes No
b Are policies and procedures reviewed annually by competent legal counsel?............................................... Yes No
c Are policies and procedures reviewed periodically with personnel as part of formal training?....................... Yes No
d Do you require use of force reports to be filed? ............................................................................................... Yes No
If yes, are they followed up on? ........................................................................................................................ Yes No
Page 5 of 5
PE-APP-LAW-GA (8-02)
National Casualty Company Scottsdale Indemnity Company
Home Office: 902 Ann Street Suite A Home Office: One Nationwide Plaza
Madison, Wisconsin 53713-2404 Columbus, Ohio 43215
Adm. Office: 8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Public Officials Liability Section
Please attach a separate page for answers requiring explanations.
Legal Name of Public Entity: ____________________________________________________ Effective Date: ______________________
A. COVERAGE REQUESTED
1. Limit of Liability: Each Wrongful Act: $___________________________ Annual Aggregate: $ _______________________
2. Coverage desired: Claims made Claims made and reported
3. Deductible requested: $ ___________________ ; or
SIR Requested: $ ___________________ With LAE Included Without LAE Included
TPA Name, Address, Telephone, and Facsimile: ____________________________________________________________________
4. Land use planning ans zoning coverage options? ........................................................................................ Yes No
5. Consent to Settle Coverage Option?............................................................................................................. Yes No
B. UNDERWRITING INFORMATION
1. Name of municipal attorney: _______________________________ Name of municipal engineer: ________________________
2. Do you have a formal procedure in place for requests for variance to land development statutes? ............ Yes No
3. Do you have a written master plan for development? ................................................................................... Yes No
When was it adopted/revised? _____________________________ (date)
4. Do you engage in any planning and zoning activities? ................................................................................. Yes No
a) Do planning and zoning officials receive training regarding “open meeting” and hearing regulations? . Yes No
b) Does your municipal attorney attend all meetings of the planning and zoning board? .......................... Yes No
5. Are there any dams within your boundaries for which you are responsible? ................................................ Yes No
If yes:
a) Do you have general liability insurance coverage for dam failure? ........................................................ Yes No
b) Please attach a copy of the most recent inspection.
6. Do you own or operate a landfill? .................................................................................................................. Yes No
If yes, has it been designated as a hazardous waste or Superfund site by the EPA?.................................. Yes No
7. Do you own or operate any nuclear power plants? ....................................................................................... Yes No
8. Has there been continuous claims made coverage for the past five (5) years? ........................................... Yes No
If no, please explain: ________________________________________________________________________________________________
Page 1 of 1
PE-APP-PO-GA (8-02)
9. Have any of the following occurred within the last five (5) years? (If any answer is yes, provide a detailed
narrative on a separate sheet of paper.)
a) Grand jury investigations or indictments of any public officials?............................................................. Yes No
b) Disputes or claims alleging the wrongful granting or refusal to grant zoning changes, building per-
mits or similar allowances? ..................................................................................................................... Yes No
c) Disputes or claims alleging wrongful approval of building designs or specifications?............................ Yes No
d) Disputes or claims alleging civil rights violations in regards to poor environmental quality in a
neighborhood? ........................................................................................................................................ Yes No
C. UTILITIES/AUTHORITIES
1. Does the entity administer any of the following?
a) Gas Utility*............................................................................................................................................... Yes No
If yes, complete supplementary questionnaire G
b) Electric Utility* ......................................................................................................................................... Yes No
If yes, complete supplementary questionnaire F
c) Water Utility ............................................................................................................................................. Yes No
If yes, complete supplementary questionnaire E
d) Sewer Utility ............................................................................................................................................ Yes No
If yes, complete supplementary questionnaire E
e) Port Authority* ......................................................................................................................................... Yes No
If yes, complete supplementary questionnaire N
f) Transit Authority*..................................................................................................................................... Yes No
If yes, complete supplementary questionnaire N
g) Airport Authority* ..................................................................................................................................... Yes No
If yes, complete supplementary questionnaire N
h) Housing Authority* .................................................................................................................................. Yes No
If yes, complete supplementary questionnaire H
i) Schools* .................................................................................................................................................. Yes No
If yes, complete supplementary questionnaire J
(*Note: There is no coverage for loss that results from the conduct of duties by or for such utility or authority unless
specifically added to the policy.)
Page 2 of 2
PE-APP-PO-GA (8-02)
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Property And Allied Lines Section
Legal Name of Public Entity: _______________________________ Effective Date:_____________________________________
A. BUILDING AND PERSONAL PROPERTY COVERAGE
Attach a signed statement of values or ACORD application including:
(1) Location address, (2) Protection class, (3) Year built (if over 30 years old, provide renovations made and
dates), (4) Construction, (5) Number of stories for each structure, (6) Sprinkler status, (7) Occupancy, (8) Area
square footage. INCLUDE ALL PROPERTY INTENDED TO BE INSURED (including items such as parking
meters, streetlights, lamps, park/playground equipment, etc.).
1. Total values from S. O. V.: Building: $ _______________________ Personal Property: $________________________
a. Values are at ❑ 90% ❑ 100% coinsurance.
b. Date of valuation: _________________________________________________________________________________________
c. Deductible Options: $500 $1,000 $5,000 $ _________________________
2. Building and Personal Property Coverage Options:
a. Business income with extra expense:
Limit: $ ______________________________________________ Location: ________________________________________
b. Ordinance or Law Coverage:
1) Building Ordinance (included in policy limit)—Make sure insurance to value is adequate.
(Coverage A)
2) Increased Cost of Construction
(Coverage B) Limit: $ ___________________________ Locations: _______________________________
3) Demolition
(Coverage C) Limit: $ ___________________________ Locations: _______________________________
c. Inflation Guard: ____________________ %
3. Earthquake Coverage:
a. Limit: $ ______________________________
b. Zone: _______________________________
c. Deductible: Zone 1 and 2: ❑ 5% or ❑ 10% ❑ Zone 3, 4, and 5: $25,000
4. Flood Coverage:
a. Limit: $ ______________________________
b. Flood Zone: List A, B, or C on SOV per location.
c. Is there any 100 year flood plain exposure within the boundaries of the entity? ........................ Yes No
d. Names of rivers, streams or lakes within one mile of any locations: ________________________________________
__________________________________________________________________________________________________________
e. Is there coverage under the National Flood program?................................................................ Yes No
Limit: $ ______________________________
PE-APP-PROP-GA (2-03) Page 1 of 1
A. BUILDING AND PERSONAL PROPERTY COVERAGE (continued)
5. Equipment Breakdown Coverage:
Limit: $ __________________________________
Deductible Options: $500 $1,000 $5,000 $ _________________________
6. Mortgagees and Loss Payees:
Name Address Location
B. CRIME AND FIDELITY
1. Money and Securities:
Limit Location
Loss inside $ ___________________ ____________________________________________________
Loss outside $ ___________________ ____________________________________________________
Deductible endorsement $ ___________________ ____________________________________________________
a. Limits Breakdown: Money: ________ % Securities: _______ % Checks: ____________%
b. Are more than $2,000 kept at premises overnight? .................................................................... Yes No
If “yes,” describe safe: ___________________________________________________________________________________
c. Type of safe or vault (circle one) B C G H Other: ______________________________________________
d. Number of messengers: __________________________________________________________________________________
2. Public Employee Dishonesty Coverage:
Limit: $ _______________________________________________ Deductible: $ _______________________________________
a. Have you ever had a loss due to employee dishonesty? .......................................................... Yes No
If “yes,” describe in Loss History.
3. Crime: (Complete the following when limits requested are $100,000 or more.)
a. Audit Procedures:
1) Is there an audit by a CPA, public accountant or equivalent, independent of your
organization?......................................................................................................................... Yes No
If “yes,” how often (check the appropriate box): ❑ Quarterly ❑ Semi-Annually ❑ Annually
2) Name and address of person or firm performing audit: ________________________________________________
______________________________________________________________________________________________________
3) Are all locations audited? ...................................................................................................... Yes No
4) Is the audit made in accordance with generally accepted auditing standards and so
certified?................................................................................................................................ Yes No
If “no,” explain the scope of the audit: _________________________________________________________________
5) Is the audit report rendered to a regulatory authority?.......................................................... Yes No
If “yes,” to whom are the reports rendered? ___________________________________________________________
6) Date of completion of last audit: _______________________________________________________________________
7) Is there an audit by an Internal Audit Department under the control of an employee who
is a public accountant or equivalent?.................................................................................... Yes No
If “yes,” to whom are the reports rendered? ___________________________________________________________
b. Internal Controls (other than audit procedures):
1) Are bank accounts reconciled by someone not authorized to deposit or withdraw? ............ Yes No
If “no,” explain: _______________________________________________________________________________________
PE-APP-PROP-GA (2-03) Page 2 of 2
B. CRIME AND FIDELITY (continued)
2) Do all checks require two signatures? .................................................................................. Yes No
If “no,” explain: _______________________________________________________________________________________
3) Are securities subject to joint control of two or more responsible employees? .................... Yes No
If “no,” explain: _______________________________________________________________________________________
c. Rating Data:
1) Classification of Employees:
List below (or attach separate sheet) the positions and number of officials/officers and employees
occupying those positions to which this insurance applies.
Positions No. of Persons Positions No. of Persons Positions No. of Persons
Note: Persons required by law to be individually bonded and treasurers or tax collectors by
whatever title known are automatically excluded from coverage.
2) From the list (or attached separate sheet) determine the:
a) Number of officials/officers, not required by law to be individually bonded, who are
authorized to manage, govern or control the insured’s employees (Class A)............. ______________
b) Number of employees who handle, have custody or maintain records of money,
securities or property; department and other division heads; assistant department
and division heads; and peace officers (including patrolmen when Faithful
Performance of Duty Coverage is being written) (Class B)......................................... ______________
c) Number of all other employees (Class C).................................................................... ______________
C. COMMERCIAL INLAND MARINE COVERAGE
1. Accounts Receivable:
a. Provide limits by location: _________________________________________________________________________________
__________________________________________________________________________________________________________
2. Valuable Papers:
a. Provide limits by location: _________________________________________________________________________________
__________________________________________________________________________________________________________
3. Contractor’s Equipment (Attach a complete schedule of equipment, including values and serial numbers for
each. Valuation should represent replacement cost of the equipment.)
a. Total limit of insurance: $ ____________________
b. Deductible: $500 $1,000 $ ______________________
c. Describe appraisal or method of valuation: ________________________________________________________________
__________________________________________________________________________________________________________
d. Largest single concentration (limit) of equipment: $ ________________________
1) Location: ____________________________________ Stored in: ❑ Building ❑ Open lot
4. Miscellaneous Equipment (attach a complete schedule of equipment, including values):
a. Limit of insurance: $ _________________________
b. Largest single concentration (limit): $ ________________________
c. Location: _________________________________________________________________________________________________
5. Fine Arts (Attach a complete schedule of fine arts, including values, description and location for each):
a. Total limit: $ _________________________
b. Describe method by which values were established and date of appraisal (attach copies): _________________
__________________________________________________________________________________________________________
PE-APP-PROP-GA (2-03) Page 3 of 3
C. COMMERCIAL INLAND MARINE COVERAGE (continued)
c. Deductible: ❑ $500 $1,000 $ ______________________
d. Optional breakage coverage: ...................................................................................................... Yes No
6. Electronic Data Processing Equipment (Attach a complete schedule by location of computers and peripheral
devices, including values and serial numbers on each. Valuation should represent replacement cost of the
equipment.)
a. Valuation shown: Actual Cash Value Replacement Cost
b. Deductible: $500 $1,000 $ ______________________
c. Total hardware value: $ ______________________
d. Data and media limit: $ ______________________
e. Extra expense limit: $ ________________________
f. Transit limit: $ _______________________________
g. Breakdown coverage deductible: $1,000 $5,000
PE-APP-PROP-GA (2-03) Page 4 of 4
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin 53713-2404 Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
General Liability Section
Legal Name of Public Entity: ________________________________________________ Effective Date: ____________________
A. RISK CLASSIFICATION
1. ❑ Governmental Subdivision 4. ❑ Public Sewer Utility
2. ❑ Public School District 5. ❑ Public Housing Authority
3. ❑ Public Water Utility 6. ❑ Other ______________________________________
B. COVERAGES (OCCURRENCE FORM)
Limits Option
1. General Aggregate Limit (other than Prod./Comp. Ops.) $ ______________________ ______________________
2. Products-Completed Operations Aggregate $ ______________________ ______________________
3. Personal & Advertising Injury $ ______________________ ______________________
4. Each Occurrence $ ______________________ ______________________
5. Fire Damage Liability $ ______________________ ______________________
6. Medical Expense $ ______________________ ______________________
Options:
a. Deductible: None Other ___________________________________________________________
b. Self-Insured Retention Limit: $ ______________________
Does Limit Include or Exclude Loss Adjustment Expense? (circle one)
7. ❑ Employee benefits liability coverage: No. of Employees: _____________
8. ❑ Employers’ liability (stop-gap) coverage: (Available only in ND, OH, WA, WV, WY)
Total employee payroll: $ ____________________
9. ❑ Additional interests:
Please provide description of each operation or interest of any organizations or individuals to be consid-
ered as additional insureds. Attach/describe agreements, contracts, hold harmless clauses and insurance
requirements.
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
PE-APP-GL-GA (2-03) Page 1 of 3
C. GOVERNMENTAL SUBDIVISION SURVEY
(Any classification requiring a supplemental questionnaire will be so marked.
Call your agent for the appropriate supplement.)
Any part of
operation sub-
Exposure?
Classification contracted to Separate Questionnaire
others?
Yes No Yes No
EXCLUDED (E&O can be covered) Com-
Airport and related facilities
plete questionnaire K
Amusement parks EXCLUDED
Blasting operations Complete questionnaire P (Item E)
Bridges Complete questionnaire A
Carnivals Complete questionnaire B
Cemeteries liability Complete questionnaire P (Item J)
Chemical spraying (herbicides and
Complete questionnaire P (Item I)
pesticides)
Dams, levees or dikes Complete questionnaire M
Day care, day camp, or nursery Complete questionnaire C
EMTs/Paramedics Complete questionnaire P (Item A)
Exhibition and convention buildings
Complete questionnaire P (Item F)
(include arenas and auditoriums)
Fairs Complete questionnaire B
Fire department Complete questionnaire P (Item A)
Fireworks and other pyrotechnics Complete questionnaire P (Item D)
Garbage or refuse collection Complete questionnaire P (Item H)
Golf courses Complete questionnaire P (Item B)
Housing projects Complete questionnaire H
Ice or roller rinks Complete questionnaire K (Items A & C)
Lakes, reservoirs Complete questionnaire K (Items A & E)
Landfills/dumps/refuse
Complete questionnaire D
sites/incinerators
Medical and ancillary care facilities EXCLUDED
Parades Complete questionnaire B
Complete questionnaire K (Items A
Parks and playgrounds
through D)
Penal Institutions, jails, correctional
EXCLUDED under General Liability
institutions
Racetracks Complete questionnaire P (Item L)
Recreational activities Complete questionnaire K
Schools and colleges Complete questionnaire J
Skate Parks—skateboarding/in-line
Complete questionnaire K (Items A & D)
skating
PE-APP-GL-GA (2-03) Page 2 of 3
C. GOVERNMENTAL SUBDIVISION SURVEY (continued)
Any part of
operation
Exposure?
Classification subcontracted Separate Questionnaire
to others?
Yes No Yes No
Ski facilities and similar areas Complete questionnaire P (Item L)
Stadiums, bleachers, grandstands
Complete questionnaire P (Item C)
(capacity over 5,000)
Streets, roads, highways, bridges—
existence, maintenance and con- Complete questionnaire A
struction hazards
Swimming pools/beaches Complete questionnaire K (Items A & E)
Transit authority Complete questionnaire N
Utilities: Sewer Complete questionnaire E (Item A)
Water Complete questionnaire E (Item B)
Electric Complete questionnaire F
Gas Complete questionnaire G
Underground storage tanks EXCLUDED for Pollution
Water slides Complete questionnaire K (Items A & E)
Wharves, piers, docks, marinas Complete questionnaire K (Items A & F)
Watercraft Complete questionnaire K (Items A & G)
Zoos Complete questionnaire P (Item K)
D. INDEPENDENT CONTRACTOR OPERATIONS
1. If any exposure is contracted, please complete the following:
Certificates of Contractor’s Entity Named as
Type of Work
Insurance Secured? Limit of Liability? Additional Insured?
❑ Yes ❑ No ❑ Yes ❑ No
❑ Yes ❑ No ❑ Yes ❑ No
❑ Yes ❑ No ❑ Yes ❑ No
❑ Yes ❑ No ❑ Yes ❑ No
❑ Yes ❑ No ❑ Yes ❑ No
❑ Yes ❑ No ❑ Yes ❑ No
2. Does the entity have legal counsel review all contracts prior to execution? ........................................ Yes No
PE-APP-GL-GA (2-03) Page 3 of 3
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Commercial Umbrella/Excess Liability
Legal Name of Public Entity: _______________________________ Effective Date: ______________________________________
A. COVERAGE
❑ $1,000,000/$1,000,000 ❑ $2,000,000/$2,000,000 ❑ $3,000,000/$3,000,000
❑ $4,000,000/$4,000,000 ❑ $5,000,000/$5,000,000 ❑ Other _________________________________
Umbrella self-insured retention requested ❑ $ -0- ❑ $10,000
Coverage desired over: ❑ GL ❑ Auto ❑ EL ❑ PO ❑ Law ❑ EPL
Carrier/Policy
Underlying Insurance Number Policy Dates Limits
Employers Liability ________________ _______________ $ ______________ Each Accident
$ ______________ Disease—Policy Limit
$ ______________ Disease—Each Employee
Previous experience: If not described elsewhere, please give details of all liability claims exceeding $25,000 or
occurrences that may give rise to claims during the past five years.
Note: Final terms and conditions of coverage are outlined in each individual binder of coverage.
PE-APP-UMB-GA (2-03)
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Commercial Automobile Section
Attach ACORD vehicle schedule and complete the following:
Legal Name of Public Entity: __________________________________________ Effective Date: __________________________
A. COVERAGES
Option 1 Limit of Liability: $ ___________________________ Deductible: $ ____________________________
Option 2 Limit of Liability: $ ___________________________ Deductible: $ ____________________________
Hired automobile coverage Annual Cost?
Non-owned automobile coverage Total number of employees?
Person Injury Protection (PIP)*
(or equivalent no-fault coverage) $ (Limit)
Added PIP (or equivalent added no-fault coverage) $ (Limit)
Property Protection Insurance (PPI) (Michigan only) $ (Limit)
Optional Basic Economic Loss (OBEL) (NY only) $ (Limit)
Auto Medical Payments Insurance $ (Limit)
Uninsured Motorist Insurance* $ (Limit)
Underinsured Motorist Insurance* $ (Limit)
Mutual Aid $ (Limit)
Physical Damage Coverage—Minimum deductibles are determined by Company
Deductible
—Comprehensive Coverage ...................................................... Yes No _____________________
—Specified causes of loss coverage ......................................... Yes No _____________________
—Collision coverage................................................................... Yes No _____________________
*As statutes require, a signed rejection form or lower limits selection form may be required.
B. UNDERWRITING QUESTIONS
1. Are all owned or leased vehicles covered under this program? ...................................................... Yes No
If “no,” provide details: ______________________________________________________________________________________
2. Describe any location(s) with a concentration of stored vehicles whose total values exceed $500,000.
LOCATION UNIT NUMBER(S) FROM VEHICLE SCHEDULE TOTAL VALUES
_______________________________________________________________________________________
_______________________________________________________________________________________
3. Does the entity have any mutual aid agreements? ......................................................................... Yes No
If “yes,” please attach copies.
PE-APP-AUTO-GA (2-03) Page 1 of 2
4. Does the insured own or operate any vehicle designed exclusively for hauling explosives, flam-
mable or hazardous materials?........................................................................................................ Yes No
Describe: ___________________________________________________________________________________________________
5. Are autos hired by the public entity (other than schools)?............................................................... Yes No
6. Do any employees drive their own vehicles in the scope of their employment? ............................. Yes No
If “yes,” list employees and their occupation: ________________________________________________________________
_____________________________________________________________________________________________________________
Are Certificates of Insurance required from these employees?....................................................... Yes No
7. Are employees allowed to take vehicles home after work?............................................................. Yes No
If “yes,” list employees and their occupation: ________________________________________________________________
Is personal use permitted?............................................................................................................... Yes No
8. Does the insured provide any type of transportation system?......................................................... Yes No
If “yes,” explain and provide any available brochures: ________________________________________________________
_____________________________________________________________________________________________________________
9. Describe automobile maintenance program, including frequency: ____________________________________________
_____________________________________________________________________________________________________________
Are logs maintained for all repairs and maintenance performed? ................................................... Yes No
10. Describe driver hiring practices:
Under age 25? ................................................................................................................................. Yes No
Over age 60? ................................................................................................................................... Yes No
Previous driver experience? ............................................................................................................ Yes No
Physical exams on a regular basis? ................................................................................................ Yes No
If “yes,” frequency: __________________________________________________________________________________________
Are motor vehicle reports checked? ................................................................................................ Yes No
If “yes,” what are standards? ________________________________________________________________________________
_____________________________________________________________________________________________________________
Describe driver training procedures (i.e., emergency vehicle training, defensive driving): _____________________
_____________________________________________________________________________________________________________
11. Is there an accident investigation program? .................................................................................... Yes No
12. Are driver safety reviews conducted annually? ............................................................................... Yes No
If “yes,” what are the standards for driver accountability? ____________________________________________________
_____________________________________________________________________________________________________________
13. Are MVR’s updated periodically for all drivers? ............................................................................... Yes No
14. What action is taken if a driver does not meet your MVR standards? _________________________________________
_____________________________________________________________________________________________________________
15. Attach list of drivers including MVR information; indicate emergency vehicle operators.
PE-APP-AUTO-GA (2-03) Page 2 of 2
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Streets/Roads/Highways/Bridges
Questionnaire A
Legal Name of Public Entity: _______________________________________________ Effective Date: ___________________
1. STREETS/ROADS/HIGHWAYS
a. Paved mileage __________ Unpaved mileage __________ Mileage maintained for others _________
b. Does the entity have a regular inspection and maintenance program? .......................................... Yes No
c. Are written records of maintenance kept? ....................................................................................... Yes No
d. Are road signs regularly inspected for visibility and missing signs? ................................................ Yes No
e. Are barricades and warning signs used at road work sites? ........................................................... Yes No
f. Is there a “prior notice” ordinance in effect? .................................................................................... Yes No
g. Provide revenues for snow removal of streets and roads not owned by the insured. $ _________________________
2. BRIDGES (Attach most current copies of bridge inspection reports.)
a. How many bridges are owned and/or maintained by the entity? ______________________________________________
b. Are all bridges posted for size and weight limits?............................................................................ Yes No
c. How many one lane bridges? .... _____________ Are warnings posted? ........................................ Yes No
d. How many drawbridges? ........... _____________ Are warnings posted? ........................................ Yes No
e. How many toll bridges?.............. _____________ Number of toll bridge crossings per year?....... ______________
f. Describe bridge inspection procedures: ______________________________________________________________________
_____________________________________________________________________________________________________________
g. What was the date of the last inspection? ____________________________________________________________________
h. Have any bridges not passed inspection (do not meet local, state or federal standards; are
structurally deficient, etc.), or are any bridges closed or condemned? ........................................... Yes No
If “yes,” list bridges, locations, reasons for current conditions and closing warnings/protection to prevent
access: _____________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
i. Is the entity involved in any bridge construction? ............................................................................ Yes No
If “yes,” describe: ____________________________________________________________________________________________
j. Does the entity contract any portion of bridge operations (construction, maintenance, inspection,
etc.)? ................................................................................................................................................ Yes No
PE-APP-QUES-A-GA (2-03)
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Special Events (Carnivals, Fairs, Parades, Etc.)
Questionnaire B
Please complete a separate questionnaire for each event.
PLEASE ATTACH ANY BROCHURES, SCHEDULE OF EVENTS, ETC.
Legal Name of Public Entity: _______________________________________________ Effective Date: ____________________
1. Description of event(s): __________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
2. Date/duration of event(s): ________________________________________________________________________________________
_________________________________________________________________________________________________________________
3. Location and ownership of premises used for the event(s): _______________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
4. Anticipated crowd attendance: ___________________________________________________________________________________
5. Are any bleachers used? .......................................................................................................................... Yes No
Capacity: _________________ (number of persons)
6. Describe entity’s responsibility for event (i.e., entity provides premises, provides funds, provides personnel, etc.):
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
7. List each sponsor/co-sponsor and their respective responsibilities for each event or activity:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
8. Are independent contractors used to provide any services? .................................................................... Yes No
If “yes,” what services? __________________________________________________________________________________________
9. Describe security/crowd control/safety precautions:
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
10. Are “Certificates of Insurance” required from all sponsors indicating the entity as “additional insured”
and showing adequate limits of insurance? .............................................................................................. Yes No
Limits required: __________________________________________________________________________________________________
11. Are alcoholic beverages (including beer) available at the event?............................................................. Yes No
12. Anticipated liquor sales receipts? ________________________________________________________________________________
13. Is there currently a liquor liability policy in force?...................................................................................... Yes No
PE-APP-QUES-B-GA (2-03)
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application Day Care
Questionnaire C
❑ Day Care ❑ Day Camp ❑ Nursery
(If the entity operates more than one, a separate questionnaire must be completed for each.)
Legal Name of Public Entity: _______________________________________________ Effective Date: ____________________
1. Name and location of facility: _____________________________________________________________________________________
2. Description of operation: _________________________________________________________________________________________
a. Is facility licensed?.............................................................................................................................. Yes No
If “yes,” by whom? ___________________________________________________________________________________________
b. Number of years in operation: ________________________________________________________________________________
Days and hours of operation: _________________________________________________________________________________
c. Maximum number of children permitted by license: ___________________________________________________________
3. Indicate the number of children within each age group and the corresponding number of attendants assigned:
Age Group No. of Children No. of Attendants
1 to 6 months
6 to 12 months
1 to 3 years
Over 3 years to 8 years
Over 8 years
4. Number of staff/attendants: ________________ Number of volunteers: _______________
5. Professional qualifications of staff: ________________________________________________________________________________
a. How are staff members hired/evaluated? _____________________________________________________________________
b. Are criminal background checks completed?..................................................................................... Yes No
6. Any previous or pending allegations of sexual or physical abuse? .......................................................... Yes No
If “yes,” explain: __________________________________________________________________________________________________
7. Describe all activities on premises: _______________________________________________________________________________
8. Describe any activities away from premises (including number of trips, who transports, etc.): ______________________
__________________________________________________________________________________________________________________
9. Are parental permission/waiver forms required? ...................................................................................... Yes No
10. Please describe the play equipment and facilities: ________________________________________________________________
__________________________________________________________________________________________________________________
11. Does each location have the following:
a. Emergency evacuation plan? ............................................................................................................. Yes No
b. Regularly inspected fire/smoke detection system? ............................................................................ Yes No
c. Two separated exits on each floor? ................................................................................................... Yes No
d. First aid equipment? ........................................................................................................................... Yes No
e. Someone on premises during business hours trained in administering first aid?.............................. Yes No
f. Play area fully fenced? ....................................................................................................................... Yes No
12. Sexual abuse/molestation coverage? ❑ No coverage Requested limits: ____________________________
PE-APP-QUES-C-GA (2-03)
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Landfill/Dump/Refuse Site/Incinerator
Questionnaire D
Please complete a separate questionnaire for each site.
Pollution Exclusion Applies.
Legal Name of Public Entity: _______________________________________________ Effective Date: _____________________
1. Type of facility: ❑ Landfill ❑ Dump ❑ Transfer station
2. Advise if the site is: ❑ owned by the entity, or ❑ operated by the entity.
3. Has the site been designated as either a hazardous waste or superfund site by the EPA? .................... Yes No
4. a. Describe the site as specifically as possible: __________________________________________________________________
b. What is immediately adjacent to landfill site? __________________________________________________________________
c. What is the nearest body of water? ___________________________________________________________________________
How far away from the site? __________________________________________________________________________________
d. What is the nearest building? _________________________________________________________________________________
How far away from the site? __________________________________________________________________________________
5. a. Total number of acres: _________________________
b. Number of acres in use: ________________________
c. Number of years operated: _____________________
d. What is the remaining useful life? _______________
e. Is the landfill licensed or certified? ...................................................................................................... Yes No
If “yes,” by what agency? _____________________________________________________________________________________
6. Security provisions:
a. Fenced? .............................................................................................................................................. Yes No
Height? ____________________________________________
b. Attendant?........................................................................................................................................... Yes No
Hours? _____________________________________________
c. Locked?............................................................................................................................................... Yes No
Describe lock policy: _________________________________________________________________________________________
7. Describe waste accepted:
a. Type (residential, commercial, etc.) ___________________________________________________________________________
b. Form (solid, liquid, sludge, etc.) _______________________________________________________________________________
c. Hazardous waste? .............................................................................................................................. Yes No
If “yes,” explain: ______________________________________________________________________________________________
8. Any record of violation or citations outstanding?....................................................................................... Yes No
If “yes,” explain: __________________________________________________________________________________________________
PE-APP-QUES-D-GA (2-03) Page 1 of 1
9. How are leachate and methane exposures evaluated and controlled? _____________________________________________
__________________________________________________________________________________________________________________
10. Number of inactive landfills:_____________ Locations: _____________ No. of acres: ________________
11. Are monitoring wells installed? ................................................................................................................. Yes No
If “yes,” describe any protection surrounding: _____________________________________________________________________
__________________________________________________________________________________________________________________
12. a. Describe closure plans for landfill: ___________________________________________________________ (Cite time frame)
b. Were EPA guidelines followed? ......................................................................................................... Yes No
13. If transfer station:
a. Are dumpsters used? ......................................................................................................................... Yes No
b. Is there an open pit?........................................................................................................................... Yes No
c. Is entity responsible for transportation to landfill? .............................................................................. Yes No
If “no,” is it contracted? (Provide certificate of insurance.) ................................................................. Yes No
PE-APP-QUES-D-GA (2-03) Page 2 of 2
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Sewer/Water Utility
Questionnaire E
Legal Name of Public Entity: _______________________________________________ Effective Date: _____________________
A. SEWER UTILITY
1. Number of utility users: Industrial:___________ Commercial: ________________ Residential: _________________
2. Provide:
Annual payroll (less clerical): $ ______________________
Plant operation: $ ______________________
Construction: $ ______________________
Cleaning: $ ______________________
3. Provide number of sewer miles: Storm: ________________ Sanitary: _________________
4. What type of facility is operated? ❑ Treatment Plant ❑ Lift Stations ❑ Pumps
5. If treatment plant is operated:
a. Type of plant? ______________________ Primary __________ Secondary ____________ Tertiary ______________
b. What regulatory agency is responsible for monitoring (DEC, EPA, Health Department)? ___________________
__________________________________________________________________________________________________________
How often? ______________________________________________________________________________________________
c. How is influent input monitored for toxic or hazardous waste? _____________________________________________
__________________________________________________________________________________________________________
d. How are chemicals labeled and where stored? ___________________________________________________________
e. What is done with residual by-product/sludge? ___________________________________________________________
__________________________________________________________________________________________________________
f. Has plant ever been fined or received a citation?........................................................................ Yes No
If “yes,” explain: __________________________________________________________________________________________
g. Are any operations contracted?................................................................................................... Yes No
If “yes,” attach Certificate of Insurance and a copy of any hold harmless agreements.
6. How old is your system? ____________________________ Year of last upgrade? _______________________________
7. Is regular maintenance performed? ................................................................................................... Yes No
Are records kept for all repairs? ......................................................................................................... Yes No
8. Have you had any past/present incidents of sewer back-up to residential or commercial property? Yes No
If “yes,” please explain (include dates, cause and corrective action taken): ____________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
PE-APP-QUES-E-GA (2-03) Page 1 of 2
B. WATER UTILITY
1. General Information
a. Annual payroll (less clerical): $ ____________________
b. Number of gallons distributed annually: _____________ Maximum annual capacity: _______________________
c. Miles of pipe: ______________________________________ Total number of employees: ______________________
d. Number of users: Residential:______________ Commercial: _______________ Industrial: _______________
e. Number of: Water treatment plants: __________ Water tanks: ___________ Water towers:______________
f. Are all facilities fenced? ............................................................................................................... Yes No
g. Is water provided to neighboring entities? ................................................................................... Yes No
If “yes,” describe and provide copies of contracts: ________________________________________________________
__________________________________________________________________________________________________________
2. Source of water supply (lake, well, etc.): ______________________________________________________________________
a. How old is your system? ________________________ Year of last upgrade? _______________________________
b. Composition of pipe?
❑ Lead ______ % ❑ Cast iron _______ % ❑ Asbestos _______ %
❑ Plastic ______ % ❑ Clay _______ % ❑ Other _______ %
3. a. Has utility completed monitoring for lead in drinking water? ....................................................... Yes No
b. Date completed: _________________________________________________________________________________________
c. Test results:
1) Tap water monitoring ________________________________________________________________________________
2) Water quality monitoring _____________________________________________________________________________
3) Lead source water monitoring ________________________________________________________________________
d. If test results exceed the lead action level of 15 ppb, please comment on treatment techniques relating to
(a) corrosion control, (b) source water, (c) public education, or (d) lead service line replacement as
applicable.
4. How often is water tested? __________________________ By which regulatory agent? __________________________
5. Has system ever been cited or fined for non-compliance with required standards? ......................... Yes No
If “yes,” please provide details, copy of non-compliance notice(s) and action(s) taken to correct problem(s).
6. Does entity contract any part of water operations (construction, maintenance, inspection, etc.)? .... Yes No
If “yes,” provide certificates of insurance.
PE-APP-QUES-E-GA (2-03) Page 2 of 2
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Electric Utility
Questionnaire F
Legal Name of Public Entity: _______________________________________________ Effective Date: _____________________
1. Number of utility users: Industrial: ______________ Commercial: ________________ Residential: ______________
2. Annual payroll (less clerical): $ ________________________
3. Main location: ____________________________________________________________________________________________________
4. Total number of locations, including substations: __________________________ Years in operation: __________________
5. Are all locations protected?....................................................................................................................... Yes No
Fenced? .................................................................................................................................................... Yes No
Lighted? .................................................................................................................................................... Yes No
Alarms? ..................................................................................................................................................... Yes No
Other? ___________________________________________________________________________________________________________
Describe controls at substation with reference to signage:_________________________________________________________
6. Surrounding area? Rural __________________ Metro ___________________ Nearest residence _______________ ft.
7. Are there any PCB transformers?............................................................................................................. Yes No
Number ________________________________________________ When is replacement scheduled? ________________________
8. Who is responsible for inspecting operations? ____________________________________________________________________
__________________________________________________________________________________________________________________
9. How frequently is inspection done? _______________________________________________________________________________
10. Who monitors and checks regulation flow? _______________________________________________________________________
11. Number of miles of distribution line:_________________ Underground: _______________ Overhead: ________________
12. Describe pole and line maintenance (who maintains, how often inspected, how documented)? ____________________
__________________________________________________________________________________________________________________
13. Are maps maintained? ___________________________________________________________________________________________
14. Maximum annual kilowatts distributed: ____________________________________________________________________________
15. Total annual revenues for electricity distributed:___________________________________________________________________
16. Advise if generating electricity: ................................................................................................................. Yes No
If “yes,” advise the source of power: ❑ Fossil fuel ❑ Hydro-electric ❑ Nuclear
What is total daily capacity? _____________________________ Peak demand daily? ___________________________________
Total annual revenues for generation: ____________________________________________________________________________
Generation: ______________ % Distribution: ______________ %
Number of miles of transmission lines? ___________________________________________________________________________
17. What is power source? ___________________________________________________________________________________________
18. Alternate power source? _________________________________________________________________________________________
19. Describe consumer complaint procedure, if any: __________________________________________________________________
__________________________________________________________________________________________________________________
20. Describe turn-on/turn-off procedures: _____________________________________________________________________________
PE-APP-QUES-F-GA (2-03)
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Gas Utility
Questionnaire G
Attach a copy of past three years D.O.T. reports
Legal Name of Public Entity: _______________________________________________ Effective Date: _____________________
1. Advise if gas is: ❑ produced, or ❑ purchased and resold.
2. Does the entity own or operate a gas wellhead or pipeline? .................................................................... Yes No
3. Number of utility users: Industrial _______________ Commercial _______________ Residential __________________
4. Annual payroll (less clerical): $ ______________________
5. Who is responsible for leakage survey? __________________________________________________________________________
6. Date of last complete leakage survey of distribution system: ______________________________________________________
Frequency of such surveys:
Business district ____________________________________ Outside business district ____________________________
7. Describe briefly, procedure of leakage survey (i.e., how detected or discovered in meters, lines, etc.): _____________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
a. Repair procedure? ___________________________________________________________________________________________
b. Are surveys conducted on a planned basis?...................................................................................... Yes No
8. What percentage of system is cathodically protected? ____________%
9. Date of last corrosion survey: ___________________________ Conducted by: ______________________________________
10. Year original system installed: ____________________________________________________________________________________
11. Describe main service replacement program: _____________________________________________________________________
__________________________________________________________________________________________________________________
a. Are new lines hydrostatic or pressure tested? ................................................................................... Yes No
b. Are records on file? ............................................................................................................................ Yes No
12. Who is gas purchased from? _____________________________________________________________________________________
__________________________________________________________________________________________________________________
13. Who is responsible for odorization? ______________________________________________________________________________
a. Are records maintained? .................................................................................................................... Yes No
b. Are monthly odorant level checks made? .......................................................................................... Yes No
c. Describe type of odorization system used: ____________________________________________________________________
______________________________________________________________________________________________________________
14. Does gas system have high and low pressure warning devices? ............................................................ Yes No
If “yes,” are devices constantly monitored? .............................................................................................. Yes No
a. Pressure records kept? ...................................................................................................................... Yes No
b. For how long? _______________________________________________________________________________________________
PE-APP-QUES-G-GA (2-03) Page 1 of 2
15. Who installs main extensions? ___________________________________________________________________________________
a. Who installs services? _______________________________________________________________________________________
b. If gas company personnel install mains and services, are welders certified?.................................... Yes No
c. Training practices: ___________________________________________________________________________________________
d. Turn-on and turn-off procedures? ...................................................................................................... Yes No
16. Does the gas company maintain a distribution map? ............................................................................... Yes No
Is it up-to-date? ......................................................................................................................................... Yes No
17. Are regulating stations adequately fenced, housed, or otherwise secured? ............................................ Yes No
18. Are there any liquefied natural gas (LNG) operations? ............................................................................ Yes No
Type of container used to hold gas:_______________________________________________________________________________
Does the gas company participate in a local or statewide “call before digging” campaign? .................... Yes No
Does the gas company follow an established procedure at time customer meter is turned on? ............. Yes No
Describe in detail: ________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
21. Are meters removed or locked-up when gas is turned off? ...................................................................... Yes No
22. Does the gas company maintain a customer complaint log? ................................................................... Yes No
a. Number of years complaint record maintained: _______________________________________________________________
b. Are leak complaints worked on same day received? ......................................................................... Yes No
c. Customer complaint frequency: ______________________________________________________________________________
PE-APP-QUES-G-GA (2-03) Page 2 of 2
Ank National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Public Housing Authority
Questionnaire H
Legal Name of Public Entity: _______________________________________________ Effective Date: _____________________
1. Total number of units: ___________ Number of conventional units: ____________ Number of residents: _____________
Number of Section 8 & 23 units: _________________________ Number of residents: ________________________________
2. Number of stories per unit: ______________________________
Advise number of buildings over four stories and heights for each: ________________________________________________
3. Type of security and/or fire protection measures in place: _________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
4. Do buildings have smoke detectors? ........................................................................................................ Yes No
If “yes”: ❑ battery-powered, or ❑ hardwired (into building electrical system?)
If battery-powered, what is the scheduled maintenance plan? _____________________________________________________
5. Are the units ADA compliant? ................................................................................................................... Yes No
6. What accommodations are made to handle the elderly or handicapped? __________________________________________
__________________________________________________________________________________________________________________
7. Describe recreational or extracurricular programs sponsored by the housing authority and the facilities:____________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
8. Day care facilities? .................................................................................................................................................................... Yes No
If “yes,” complete questionnaire C.
9. Lead Abatement Information (Complete for each location built prior to 1978.)
a. Have these buildings been tested for the presence of lead? ............................................................. Yes No
b. Are there any known lead-related claims, past or present? ............................................................... Yes No
Provide complete details: _____________________________________________________________________________________
______________________________________________________________________________________________________________
c. Does the insured have a certificate of completion for lead abatement? ............................................ Yes No
If “yes,” attach a copy and complete the following questions:
d. What method of lead abatement was used?
❑ Paint: ❑ Encapsulation ❑ Component replacement ❑ Abrasive removal
❑ Enclosure ❑ Chemical removal ❑ Hand removal/scraping
❑ Soil: _____________________________________________________________________________________________________
❑ Water: ___________________________________________________________________________________________________
e. Is annual retesting done at this location? ................................................................................................................. Yes No
(Attach the latest certificate)
f. Is this authority in compliance with the Housing and Community Development Act?........................ Yes No
If “no,” describe measures being taken to bring buildings into compliance: _____________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
PE-APP-QUES-H-GA (2-03)
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Recreational Activities
Questionnaire K
Legal Name of Public Entity: ______________________________ Effective Date: _____________________________________
A. MANAGEMENT
1. Does the entity have a regular inspection/maintenance program for all facilities and equipment? ... Yes No
(Parks, playgrounds, skating rinks, equipment, buildings, etc.)
2. How often? Weekly Monthly Other
3. Are all regular inspections and corrective actions documented?....................................................... Yes No
B. PARKS/PLAYGROUNDS
1. Is there playground equipment?......................................................................................................... Yes No
2. What surface is provided underneath playground equipment? _________________________________________________
C. ICE/ROLLER SKATING Please complete a separate questionnaire for each facility.
1. Type of rink: Ice Roller Location:____________________ Indoor Outdoor
2. Size of rink (square feet): ___________________________ Annual sales/receipts: $ ________________________________
3. Are warning signs posted? ................................................................................................................. Yes No
Is rink lighted? .................................................................................................................................... Yes No
4 Is ice hockey permitted?..................................................................................................................... Yes No
If “yes,” complete E. below
5. Hours and days of operation: _________________________________________________________________________________
Youth Adult Supervised?
Participants:
Yes No
6. Describe procedures for checking ice thickness: ______________________________________________________________
______________________________________________________________________________________________________________
D. SKATE PARKS Please complete a separate questionnaire for each facility
1. Does the insured have a specifically designated area for the skate park? ........................................ Yes No
2. Activity: Skateboard In-Line Skates
INCLUDE A COPY OF THE RISK MANAGEMENT GUIDELINES FOR OPERATION OF THE SKATE PARK.
3. Number of pipes over 2 ft. in height: ..................................................................................... ____________________
Number of ramps over 2 ft. in height: .................................................................................... ____________________
Maximum height of pipes: ______________________ ramps _______________________________________________
Type of construction: Wooden __________________ % Concrete __________________% Other _______________
Permanent __________________________________________ Portable ____________________________________________
4. Has any law, ordinance or statute been passed giving skate park immunity to the insured?............ Yes No
If “yes,” please explain: ______________________________________________________________________________________
______________________________________________________________________________________________________________
5. Are there any vendor activities at the skate park? _____________________________________ Yes No
If “yes,” please describe: (Rentals, Concessions, etc.) ________________________________________________________
______________________________________________________________________________________________________________
PE-APP-QUES-K-GA (2-03) Page 1 of 1
E. 1. ENTITY ORGANIZED ACTIVITIES—Please attach detailed description of each activity and any brochures or
schedules available
Activity Example: Number of
Entity Sponsored/ Third Party Sponsored
Baseball, football, Participants
Supervised?
hockey, soccer Youth Adult Supervised? COI to Entity
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
Yes No Yes No Yes No
a. Does entity secure waiver and release and/or consent forms for all participants? ..................... Yes No
Please attach copies of any forms used.
Do any participants provide their own insurance? ....................................................................... Yes No
2. a. Describe any activities away from premises: ______________________________________________________________
b. What transportation is provided, if any?___________________________________________________________________
c. Are parental permission/waiver forms required? ......................................................................... Yes No
(If “yes,” attach copy of same.)
F. WATERFRONT ACTIVITIES EXPOSURES (Swimming Pools, Beaches, Lakes, Reservoirs, etc.)
(Please complete a separate questionnaire for each area.)
1. a. Type of exposure: ❑ Pool ❑ Beach ❑ Pond ❑ Lake
❑ Reservoir ❑ Ocean ❑ River ❑ Stream
b. Name and location of exposure: __________________________________________________________________________
2. a. Pool(s) square footage/frontage/size: _____________________________________________________________________
b. Number of diving boards: _______________________ Height of each: ______________________________
Depth of diving well: ____________________________ Depth markers?....................................... Yes No
3. a. Identify all activities (swimming, boating, ice skating, etc.): ________________________________________________
b. Swimming area:
1) Is swimming area roped or marked? ..................................................................................... Yes No
If “yes,” explain area and type marking: _______________________________________________________________
2) Are life guards provided? ...................................................................................................... Yes No
How many? ____________________ Hours on duty? _____________ Certified?................... Yes No
3) Is boating permitted near the swimming area? ..................................................................... Yes No
4) Is diving permitted? ............................................................................................................... Yes No
Supervised?........................................................................................................................... Yes No
5) Depth of water? ________________
Is swimming area checked for underground obstructions, etc.?........................................... Yes No
4. Describe maintenance and repair of facilities: _________________________________________________________________
______________________________________________________________________________________________________________
5. How many water slides do you have? _______________ How high are the slides? ____________________________
a. Number of curves in each slide?.................................................................................................. Yes No
Attendants at top?............................. Yes No Attendants at bottom? ............................. Yes No
b. Attendance capacity? ___________________________ Average daily attendance? __________________________
c. Explain additional controls and safety features: ___________________________________________________________
__________________________________________________________________________________________________________
d. Days and hours of operation: _____________________________________________________________________________
e. What controls, if any, are used to eliminate or discourage after hour accessibility? ________________________
G. PIERS/MARINAS/WHARVES/DOCKS EXPOSURE
1. Type of facility: ❑ Pier ❑ Marina ❑ Wharf ❑ Dock
2. Square footage: _____________________________________ What body of water? ________________________________
3. Describe use: ________________________________________________________________________________________________
PE-APP-QUES-K-GA (2-03) Page 2 of 2
4. Are there any gasoline pumps (if marina)? ........................................................................................ Yes No
If “yes,” describe controls:
5. Are boats allowed to dock overnight? ................................................................................................ Yes No
Number of slips available: ______________
6. What are annual fees? _______________________________________________________________________________________
7. Are there any power lifts?................................................................................................................... Yes No
8. Describe any storage facilities (i.e., dry docking) or repair facilities:____________________________________________
9. If marina, receipts: $ _________________________________________________________________________________________
10. Are boats rented to the public? .......................................................................................................... Yes No
If “yes,” what are receipts? $ ________________
a. Size and type of boats: ___________________________________________________________________________________
b. Release/rental agreement?.......................................................................................................... Yes No
(attach copy)
c. Age restrictions? .......................................................................................................................... Yes No
Describe: ________________________________________________________________________________________________
11. Are there any concessions? ............................................................................................................... Yes No
H. WATERCRAFT EXPOSURE
1. Describe watercraft: __________________________________________________________________________________________
Manufacturer’s name: _______________________________ Year: _________________ Length: ___________________
H. P.: _________________________ Inboard:__________________________ Outboard: ___________________________
2. What is watercraft’s use? ____________________________________________________________________________________
3. Boats rented to others? ...................................................................................................................... Yes No
Receipts? $ ____________________________
PE-APP-QUES-K-GA (2-03) Page 3 of 3
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application Dams And Reservoirs
Questionnaire M
Note: If the entity operates more than one dam or reservoir,
a separate questionnaire must be completed for each structure.
Legal Name of Public Entity: ______________________________ Effective Date: _____________________________________
1. ❑ DAM ❑ RESERVOIR HAZARD CODE: ____________________________________
2. Name of structure: _______________________________________________________________________________________________
a. Location: ____________________________________________________________________________________________________
b. Year built: __________________________________________ Under the direction of: _______________________________
c. Name of tributary rivers:
Upstream ____________________________________________________________________________________________________
Downstream _________________________________________________________________________________________________
d. Purpose: ❑ Flood control ❑ Irrigation ❑ Water supply ❑ Industrial ❑ Power*
* If “power,” please describe alternate source in event of power failure: _______________________________________
______________________________________________________________________________________________________________
e. Construction: ❑ Concrete ❑ Earthen ❑ Steel Sheered ❑ Timber
f. Dimensions: Height: ________________ Top width: ____________________ Base width:___________________
g. Normal pond measurements:_________________________________________________________________________________
Number of acres: _______________ Storage capacity (gallons): _________________ Acre feet:_________________
Additional storage available in flood state?........................................................................................ Yes No
If “yes,” describe: ____________________________________________________________________________________________
______________________________________________________________________________________________________________
3. Upstream exposure?................................................................................................................................. Yes No
If “yes,” specifically describe, including distance (housing, industrial complexes, etc.): _____________________________
__________________________________________________________________________________________________________________
4. Downstream exposures (indicate if exposure is present, including distance):
a. Housing: ............................................................................................................................................. Yes No
Distance: ___________________________________________ Number: ____________________________________________
b. Other structures:................................................................................................................................. Yes No
Distance: ___________________________________________ Number: ____________________________________________
c. Industrial complexes:.......................................................................................................................... Yes No
Distance: ___________________________________________ Number: ____________________________________________
d. Public utilities:..................................................................................................................................... Yes No
Distance: ___________________________________________ Type: _______________________________________________
e. Pumping stations: ............................................................................................................................... Yes No
Distance: ___________________________________________
PE-APP-QUES-M-GA (2-03) Page 1 of 2
f. Lower dams: ....................................................................................................................................... Yes No
Distance: ___________________________________________ Names: _____________________________________________
g. Bridge(s): ............................................................................................................................................ Yes No
Distance: ___________________________________________ Number: ____________________________________________
h. Highway(s):......................................................................................................................................... Yes No
Distance: ___________________________________________ Number: ____________________________________________
i. Railroad(s): ......................................................................................................................................... Yes No
Distance: ___________________________________________ Number: ____________________________________________
j. Agricultural area: ................................................................................................................................ Yes No
Distance: ___________________________________________
Type of exposure (livestock, crops, etc.) ______________________________________________________________________
k. Recreational Areas: ............................................................................................................................ Yes No
Distance: ___________________________________________ Types: ______________________________________________
______________________________________________________________________________________________________________
l.Schools:.............................................................................................................................................. Yes No
Distance: ___________________________________________
m. Hospitals:............................................................................................................................................ Yes No
Distance: ___________________________________________
n. Camp: ................................................................................................................................................. Yes No
Distance: ___________________________________________
o. Maximum number of people flood could affect: _______________________________________________________________
5. Who inspects dams? ____________________________________ How often? _________________________________________
Date of last inspection on file? ____________________________________________________________________________________
Status of any recommendations made: ___________________________________________________________________________
__________________________________________________________________________________________________________________
6. During the past five years, has any company ever canceled, declined or refused to issue similar
insurance to the applicant? ....................................................................................................................... Yes No
If “yes,” explain: __________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PLEASE ATTACH PHOTOS AND COPIES OF MOST CURRENT ENGINEERING OR INSPECTION REPORTS.
PE-APP-QUES-M-GA (2-03) Page 2 of 2
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Port/Transportation/Airport Authorities
Questionnaire N
Legal Name of Public Entity: ______________________________ Effective Date: _____________________________________
A. PORT AUTHORITY
1. ❑ River ❑ Ocean ❑ Lake ❑ Railroad ❑ Other
B. TRANSIT AUTHORITY
1. Number of employees: _______________________________________________________________________________________
2. Revenues: ___________________________________________________________________________________________________
3. Type of vehicles: _____________________________________________________________________________________________
4. Number of passengers served annually: ______________________________________________________________________
Type of service provided: ____________________________________________________________________________________
Days and hours of operation: _________________________________________________________________________________
Number of bus shelters: ______________________________________________________________________________________
Number of bus stops—signed only: __________________________________________________________________________
5. Automobile liability carrier: ___________________________________________________________________________________
6. Who maintains the vehicles? _________________________________________________________________________________
C. AIRPORT AUTHORITY
1. Is this airport owned? ......................................................................................................................... Yes No
Operated?........................................................................................................................................... Yes No
Or leased to a third party?.................................................................................................................. Yes No
2. Number of daily commercial passenger flights: _______________________________________________________________
3. Is there a fixed-base operator? .......................................................................................................... Yes No
4. Is there a tower?................................................................................................................................. Yes No
5. Is airport FAA controlled?................................................................................................................... Yes No
6. Who writes airport premises liability policy? ___________________________________________________________________
Limits: _______________________________________________________________________________________________________
7. If airport is leased to a third party, does lessee have airport premises liability coverage, and does
the policy name our insured as additional insured? ........................................................................... Yes No
8. Are there any air shows or exhibitions? ............................................................................................. Yes No
If “yes,” attach narrative.
9. Is there a separate board/commission that controls the operations of the airport? ........................... Yes No
If “yes,” attach narrative describing: (1) responsibilities of the board, and (2) what kind of decisions
are made by the board.
PE-APP-QUES-N-GA (2-03)
National Casualty Company Scottsdale Indemnity Company
Madison, Wisconsin Home Office: One Nationwide Plaza
Property/Casualty Home Office: Columbus, Ohio 43215
8877 North Gainey Center Drive Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258 Scottsdale, Arizona 85258
Scottsdale Insurance Company Scottsdale Surplus Lines Insurance Company
Home Office: One Nationwide Plaza Adm. Office: 8877 North Gainey Center Drive
Columbus, Ohio 43215 Scottsdale, Arizona 85258
Adm. Office: 8877 North Gainey Center Drive
Scottsdale, Arizona 85258
1-800-423-7675
Public Entity Application
Miscellaneous Exposure
Questionnaire P
Legal Name of Public Entity: ______________________________ Effective Date: _____________________________________
A. EMERGENCY SERVICES EXPOSURE
1. E.M.T.’s/Paramedics/E.M.T.A.’s: Paid ____________ Volunteers_____________ Subcontracted ____________
Number of: EMTs _____________ EMTAs ____________ Paramedics ____________
a. Describe training/certification procedures: ________________________________________________________________
__________________________________________________________________________________________________________
b. Approximate number of annual calls: _____________________________________________________________________
Radius of operations: ____________________________________________________________________________________
2. Fire Department: Regular Volunteer
a. Number of firefighters: Paid ___________________ Volunteer ___________________
b. Describe training/certification procedures: ________________________________________________________________
__________________________________________________________________________________________________________
Approximate number of annual calls: _______________________________
c. Radius of operations: _____________
Do any fire marshals carry guns or other weapons?................................................................... Yes
d. No
Total square footage at all fire stations/firehouses: ________________________________________________________
e.
Describe all fund-raising activities:________________________________________________________________________
f.
Are mutual aid agreements in place with neighboring communities? ......................................... Yes
g. No
Attach copies.
1) Has legal counsel reviewed and approved the agreements? ............................................... Yes No
B. GOLF COURSES EXPOSURE
1. Name of golf course: _________________________________________________________________________________________
a. Location:_________________________________________________________________________________________________
b. Number of holes:_________________________________________________________________________________________
2. Receipts: $ ____________________________
3. Do they provide concessions? ........................................................................................................... Yes No
Annual receipts: Food __________________________________ Liquor ____________________________________
C. STADIUMS/BLEACHERS/GRANDSTANDS EXPOSURE
STADIUMS BLEACHERS GRANDSTANDS
1. What are total receipts for: _______________ _______________ _______________
2. Describe construction: _______________ _______________ _______________
3. Number of separate stadiums/bleachers/grandstands: _______________ _______________ _______________
4. Seating capacity of each stadium/bleacher/grandstand: _______________ _______________ _______________
PE-APP-QUES-P-GA (2-03) Page 1 of 3
D. FIREWORKS EXPOSURE
1. List the types of events and scheduled dates:_________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2. Are displays conducted by licensed pyrotechnicians?....................................................................... Yes No
If “no,” please explain (Who will set up and launch? Experience?): ___________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
3. How many fireworks launchers are there? ____________________________________________________________________
4. Where is display held? (River, park, open field, etc.)? ________________________________________________________
______________________________________________________________________________________________________________
5. How long will display last? ___________________________________________________________________________________
6. Will emergency vehicles be on premises?......................................................................................... Yes No
If “yes,” number of vehicles: __________________________________________________________________________________
7. Distance from crowd: ________________________________________________________________________________________
8. Distance to nearest structure: ________________________________________________________________________________
E. BLASTING EXPOSURE
1. Describe all blasting operations: ______________________________________________________________________________
2. Is blaster certified? ............................................................................................................................. Yes No
Number of years experience: _________________________________________________________________________________
3. Number of shots per year: ____________________________________________________________________________________
4. Is blasting contracted out? ................................................................................................................. Yes No
If “yes,” provide a copy of the Certificate of Insurance. Entity should be named as an additional insured and pol-
icy limits should be concurrent.
If “no,” please provide details of:
a. Safety precautions
b. Site monitoring
c. Transport/storage of explosives
F. CONVENTION/CIVIC CENTER EXPOSURE (EXHIBITION BUILDINGS, ARENAS, ETC.)
(If the entity operates more than one, a separate questionnaire must be completed for each.)
1. Description and address of each facility: ______________________________________________________________________
______________________________________________________________________________________________________________
2. Number of days in use: ______________________________________________________________________________________
3. Description of any and all events or use:______________________________________________________________________
______________________________________________________________________________________________________________
4. Attach certificates of insurance secured from individuals or organizations using the facility(ies).
5. Area, square footage: ________________________________________________________________________________________
6. Total occupancy capacity: ____________________________________________________________________________________
G. RIFLE RANGES
1. Indoor? ............................................................................................................................................... Yes No
Outdoor? ............................................................................................................................................ Yes No
2. What security measures are taken (including signage)? _______________________________________________________
______________________________________________________________________________________________________________
3. Police only? ........................................................................................................................................ Yes No
Open to public? .................................................................................................................................. Yes No
4. If public, is a range officer on duty whenever the shooting areas are operating? ............................. Yes No
PE-APP-QUES-P-GA (2-03) Page 2 of 3
5. Skeet? ................................................................................................................................................ Yes No
Stationary targets? ............................................................................................................................. Yes No
6. What is the distance to the nearest buildings? ________________________________________________________________
7. Is the range near an industrial or residential section?........................................................................ Yes No
8. Does the insured host competitions on the premises? ...................................................................... Yes No
H. GARBAGE COLLECTION
1. Who owns and operates it? __________________________________________________________________________________
2. Where is the collection going?________________________________________________________________________________
3. Is the landfill certified? ........................................................................................................................ Yes No
4. What type of trash?
Household .......................................................................................................................................... Yes No
Commercial ........................................................................................................................................ Yes No
Industrial ............................................................................................................................................. Yes No
I. CHEMICAL SPRAYING
1. Purpose and frequency of spraying operations: _______________________________________________________________
2. What employees do the spraying?____________________________________________________________________________
3. Are the employees properly licensed? ............................................................................................... Yes No
4. Please list the chemicals used: _______________________________________________________________________________
______________________________________________________________________________________________________________
5. Where are the chemicals stored? ____________________________________________________________________________
J. CEMETERIES
1. Describe operations performed by insured: ___________________________________________________________________
______________________________________________________________________________________________________________
2. How many plots are in the cemetery? ________________________________________________________________________
3. How many new burial plots are expected for the next 12 months? _____________________________________________
4. How many burials have been performed in the past three years? _____________________________________________
K. ZOO EXPOSURE
1. What type of animals are kept (i.e., man-eaters, farm, birds, reptiles, snakes, etc.)? ___________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
2. Is petting allowed?.............................................................................................................................. Yes No
3. Are visitors allowed to feed the animals? ........................................................................................... Yes No
4. Explain security and controls for #2 and #3: __________________________________________________________________
______________________________________________________________________________________________________________
5. Is a charge being made for #2 or #3? ................................................................................................ Yes No
If “yes,” what are the annual receipts? ________________________________________________________________________
6. Is this operation sponsored by the insured? ...................................................................................... Yes No
7. If this operation is contracted by the insured, are “Certificates of Insurance” obtained? ................... Yes No
Limits of liability the insured requires from the contractor: _____________________________________________________
L. MISCELLANEOUS EXPOSURES
Provide complete details of the operation(s):______________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
PE-APP-QUES-P-GA (2-03) Page 3 of 3