Get documents about "School Board and EPLI
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- 9/11/2012
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Document Sample
Educational Entity Errors and Omission Application
THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY
Name of Educational Entity:
Mailing Address:
City: State: Zip:
Telephone: Ext: Fax: Email:
Effective Date:
Limit Requested:
$1,000,000/$1,000,000 $1,000,000/$3,000,000
Deductible Requested
$2,500 $5,000 $7,500 $10,000 $15,000 $25,000 $50,000 $100,000 Other
Is Employment Practices Liability Insurance desired? YES NO
If so, complete the EPLI section of this application starting on page 3.
Actual year-end financials for past three years
Accumulated
Year Total Revenue Total Expenditures
Surplus/Deficit
$ $ $
$ $ $
$ $ $
NATURE OF ENTITY
Public Institution or Public School Administrative Service
Private Institution or Private School Other, explain under supplemental Section
Number of members comprising School Board, Board of Governors, Regents or Trustees:
Are any school openings or closings anticipated within the next 12 months? YES NO
Is the entity currently accredited? YES NO
Number of schools comprising Educational Entity?
Total number of Faculty / Teachers
Full Time Part Time Administrators Registered Nurses
Counselors/Psychologists Volunteers Other LPNs
Percentage of Faculty Tenured: %
Trident Insurance Services of New England, Inc. T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302 Page 1 of 7 www.metrogard.com
Total current enrollment Full Time Part Time
Expected enrollment in 3 years Full Time Part Time
Describe any current Educators or similar insurance Policy to that being applied for:
Company: Effective Date:
Limits: $ Deductible/Retention: $ Premium: $
Has any similar insurance been declined, cancelled or not renewed? YES NO
If “YES”, Give reason:
Have you ever been self-insured? YES NO
If “YES”, list dates:
CLAIM HISTORY
For the purpose of this application, “claim” shall mean a “lawsuit” or other written demand seeking “damages”
as a result of a wrongful act. Answer the following questions based on this definition.
With respect to claims over the last five years for which any settlement was or may have been paid, please provide the
following information:
Date
Claim
Damages Damages
Received Description of Claim Claimant Legal Expense
Paid Reserved
by
Insured
$ $ $
$ $ $
$ $ $
Have any of the following situations occurred within the last five years?
H as any claim been made or is now pending against the Entity or any person in his/her YES
capacity as an official or employee of the Entity that is not listed in the claims history above? NO
Does any official or employee have knowledge of any fact, circumstance or situation, which YES
might reasonably be expected to give, rise to a claim against them or against the Entity? NO
If yes to any of the above, explain under Supplement Section.
ADDITIONAL INFORMATION / CERTIFICATION
Provide any additional information that you feel is relevant to our review of your application:
If EPLI is not being requested proceed to Page #6.
STOP
If EPLI is being request, continue on the next page.
Trident Insurance Services of New England, Inc. T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302 Page 2 of 7 www.metrogard.com
Date of first continuous EPLI coverage: Insurance Company:
Deductible Requested (If different from the Educational Entity Policy)
$2,500 $5,000 $7,500 $10,000 $15,000 $25,000 $50,000 $100,000 Other
PREVIOUS AND OTHER INSURANCE
Have you previously purchased employment practices liability insurance? YES NO
If "Yes," please state for each prior policy:
Policy Limits/Deductible or Self Insured
Insurer Policy Period
Retention
$
$
$
Has any previous employment practices liability insurer ever cancelled or non-renewed your coverage? YES NO
If "Yes," please state the reasons given by such insurer for the cancellation or non-renewal.
(Use supplemental section, Page 6, if necessary.)
Has any insurer ever declined or rejected your application for employment practices liability YES NO
insurance?
If "Yes," please state the reasons, if any, given by such insurer for the declination.
(Use supplemental section, Page 6, if necessary.)
LOSS HISTORY
You must advise us of all Claims that have been made against the educational entity or its employees to be insured
during the past 5 years (irrespective of whether or not covered by insurance) and all incidents, facts or circumstances known to
any of your Officers, Directors, Managers, Or Supervisory Employees where an applicant for employment, Employee or third
party has either written about or verbally mentioned making a Claim for Inappropriate Employment Conduct, Harassment or
Discrimination.
Have any Claims (including lawsuits or threatened lawsuits) been made against the educational entity or YES NO
its employees to be insured, by any Employee (including Officers) or applicant for employment, during
the past 5 years, for alleged Inappropriate Employment Conduct, Harassment or Discrimination?
If "Yes," how many such Claims have been made?
For each Claim, please describe in detail such Claim, including whether such Claim is still pending, the total incurred for defense of
such Claim, and the total paid for settlement of judgment rendered.
(Use supplemental section, Page 6, if necessary.)
Have any Claims (including lawsuits or threatened lawsuits) been made against the educational entity or YES NO
its employees to be insured, by any third party, during the past 5 years, for alleged Harassment or
Discrimination?
If "Yes," how many such Claims have been made?
Have any complaints or charges been filed against the educational entity or its employees to be YES NO
insured, with any regulatory agency (including but not limited to the National Labor Relations Board, the Equal
Employment Opportunity Commission or any similar Federal or State agency) during the past 5 years?
If "Yes," please describe in detail each such complaint or charge, the findings made by the
regulatory agency and the total incurred for defense of the complaint or charge.
(Use supplemental section, Page 6, if necessary.)
Is any Official, Director, Manager or Supervisory Employee employed by the educational entity or its YES NO
employees to be insured aware of any facts, circumstances, disagreements or incidents which might result in
a Claim against you or any such subsidiary, by any Employee (including Officers) or applicant for
employment, for Inappropriate Employment Conduct, Harassment or Discrimination?
If "Yes," please describe all such facts, circumstances, disagreements or incidents.
(Use supplemental section, Page 6, if necessary.)
Trident Insurance Services of New England, Inc. T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302 Page 3 of 7 www.metrogard.com
Is any Official, Director, Manager or Supervisory Employee employed by the educational entity or its YES NO
employees you or any subsidiary to be insured aware of any facts, circumstances, disagreements or
incidents which might result in a Claim against you or any such subsidiary, by any third party for Harassment
or Discrimination?
If "Yes," please describe all such facts, circumstances, disagreements or incidents.
(Use supplemental section, Page 6, if necessary.)
Has any employee of the Entity been suspended, demoted, dismissed, transferred or had their contract of YES NO
employment non-renewed within the last twelve months
(Use supplemental section, Page 6, if necessary.)
Please provide your loss runs for the last 5 years. Attach the details behind this application, including a description of
any single loss over $10,000 and a description of the measures taken to prevent reoccurrence of these large losses.
EMPLOYEES AND SPECIAL GROUPS
Number of Employees, including Partners, Directors and Officers, for all locations and Subsidiaries to be insured:
Full Time Part Time Seasonal Temporary Leased
If you have any "Seasonal” or "Temporary" Employees, please provide an explanation of the work duties YES NO
and average length of employment for each group. (Use supplemental section, Page 6, if necessary.)
Do any of your Employees belong to a union or do you have collective bargaining agreements impacting YES NO
any of your Employees?
Collective
Union Number of Employees Bargaining
Agreement
YES NO
YES NO
YES NO
Are there any groups of persons who are not directly employed by you or any subsidiary to be insured YES NO
(such as Employees of subsidiaries not to be insured, suppliers, consultants, wholly-controlled entities,
etc.) for which you may legally be deemed an "employer" or for which you may have liability, either by
operation of law or by contract or other means.
If "Yes," please explain. (Use supplemental section, Page 6, if necessary.)
NOTE: Claims made by any such persons who are not identified in this application will not be subject to
coverage under the policy, if any.
In the past year, have you or any of your staff attended an educational program that addresses EPL YES NO
issues?
Metrogard Program EPLI Seminar Date: How many attended?
Other Seminar Name/Sponsor: Date: How many attended?
Trident Insurance Services of New England, Inc. T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302 Page 4 of 7 www.metrogard.com
For full-time Employees who have left during the 2 years preceding this application, please state:
Past Year Employees Officers
Terminated
Left Voluntarily
TOTAL
Prior Year Employees Officers
Terminated
Left Voluntarily
TOTAL
YES NO
Are you anticipating any reductions / lay-offs in staff?
HUMAN RESOURCES
Please indicate whether the following are true for you the educational entity or its employees to be insured. For any "No" response,
please provide full details. (Use supplemental section, Page 6, if necessary.)
YES NO
There is an Employee Handbook which is provided to all non-union Employees
YES NO
All Employees are required to acknowledge in writing receipt of the Employee Handbook
YES NO
All new Employees are given an induction or appropriate training upon joining
The Employee Handbook has been reviewed by your attorney or Human Resources Department YES NO
If “Yes” when was it last reviewed?
Personnel files, with attendance records for vacation, sick leave and personal days recorded, are YES NO
maintained for each Employee
All Employees, whether full time or part time, receive at least annual written performance evaluations, and YES NO
those evaluations are kept in each Employee's personnel file
All Officer or Employee disciplinary actions or terminations are reviewed and approved, before YES NO
implementation, by either your labor attorney or your Human Resources Department
Do you have a full-time Human Resources Department or a retained attorney who has labor law YES NO
expertise? If so, what is their name?
Trident Insurance Services of New England, Inc. T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302 Page 5 of 7 www.metrogard.com
SUPPLEMENTAL SECTION
Trident Insurance Services of New England, Inc. T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302 Page 6 of 7 www.metrogard.com
The signing of this Application does not bind the undersigned to purchase the insurance, nor does review of the Application
bind the insurance company to issue a policy. This Application shall be the basis of the contract should a policy be issued and
will be referenced in the policy.
If this is a Renewal Application, it shall be a supplement to the Application(s) attached to the current policy and said
Applications together with this Renewal Application constitute the complete Application which shall be the basis of the contract
should a policy be issued.
DECLARATION
I declare that to the best of my knowledge and belief, and after surveying all Officers, Directors and senior management personnel,
the statements set forth herein are true and include all material information. I further declare that if the information supplied
herein changes between the date of this application and the commencement date of the policy issued in connection with the
application, I will immediately notify Insurers of such change, and accept that in such circumstances, the quotation may be modified
or withdrawn.
Date: Applicant's authorized Signature of Individual in charge of Human Resources or a Title:
Principal Partner or Officer
APPLICATION SUPPLEMENT
APPLICABLE IN ALL NEW ENGLAND STATES OTHER THAN MAINE AND VERMONT
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and civil penalties.
Date: Applicant’s Signature: Title:
Trident Insurance Services of New England, Inc. T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302 Page 7 of 7 www.metrogard.com
