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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
PRODUCER NAME: DATE APPLICATION COMPLETED:
AGENCY NAME: DATE QUOTE NEEDED TO AGENT:
AGENCY LOCATION: DATE COVERAGE TO INCEPT:
AGENCY WEB SITE: E MAIL ADDRESS:
1) NAMED INSURED: CONTACT NAME:
STREET ADDRESS: PUBLIC or PRIVATE SCHOOL?
CITY: STATE: ZIP CODE:
2) PROPOSED PLAN - Please enter limits and retentions desired. Insert "NA" if coverage is not desired.
NOTE: PROTECTED CELLS AUTOMATICALLY PULL DATA FROM THE SCHEDULE SHOWN IN SECTION 4)
A. Coverage I (Property - Real & Pers, Auto PhysDam, Bus Inc & Ext Exp, Prop in Transit and Data Proc Media & Equip - MAXIMUM LIMIT $1,000,000 INCLUSIVE OF SIR )
Per Loss Limit Proposed SIR: $25,000
Quake (Annual Aggregate) Sublimit NOTE: $25,000 minimum
Flood (Annual Aggregate) Sublimit
B. Coverage II (General Liability) - MAXIMUM LIMIT $10,000,000 INCLUSIVE OF SIR ) Proposed SIR: $50,000
Liability Per Occurrence Liability Policy Aggregate NOTE: $50,000 minimum
Premises Medical Payments Products / Completed Operations
C. Coverage III (Automobile Liability - MAXIMUM LIMIT $10,000,000 INCLUSIVE OF SIR ) Proposed SIR: $50,000
Liability Per Accident No-Fault Coverage/PIP NOTE: $50,000 minimum
Un/Underinsured Motorists Auto Medical Payments
D. Coverage IV (CLAIMS MADE School Board Legal Liability - MAXIMUM LIMIT $10,000,000 INCLUSIVE OF SIR ) Proposed SIR: $50,000
Liability Per Claim Liability Policy Aggregate NOTE: $50,000 minimum
Sexual Harassment Per Claim Sexual Harassment Policy Aggregate
Sexual Abuse Per Claim Sexual Abuse Policy Aggregate
E. Coverage V (Workers' Compensation - MAXIMUM LIMIT $200,000 EXCESS OF SIR ) Proposed SIR: $100,000
Workers Compensation NOTE: $100,000 minimum
Employer's Liability
F. Coverage VI (Crime - MAXIMUM LIMIT $500,000 INCLUSIVE OF SIR ) Proposed SIR: $25,000
Employee Dishonesty Money Orders & Counterfeit Currency NOTE: $25,000 minimum
Money & Securities (Inside Premises) Depositors Forgery
Money & Securities (Outside Premises)
G. Any other coverage required (please attach additional information as necessary):
Requested Limit Proposed Underlying Limit
Excess Property
Excess Liability
Excess Workers' Comp
All Lines Aggregate School Package Application - Main Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
3) CURRENT PROGRAM INFORMATION
COVERAGE TYPE CARRIER NAME LIMITS RETENTION RETRO DATE PREMIUM
A. Property (incl APD)
B. General Liability
C. Automobile Liability
D. School Board Legal
E. Workers' Comp
F. Crime
G.
H.
I.
Expiring Loss Fund (if applicable) $0
4) PROPERTY INFORMATION PROTECTION CLASS
NOTE: YOU MUST FORWARD A COMPLETE PROPERTY SCHEDULE WITH THIS APPLICATION ! APPRAISAL DATE
A. Values - IMPORTANT THAT 100% REPLACEMENT COST VALUES BE SHOWN $ VALUES % OF TOTAL
Total Building Values NA
Total Contents Values NA
Total Auto Physical Damage Values (all licensed vehicles) NA
Total Equipment Values NA
Total EDP Equipment Values NA
Total EDP Media Values NA
Total EDP Extra Expense Values NA
Total Accounts Receivable Values NA
Total Valuable Papers Values NA
Total Business Interruption Values NA
Total Extra Expense Values NA
Total Rental Income Values NA
Total Transit Values NA
Total Course of Construction Values NA
Total All Other Miscellaneous Values NA
Total Property Values: $0 NA
B. If flood coverage is requested, provide details of the flood exposure. List property values (Real & Personal) within Federally-defined flood plains (A & V):
LOCATION ADDRESS & DESCRIPTION $ VALUES @ LOCATION % OF TOTAL
NA
NA
NA
C. Construction Details - THIS SECTION MUST BE COMPLETED IN ORDER TO SECURE A QUOTATION!
ISO CLASSIFICATION # OF LOCATIONS % OF TOTAL
[1] Frame or Brick Veneer NA
[2] Brick NA
[3] Non-Combustible NA
[4] Masonry Non-Combustible NA
[5] Semi-Fire Resistive NA
[6] Fire Resistive NA
Any Other Classifications (describe) NA
Total # of Locations: 0 NA
All Lines Aggregate School Package Application - Main Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
D. Protection Details - THIS SECTION MUST BE COMPLETED IN ORDER TO SECURE A QUOTATION!
CLASSIFICATION # OF LOCATIONS % OF TOTAL
Sprinklered NA
Burglar Alarm - Local Sound NA
Central Station Alarms (both Burglar & Fire) NA
Security Guards NA
Smoke Detectors NA
All Other Types of Protection (describe) NA
Total # of Locations: 0 NA
5) GENERAL LIABILITY
NOTE: YOU MUST FORWARD COMPLETE FINANCIAL INFORMATION WITH THIS APPLICATION !
A. GL Rating Information
AVERAGE DAILY ABSENTEEISM TRUANCY
CATEGORY ENROLLMENT ATTENDANCE RATE RATE
Pupils
Elementary & Junior High Students NA
Senior High Students NA
Totals by Category: 0 0 NA NA
Employees TOTAL NUMBER % OF TOTAL
Teachers NA
Coaches NA
Nurses NA
Nurse Practitioners NA
Physicians NA
Other (describe) NA
Total Employees: 0 NA
Stadiums / Exhibition Centers USAGE CONSTRUCTION SEATING CAPACITY RECEIPTS
1.
2.
3.
4.
5.
Swimming Pools OPEN TO PUBLIC? # LIFEGUARDS POOL DEPTH # DIVING BOARDS BOARD HEIGHT
1.
2.
3.
4.
5.
Please describe required lifeguard training & certification:
B. Lead Exposure Questionnaire
1. Does School have any procedures for testing lead exposure levels in paint, dust, drinking water and soil at any buildings built prior to 1980?
Explain.
2. Have there been any adverse results arising out of the testing procedures described in B.1. above? Please explain.
All Lines Aggregate School Package Application - Main Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
3. Describe follow-up / abatement procedures.
C. Independent Contractor Operations Questionnaire
1. Does the School ever make use independent contractors? If yes, please describe the contractor types used & purposes:
2. Does the School require the following:
Certificate of Insurance?
Limits at least equal to those carried by the School (if general contractor)?
Is the School named as an Additional Insured on the contractor's policy?
Are there Hold Harmless Agreements used in all of the School's contracts?
3. Do you hold any special events in which you do not transfer liability to the contractor performing the special event?
D. Athletic Participants Questionnaire
1. Is a signed consent form from parents or guardians required and kept on file? (If "Yes", please attach a copy)
2. Are medical exams required and copies of doctors' permission forms kept on file for all athletes?
3. Are certified trainers and coaches used in the athletic program?
4. Is there a physician in attendance at all sporting events?
5. Is applicant securing AD&D / sports excess medical insurance on its participants?
If so, what carrier, limits, and coverage are in place?
6. Number of trampolines? -
7. Ratable athletic activities: # of PARTICIPANTS
Baseball 0
Basketball 0
Boxing 0
Cheerleading 0
Diving 0
Field Hockey 0
Football 0
Golf 0
Gymnastics 0
Ice Hockey 0
Rugby 0
Soccer 0
Softball 0
Swimming 0
Tennis 0
Track & Field 0
Volleyball 0
Weight Lifting 0
Wrestling 0
All Other Athletic Activities 0
Total # of Participants: 0
E. Living Quarters / Dormitories Questionnaire BUILDING AGE of NUMBER of SPRINKLERED? SMOKE / FIRE
NUMBER of RESIDENTS CONSTRUCTION BUILDING FLOORS (Yes / No) DETECTORS?
1.
2.
3.
4.
5.
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
F. Services Questionnaire (please show receipts associated with each) FOOD LIQUOR OTHER TOTAL
Cafeterias 0
Restaurants 0
Stores 0
Totals: 0 0 0 0
G. Other Questions
1. Do you operate a day care facility? Daily Attendance? # Care Staff?
2. Please attach additional information regarding extracurricular activities (e.g. newspapers, yearbooks, radio stations, etc.)
6) AUTOMOBILE LIABILITY
A. CATEGORY # THIS TYPE % THIS TYPE
Private Passenger Cars (up to 10,000 lbs GVW) - Non Emergency NA
15-Passenger Vans NA
Other Vans, Pickup Trucks, other Light Trucks (up to 10,000 lbs GVW) NA
Medium Weight Trucks (10,000 to 20,000 lbs GVW) NA
Heavy Trucks (20,000 to 50,000 lbs GVW) NA
Extra-Heavy Trucks (greater than 50,000 lbs GVW) NA
Motorcycles NA
Buses NA
Miscellaneous Autos NA
Mobile Equipment NA
Trailers, All Types NA
Total Automobiles: 0 NA
B. Underwriting Criteria for Buses ONLY (if applicable)
1. Is the bus service contracted? Name of Company used:
Company's Insurance Carrier: Limits Carried:
Insurance Certificate on File? Is School named an Additional Insured?
2. Describe operations of any passenger vans or buses (including radius, frequency, receipts, etc.):
3. Describe operations of any trucking exposures (including radius, frequency, receipts, etc.):
4. Describe any vehicles modified to handle handicapped or wheelchair passengers:
5. Please advise in which state the Insured has Automobile operations / exposure:
6. Please attach a copy of the policy on personal use of owned or leased vehicles.
7) SCHOOL BOARD LEGAL LIABILITY - this coverage is provided on a CLAIMS-MADE basis
SURPLUS or
A. Budget (last three years) BOND RATING YEAR REVENUES EXPENDITURES DEFICIT (+/-)
1. Current Fiscal Year 0
2. Prior Fiscal Year 0
3. Fiscal Year Two Years Prior 0
ACCUMULATED SURPLUS
All Lines Aggregate School Package Application - Main Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
B. Exposure Information
1. Type Employees ACCOUNTANTS ARCHITECTS ATTORNEYS ENGINEERS ALL OTHER TOTAL
Full Time: 0
Part Time: 0
Total Employees: 0 0 0 0 0 0
2. Have any of the following occurred within the past three years?
a. Have you had a strike, slowdown, or other employee disruption?
b. Has there been a layoff of employees or reductions in service?
c. Have there been any disputes or suits involving voting or voting rights violations?
d. Has any person, former employee, or job applicant made claim alleging unfair or improper treatment
regarding employee hiring, remuneration, advancement, or termination of employment?
3. Does your School administer or act in a fiduciary capacity for any employment benefit or any self-insurance fund?
4. Does your School follow a formal, written procedure for employee disputes / complaints?
8) COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION
9) FRAUD WARNING REQUIREMENTS
STATE STATUTORY REFERENCE POLICY APPLICATION WARNING STATEMENT
AL NONE
AK NONE
AZ NONE
AR IC § 23-66-503 The following statement must be included on applications for insurance: Any person who knowingly presents a false
or fraudulent claim for payment of a loss or benefit or knowingly presents false information on an application for
insurance is guilty of a crime and may be subject to fines and confinement in prison.
CA NONE
CO IC § 10-1-127 The following statement must be permanently affixed to all printed applications for insurance: It is unlawful to knowingly
provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly
provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable
from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
CT NONE
DE NONE
DC IC § 22-3255.09 The following statement must be conspicuously included on all insurance application forms: WARNING: It is a crime to
provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other
person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
FL IC § 817.234;Inf Bulletin 96-1 The following statement must be included on all application forms: Any person who knowingly and with intent to
injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,
incomplete, or misleading information is guilty of a felony of the third degree.
GA NONE
All Lines Aggregate School Package Application - Main Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
HI IC § 431:10C-307.7 The following statement must be included on all motor vehicle application forms: For your protection, Hawaii law
requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
punishable by fines or imprisonment, or both.
ID NONE
IL NONE
IN NONE
IA NONE
KS NONE
KY IC § 304.47-030 The following statement must be included on all applications: Any person who knowingly and with intent to defraud
any insurance company or other person files an application for insurance 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.
LA IC R.S. § 40:1424 The following statement must either be permanently affixed to or included as part of all applications: Any person who
knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
prison.
ME IC 24-A § 2186 The following statement must be permanently affixed to all applications: It is a crime to knowingly provide false,
incomplete, or misleading information to an insurance company for the purpose of defrauding the company.
Penalties may include imprisonment, fines, or a denial of insurance benefits.
MD NONE
MA NONE
MI NONE
MN NONE
MS NONE
MO NONE
MT NONE
NE NONE
NV NONE
NH NONE
NJ NJAC § 11:16-1.2;N.J.S.A. 17:33A-6 The following statement must be prominently and clearly included on all application forms: Any person who includes
any false or misleading information on an application for an insurance policy is subject to criminal and civil
penalties.
NM IC § 59A-16C-8 The following statement must be permanently affixed to all applications for insurance: ANY PERSON WHO KNOWINGLY
PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY
PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE
SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.
NY 11 NYCRR 86.4 The following statement must be included on all insurance applications for commercial insurance and accident and health
insurance except automobile insurance:
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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated
value of the claim for each such violation.
The following statement must be included on all insurance applications for automobile insurance:
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 conspires 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 subject motor vehicle or stated claim
for each violation.
NC NONE
ND NONE
All Lines Aggregate School Package Application - Main Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
OH IC § 3999.21 The following statement must be included on or attached as an addendum to all applications for insurance: Any person
who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
files a claim containing a false or deceptive statement is guilty of insurance fraud.
OK IC 36 § 3613.1 The following statement must be included either on or attached as an addendum to every insurance policy or application:
WARNING: Any person who knowingly, and with intent to injury, defraud, or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is
guilty of a felony.
OR Bulletin 98-5 Warning statements are not mandatory, but may be included on applications. The following is the suggested language:
Any person who knowingly and with intent to defraud or solicit another to defraud an insurer; (1) by submitting
an application, or (2) by filling a claim containing a false statement as to any material fact, may be violating state
law.
PA 75 Pa. C.S.A. § 1822 The following statement must be included on all applications for insurance: Any person who knowingly and with intent
to injure or defraud any insurer files an application or claim containing any false, incomplete, or misleading
information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up
to $15,000.
RI NONE
SC NONE
SD NONE
TN IC § 56-47-112;IC § 56-53-111 The following statement must be permanently affixed to all applications for insurance: It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the
company. Penalties include imprisonment, fines, and denial of insurance benefits.
TX NONE
UT IC § 34-2-110 - The following statement must be prominently displayed or printed on all applications for Workers' Compensation
Workers' Compensation ONLY insurance: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be
filed false or fraudulent report or billing for health care fees or other professional services is guilty of a crime
and may be subject to fines and confinement in state prison.
VT NONE
VA RL § 52-40 The following statement must be permanently affixed to or included as part of all insurance applications: It is a crime to
knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
WA NONE All applications for insurance must contain a statement, permanently affixed to the application, that clearly states in
substance:
It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
WV NONE
WI NONE
WY NONE
COVERAGE NOTICE
If this account meets our underwriting standards, liability coverage will be quoted as follows:
* Automobile Liability, General Liability and Law Enforcement Liability will be quoted on an OCCURRENCE basis.
* School Board Legal Liability will be quoted on a CLAIMS-MADE basis.
The information provided in this application and all schedules are true and correct to the best of my knowledge.
Signed: Signed:
Date: Date:
Named Insured: Agent/Broker Name:
All Lines Aggregate School Package Application - Main Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
UNINSURED / UNDERINSURED MOTORISTS SELECTION FORM
Uninsured motorists insurance provides protection for damages as a result of bodily injury and/or property damage caused by a negligent motorist who has no insurance
to pay for the damages caused.
Underinsured motorists insurance provides protection for damages as a result of bodily injury and/or property damage caused by a negligent motorist who does not have
enough liability insurance to pay for the damages caused. Underinsured motorists coverage will apply only if your own underinsured motorist limit is higher than the bodily injury
limit of the negligent motorists.
You have the right to reject Uninsured/Underinsured Motorists coverage or to select a limit shown below.
I want to REJECT Uninsured/Underinsured Motorists coverage completely.
Not allowed in - CT, DC, IL, KS, ME, MD, MA, MN, MO, NE, NH, NJ, NY, ND, OR, SC, SD, UT, VT, VA, WI, WV
Alabama I want to select limits of $ 40,000
Alaska I want to select limits of $ 125,000
Arizona I want to select limits of $ 30,000
Arkansas I want to select limits of $ 25,000 / $ 50,000 / $ 25,000
California I want to select limits of $ 35,000
Colorado I want to select limits of $ 25,000 / $ 50,000
Connecticut I want to select limits of $ 40,000
Delaware I want to select limits of $ 15,000 / $ 30,000 / $ 10,000
DC I want to select limits of $ 25,000 / $ 50,000 / $ 5,000
Florida I want to select limits of $ 20,000 VLFL02 (06-04) will need to be signed upon binding
Georgia I want to select limits of $ 75,000
Hawaii I want to select limits of $ 20,000 / $ 40,000
Idaho I want to select limits of $ 50,000
Illinois I want to select limits of $ 40,000
Indiana I want to select limits of $ 60,000
Iowa I want to select limits of $ 20,000 / $ 40,000
Kansas I want to select limits of $ 50,000
Kentucky I want to select limits of $ 60,000
Lousiana I want to select limits of $ 10,000 / $ 20,000 for vehicles under 20,000lbs
$ 25,000 / $ 50,000 for vehicles 20,000lbs-50,000lbs
$ 100,000 / $300,000 for vehicles >50,000lbs
VLLA03 (06-04) & VLLA04 (06-04) will need to be signed upon binding
Maine I want to select limits of $ 100,000
Maryland I want to select limits of $ 55,000
Massachusetts I want to select limits of $ 20,000 / $ 40,000
Michigan I want to select limits of no minimum
Minnesota I want to select limits of $ 50,000
Mississippi I want to select limits of $ 10,000 / $ 20,000 / $ 5,000
Missouri I want to select limits of $ 50,000
Montana I want to select limits of $ 25,000 / $ 50,000
Nebraska I want to select limits of $ 50,000
Nevada I want to select limits of $ 15,000 / $ 30,000
New Hampshire I want to select limits of $ 25,000 / $ 50,000
New Jersey I want to select limits of $ 35,000
New Mexico I want to select limits of $ 60,000
New York I want to select limits of $ 25,000 / $ 50,000
North Carolina I want to select limits of $ 85,000
North Dakota I want to select limits of $ 50,000
All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
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Ohio I want to select limits of $ 12,500 / $ 25,000
Oklahoma I want to select limits of $ 50,000
Oregon I want to select limits of $ 60,000
Pennsylvania I want to select limits of $ 35,000
Rhode Island I want to select limits of $ 75,000
South Carolina I want to select limits of $ 40,000
South Dakota I want to select limits of $ 25,000 / $ 50,000
Tennessee I want to select limits of $ 60,000
Texas I want to select limits of $ 55,000
Utah I want to select limits of $ 25,000 / $500,000 for Schools & Governmental Entities
Vermont I want to select limits of $ 100,000 VLVT01 (05-04) will need to be singed upon binding
Virginia I want to select limits of $ 70,000
Washington I want to select limits of $ 60,000
West Virginia I want to select limits of $ 50,000
Wisconsin I want to select limits of $ 100,000
Wyoming I want to select limits of $ 50,000
I want to select limits equal to policy limits for Automobile Bodily Injury
Signature Date
All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
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sts coverage will apply only if your own underinsured motorist limit is higher than the bodily injury
All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
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All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
WORKERS' COMPENSATION APPLICATION
1) NAMED INSURED: 0 CONTACT NAME: 0
ADDRESS: 0
CITY: 0 STATE: 0 ZIP CODE: 00000
2) GROSS PAYROLL DISTRIBUTION BY CLASSIFICATION CODE
prosective policy current year 1st prior year 2nd prior year 3rd prior year
WC CODE CLASSIFICATION ESTIMATED ESTIMATED AUDITED AUDITED AUDITED
TOTALS 0 0 0 0 0
EXPERIENCE MODIFICATIONS
3) CONCENTRATION OF RISK prospective policy
LOC ADDR CONSTRUCTION OCCUPANCY ZIP CODE # EMPL ALL SHIFT # EMPL IN MAX SHIFT EST PAYROLL
TOTAL # OF EMPLOYEES (from Main App) 0 TOTALS 0 0 0
4) UNDERWRITING
a. Federal Employers Identification Number (FEIN)
b. Date applicant qualified as a Self-Insured:
c. Does applicant have any employees who may be subject to the Longshoremen and Harbor Workers Act, Jones Act, or Federal Employee's Liability Act?
If "Yes", describe
d. Do the operations of the applicant include volunteer or donated labor?
If "Yes", describe
e. Provide details of any OSHA or State OSHA violation within the past 5 years.
5) COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION
All Lines Aggregate School Package Application - Workers' Compensation Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED
RISK MANAGEMENT PRACTICES QUESTIONNAIRE
NAMED INSURED: 0 Contact Name 0
Address 0
City 0 State 0 Zip Code 0
Risk Management
Does the Insured have a Full Time Risk Management Program in place?
- If "yes", how long has the Risk Management Program been in place?
- If "yes", how long has the Risk Manager been in place?
Does the entity have a loss control safety and procedures manual?
If "yes", is it distributed to all employees?
Does the entity have an employee procedures manual?
If "yes", is it distributed to all employees?
Are formal safety meetings conducted?
If "yes", how often are they held?
How are losses reported?
- How long has the account been Self Insured?
Auto
What are requested UM limits?
Are MVRs checked annually for regular drivers?
Stability of Entity
Is the entity in a growth mode, or has population been steady over the years?
Does the entity have a master plan for their growth?
What is the entity's zoning process?
Additional Comments
All Lines Aggregate School Package Application - Risk Management Practices Questionnaire
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
EXPOSURE HISTORY COMPARISON
Property / APD GL LAW E&O AL WC Crime
$ TIV #Students # F/T Officers #Teachers # Vehicles $ Payroll # Employees
9th year prior
8th year prior
7th year prior
6th year prior
5th year prior
4th year prior
3rd year prior
2nd year prior
1st year prior
current
prospective
All Lines Aggregate Public Entity Package Application - Exposure History Comparison
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ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED
CAMPUS SECURITY SUPPLEMENTAL QUESTIONNAIRE - SCHOOLS
YES / NO
1. Do you use metal detectors on any School Grounds?
2. Are City or County Police contacted when a situation occurs on any School Grounds?
3. Do you have armed Police or Security Officers on any school grounds?
4. Do you use Police-trained dogs on School Grounds for bomb or drug searches that are conducted by your Police or Security Officers?
5. Do officers have arrest authority?
6. Do you have a policy and procedures manual for the Police or Security Officers?
7. If you have a policy and procedures manual, when was it last updated?
8. Are your Police and Security Officers Employees or Independent Contractors?
9. Please give the number of Full-Time Officers.
10. Please give the number of Part-Time Officers.
11. Please describe personnel screening measures prior to hiring.
12. Please describe training requirements prior to hiring.
13. Please describe continuing education requirements for Employees.
If "YES" to any of the above answers, please provide a five-year loss history.
All Lines Aggregate School Package Application - Campus Security Supplemental Questionnaire
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
SEXUAL ABUSE & MOLESTATION COVERAGE APPLICATION
1) NAMED INSURED: 0 CONTACT NAME: 0
ADDRESS: 0
CITY: 0 STATE: 0 ZIP CODE: 00000
2) PROPOSED PLAN - Enter limits and retentions desired. Insert "NA" if coverage is not desired.
Limit Per Occurrence Policy Aggregate Proposed SIR:
3) HAS ANY INSURER EVER CANCELLED OR NON-RENEWED THIS TYPE OF COVERAGE? (if YES, please explain)
4) UNDERWRITING & RISK MANAGEMENT - SEXUAL ABUSE INFORMATION
A. Any clients with: Handicaps? Emotional? Physical?
Special Education?
B. Do all employees complete an employment application?
C. Does pre-employment background checks include the following:
Personal References? Police Record? Education Verification?
D. Are records kept documenting this investigation as part of each employee's personnel file?
E. Is an application obtained on volunteers? Does background check include obtaining police records?
F. Are child abuse and neglect laws reviewed with new employees and volunteers?
G. Does the facility have written policies that include physical or sexual abuse?
Are these policies reviewed with employees and volunteers?
H. Are clients in your care overnight?
I. Are procedures in place that more than one employee or volunteer is present at all times when a client is in your care?
J. Are services to clients subcontracted to others?
K. Are your clients instructed to report possible instances of sexual misconduct or abuse?
L. Are known or suspected molestation or abuse incidents reported by your organization to proper police authorities?
Are employees and volunteers advised of this procedure?
5) LOSS HISTORY
A. Please furnish first dollar loss history, for the past five years, for all sexual abuse and/or molestation claims:
Date of Claim Claimant's Name $ Defense Amount $ Indemnity Amount $ Reserve (if open) Status (open/closed) Nature of Claim
All Lines Aggregate School Package Application - Sexual Abuse Molestation Coverage Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
SEXUAL ABUSE & MOLESTATION COVERAGE APPLICATION
B. 1. Are there any unknown or suspected cases reported to date?
2. Are you aware of any occurrences that could lead to or result in claims concerning sexual abuse or misconduct being made against you?
3. Have any claims concerning sexual abuse or misconduct been filed against you or your organization?
4. Have any public authorities investigated your operation relating to sexual abuse or misconduct?
5. Have any parents, guardians, or others alleged sexual abuse in connection with your premises or operations?
6. Please describe any unknown or suspected claims reported to date:
6) COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION
The application further warrants that if the information supplied on the application changes between the date of this application and the inception date of the policy period, it
will immediately notify Alternative Market Specialists of such change. Signing of this application does not bind the Company to offer or the Applicant to accept insurance,
but it is agreed that this application shall be the basis of the insurance contract and will be attached and made part of the policy should a policy be issued.
NAMED INSURED AUTHORIZED SIGNATURE TITLE
DATE
All Lines Aggregate School Package Application - Sexual Abuse Molestation Coverage Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
SEXUAL HARASSMENT COVERAGE APPLICATION
1) NAMED INSURED: 0 CONTACT NAME: 0
ADDRESS: 0
CITY: 0 STATE: 0 ZIP CODE: 00000
2) PROPOSED PLAN - Enter limits and retentions desired. Insert "NA" if coverage is not desired.
Limit Per Occurrence Policy Aggregate Proposed SIR:
3) HAS ANY INSURER EVER CANCELLED OR NON-RENEWED THIS TYPE OF COVERAGE? (if YES, please explain)
4) EMPLOYEE INFORMATION
A. Number of FULL-time employees 0
B. Number of PART-time employees 0
C. For each of the past five years, what has been your annual percentage turnover rate of employees?
5th year prior 4th year prior 3rd year prior 2nd year prior 1st year prior
D. Percentage of employees with salaries less than $100,000
Percentage of employees with salaries between $100,000 & $360,000
Percentage of employees with salaries greater than $360,000
5) CLAIMS HANDLING INFORMATION
A. 1. Who in the Applicant Organization has been designated to handle claims?
NAME ADDRESS CITY, STATE, ZIP PHONE
2. With respect to claims incidents, etc., do you have a written procedure for obtaining information? (if YES, please attach a copy)
6) UNDERWRITING & RISK MANAGEMENT - SEXUAL HARASSMENT INFORMATION
A. Does the Applicant have a Human Resources or Personnel Department? (if NO, please describe handling of this function)
B. Is there a hiring / screening process for new employees?
C. Is there a policy/procedure concerning employee background (including criminal) checks?
D. Are Human Resources files maintained in a central location?
E. Are policies and procedures in place concerning Sexual Harassment, Discrimination, Equal Opportunity, etc.? (if "Yes" please provide a copy)
F. Does the Sexual Harassment policy include a clear and open reporting procedure?
G. Is the Sexual Harassment policy "Zero Tolerance"?
All Lines Aggregate School Package Application - Sexual Harassment Coverage Application
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
SEXUAL HARASSMENT COVERAGE APPLICATION
H. Is the Sexual Harassment policy understandable (i.e. clear and concise)?
I. Are new employees provided with a copy of the Sexual Harassment policies and procedures at orientation?
J. Are policies and procedures disseminated to all employees?
K. Is training on the Sexual Harassment policies and procedures offered to all employees?
L. Is training documented in the employee's personnel files?
M. Is training provided for all supervisory personnel?
N. Is training documented in the supervisory personnel's personnel files?
O. Does top management support the Sexual Harassment policies and procedures?
P. Has legal counsel reviewed the Sexual Harassment policy? (If "yes, provide date of latest review; if "no", describe the review process)
7) LOSS HISTORY
A. Please furnish first dollar loss history, for the past five years, for all Sexual Harassment claims:
Date of Claim Claimant's Name $ Defense Amount $ Indemnity Amount $ Reserve (if open) Status (open/closed) Nature of Claim
B. 1. Are you aware of any occurrences that could lead to or result in claims being made against you?
2. Please describe any unknown or suspected claims reported to date:
8) COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION
The application further warrants that if the information supplied on the application changes between the date of this application and the inception date of the policy period, it wil
immediately notify Alternative Market Specialists of such change. Signing of this application does not bind the Company to offer or the Applicant to accept insurance,
but it is agreed that this application shall be the basis of the insurance contract and will be attached and made part of the policy should a policy be issued.
NAMED INSURED AUTHORIZED SIGNATURE TITLE
DATE
All Lines Aggregate School Package Application - Sexual Harassment Coverage Application
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ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED
TERRORISM ACTIVITIES QUESTIONNAIRE
Please list every location where that location's Total Insured Values (inclusive of ALL coverages, e.g. Business Interruption, Extra Expense, etc.) is GREATER THAN $50 Million
LOCATION ADDRESS & DESCRIPTION $ TIV % OF TOTAL
1.
2.
3.
YES / NO
1. Does the Insured own or operate any Airports and/or Airline Companies (including Flight Schools and/or Crop Dusting)?
2. Does the Insured have any Bridges greater than 300 feet in length?
3. Does the Insured own, lease or operate any Convention / Exhibition Centers / Theatres / Concert Halls with seating >10,000?
4. Does the Insured own, lease or operate any Dams greater than 300 feet in length, with a downstream population >25,000?
5. Does the Insured provide Emergency Services (e.g. Police, Fire, EMTs) in cities where the population is greater than 250,000?
6. Does the insured own or lease space in any Federal and/or State Government Buildings, and/or National Landmarks?
7. Does the Insured own or operate any Hospitals with a bed count greater than 300 in cities where the population is greater than 250,000?
8. Does the Insured own or manage space in any Office Buildings greater than 25 stories in height?
9. Does the Insured own, lease or operate/manage any Residential Buildings greater than 25 stories in height?
10. Does the Insured operate or have any Port / Transit Authorities?
11. Does the Insured operate or have any Railroads? (not including sidetrack agreements)
12. Does the Insured operate a Public School District within cities where the population is greater than 250,000?
13. Does the Insured own, lease or operate any Stadiums/Sports arenas with seating capacities greater than 10,000?
14. Does the Insured have any Tunnels greater than 300 feet in length?
15. Does the Insured operate any Universities?
16. Does the Insured own, lease or operate any Utilities (e.g. electric, gas, water & sewer) with greater than 250,000 customers?
17. Does the insured own or lease any gas or oil pipelines?
18. Is your entity's population greater than 250,000?
If you answered yes on #18 - Do you provide emergency services (ie. Police, firefighters, EMTs)?
19. Do you employ any Architects or Engineers?
20. Do you have a Seaport or Maritime operation, or do you operate any Commuter Ferries?
Please mark Yes even if the exposure is insured elsewhere.
FOR ANY QUESTION ANSWERED "YES", YOU ARE REQUIRED TO PROVIDE ADDITIONAL DETAILS & INFORMATION ABOUT YOUR ANSWER
All Lines Aggregate School Package Application - Terrorism Activities Questionnaire
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
LOSS SUMMARY
(All losses should include the deductible part of the loss)
DESCRIPTION or AUTO AUTO CRIME GENERAL LAW ENFRC PROPERTY SCH BOARD WORKERS' TOTAL
CATEGORY LIABILITY PHYS DAM LIABILITY LIABILITY & IN MARINE LEGAL LIAB COMP ALL LINES
Current
Loss Run Valuation Date NA
Total Incurred $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Reserve $ $0
Total Paid $ $0
Total Incurred # 0 0 0 0 0 0 0 0 0
Total Open # 0
Total Closed # 0
1st year prior
Loss Run Valuation Date NA
Total Incurred $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Reserve $ $0
Total Paid $ $0
Total Incurred # 0 0 0 0 0 0 0 0 0
Total Open # 0
Total Closed # 0
2nd year prior
Loss Run Valuation Date NA
Total Incurred $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Reserve $ $0
Total Paid $ $0
Total Incurred # 0 0 0 0 0 0 0 0 0
Total Open # 0
Total Closed # 0
3rd year prior
Loss Run Valuation Date NA
Total Incurred $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Reserve $ $0
Total Paid $ $0
Total Incurred # 0 0 0 0 0 0 0 0 0
Total Open # 0
Total Closed # 0
4th year prior
Loss Run Valuation Date NA
Total Incurred $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Reserve $ $0
Total Paid $ $0
Total Incurred # 0 0 0 0 0 0 0 0 0
Total Open # 0
Total Closed # 0
5th year prior
Loss Run Valuation Date NA
Total Incurred $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Reserve $ $0
Total Paid $ $0
Total Incurred # 0 0 0 0 0 0 0 0 0
Total Open # 0
Total Closed # 0
Total all years
Loss Run Valuation Date NA NA NA NA NA NA NA NA NA
Total Incurred $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Reserve $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Paid $ $0 $0 $0 $0 $0 $0 $0 $0 $0
Total Incurred # 0 0 0 0 0 0 0 0 0
Total Open # 0 0 0 0 0 0 0 0 0
Total Closed # 0 0 0 0 0 0 0 0 0
All Lines Aggregate School Package Application - Multi-Year Loss Summary
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
CLAIMS IN EXCESS OF 50% OF PROPOSED SIRs or $25,000 (whichever is less)
POLICY DATE COV CLAIM CLAIMANT TOTAL CLAIM $ TOTAL CLAIM $ TOTAL CLAIM $ O
# PERIOD OF LOSS TYPE NUMBER NAME PAID TO DATE RESERVED INCURRED C CLAIM DESCRIPTION
1 $0
2 $0
3 $0
4 $0
5 $0
6 $0
7 $0
8 $0
9 $0
10 $0
11 $0
12 $0
13 $0
14 $0
15 $0
16 $0
17 $0
18 $0
19 $0
20 $0
21 $0
22 $0
23 $0
24 $0
25 $0
All Lines Aggregate School Package Application - Claims in Excess of $25,000
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