Boating Injury Attorney Oklahoma by gad15170

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									          ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                               MAIN APPLICATION


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:
   CITY:                                                                                             STATE:                                     ZIP CODE:
   PHONE:



2) PROPOSED PLAN - Please enter limits and retentions desired. Insert "NA" if coverage is not desired.

   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 and Law Enforcement Liability) - MAXIMUM LIMIT $1,000,000 INCLUSIVE OF SIR )                   Proposed SIR:               $50,000
                                   Liability Per Occurrence                                            Liability Policy Aggregate               NOTE: $50,000 minimum
                                   Law Enforcement Liability                                           Products / Completed Operations
                                   Premises Medical Payments

   C. Coverage III (Automobile Liability - MAXIMUM LIMIT $1,000,000 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 Public Officials Errors & Omissions Liability - MAXIMUM LIMIT $1,000,000 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

   E. Coverage V (Workers' Compensation - MAXIMUM LIMIT $250,000 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 Public Entity Package Application - Main Application
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          ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                                MAIN APPLICATION

3) CURRENT PROGRAM INFORMATION
      COVERAGE TYPE             CARRIER NAME                                                           LIMITS                RETENTION         RETRO DATE              PREMIUM
   A. Property (incl APD)
   B. General Liability
   C. Law Enforcement Liability
   D. Automobile Liability
   E. Pub Off E&O Liability
   F. Workers' Comp
   G. Crime
   H.
   I.
   J.
                                                                          Expiring Loss Fund (if applicable)                                    Total Premiums:                 $0
   CURRENT THIRD PARTY ADMINISTRATOR:
   TPA CONTACT NAME:                                                                                TPA CONTACT PHONE NUMBER:



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




                                                           All Lines Aggregate Public Entity Package Application - Main Application
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         ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                             MAIN APPLICATION

  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

  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. Entity Information: Does the public entity own or operate any of the following? (Please Answer Yes / No ):
                                 Airports (ALA policy excludes)                                            Hospitals
                                 Amusement Park, Carnival, Circus                                          Housing Authority, Projects
                                 Athletic Participants                                                     Independent Contractors
                                 Beaches, Lakes                                                            Jail or Detention Facilities
                                 County Homes                                                              Landfills
                                 Blasting Operations                                                       Law Enforcement Activities
                                 Bleachers, Arenas, Stadiums                                               Marinas
                                 Cemeteries                                                                Nursing Homes
                                 Dams, Reservoirs                                                          Racing / Rodeo Exhibitions
                                 Day Care Centers or Day Camps                                             Recreational Facilities (Parks, Camps, etc.)
                                 Electric Utility                                                          Schools and Colleges
                                 EMT's, Paramedics, Nurses                                                 Sewer Utility
                                 Fairs, Festivals                                                          Ski Facility
                                 Fire Department                                                           Streets, Roads, Highways, Bridges
                                 Fireworks Displays                                                        Transportation System (Buses, Rail Service or Subways)
                                 Garbage Collection                                                        Water Utility
                                 Gas Utility                                                               Watercraft
                                 Golf Course                                                               Wharves, Piers, Docks
                                 Health Department                                                         Zoo
         Any additional exposures not mentioned in the checklist above:

         Any exposures checked yes above that insured elsewhere or subcontracted out to others:




                                                       All Lines Aggregate Public Entity Package Application - Main Application
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          ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                               MAIN APPLICATION

   B. General Information
                                   Population
                                   Employee Count
                                   Total Payroll

   D. Independent Contractor Operations Questionnaire
      1. Does the Entity ever make use independent contractors?                                                    If yes, please describe the contractor types used & purposes:



      2. Does the Entity require the following:
                                  Certificate of Insurance?
                                  Limits at least equal to those carried by the Entity (if general contractor)?
                                  Is the Entity named as an Additional Insured on the contractor's policy?
                                  Are there Hold Harmless Agreements used in all of the Entity's contracts?
      3. Do you hold any special events in which you do not transfer liability to the contractor performing the special event?



6) AUTOMOBILE LIABILITY

   A. CATEGORY                                                                                                                                    # THIS TYPE              % THIS TYPE
         Private Passenger Cars (up to 10,000 lbs GVW) - Non Emergency                                                                                                              NA
         Private Passenger Cars (up to 10,000 lbs GVW) - Emergency (e.g. Fire, Police)                                                                                              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
         Fire Trucks                                                                                                                                                                NA
         Ambulances                                                                                                                                                                 NA
         Motorcycles                                                                                                                                                                NA
         Buses                                                                                                                                                                      NA
         Miscellaneous Autos                                                                                                                                                        NA
         Mobile Equipment                                                                                                                                                           NA
         Trailers, All Types                                                                                                                                                        NA
                                                                                                                      Total Automobiles:                       0                    NA

   B. Underwriting Criteria
      1. Describe operations of any passenger vans or buses (including radius, frequency, receipts, etc.):



      2. Describe any vehicles modified to handle handicapped or wheelchair passengers:




7) PUBLIC OFFICIALS' ERRORS AND OMISSIONS 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
      4. The following rating information is to be taken from the applicant's most recent fiscal year budget.
         Please complete all items, then attach a scanned copy,or mail a photocopy, of the most current budget when you return this application.




                                                          All Lines Aggregate Public Entity Package Application - Main Application
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                                              MAIN APPLICATION

    5. Please explain any deficit postions.



       BUDGETED EXPENDITURES                                                                                   EXPENDITURES FOR SEPARATELY RATED EXPOSURES
       General Fund                                                                                            Airports
       Special Revenue Fund                                                                                    EMT's Paramedics
       Other Special Funds or Accounts                                                                         Golf Courses
       Total Budgeted Operating Expenditures                                  0                                Hospitals / Clinics
                                                                                                               Housing Projects
       Less: Items to be paid out in current year                                                              Lakes / Dams / Reservoirs
       Capital Improvements                                                                                    Nursing Home
       Debt Service Funds                                                                                      Penal Institutions
       Other Indebtedness                                                                                      Police
       Independent Contractors                                                                                 Schools
       Insurance Costs                                                                                         Utility - Electric
       OPERATING EXPENDITURES                                                 0                                Utility - Gas
                                                                                                               Utility - Water / Sewer
                                                                                                               Wharves / Piers / Docks / Marinas
       Operating Expenditures                                                 0                                Zoos / Ski Facilities
                                                                                                               TOTAL EXPENDITURES                                      0
       Less Separately Rated Exposure Expenditures                            0

       Net Operating Expenditures (Rating Base)                               0



    6. Type Employees                ACCOUNTANTS                 ARCHITECTS                ATTORNEYS               ENGINEERS               ALL OTHER          TOTAL
                     Full Time:                                                                                                                                   0
                    Part Time:                                                                                                                                    0
             Total Employees:                         0                        0                      0                          0                  0             0
    7. Indicate elected (E) or appointed (A) officials:
                                 Mayor                                                                      President / Chair of County Commission
                                 City Manager or Administrator                                              County Commissioner / Supervisor
                                 City / County Clerk                                                        Personnel Director
                                 City Council Members
    8. 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?
    9. Does your entity administer or act in a fiduciary capacity for any employment benefit or any self-insurance fund?
    10. Does the Insured have a zoning commission?
    11. Does your entity follow a formal, written procedure for employee disputes / complaints?
    12. Does the Insured administer a centralized emergency dispatch system for other entities?
          If yes, please submit a copy of the current contract.




                                                      All Lines Aggregate Public Entity Package Application - Main Application
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         ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
              ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                            MAIN APPLICATION

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
  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.




                                                All Lines Aggregate Public Entity Package Application - Main Application
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       ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
             ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                          MAIN APPLICATION

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
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




                                                 All Lines Aggregate Public Entity Package Application - Main Application
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                                MAIN APPLICATION

SC                  NONE
SD                  NONE




                                      All Lines Aggregate Public Entity Package Application - Main Application
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        ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
               ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                              MAIN APPLICATION

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 insurance:
                Workers' Compensation ONLY              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.
     * Public Officials' Errors and Omissions 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 Public Entity Package Application - Main Application
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         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 Public Entity Package Application - Uninsured / Underinsured Motorists Selection Form
   10-MAR-07                                                D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                        Page 10 of 31
        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 Public Entity Package Application - Uninsured / Underinsured Motorists Selection Form
10-MAR-07                                   D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                Page 11 of 31
sts coverage will apply only if your own underinsured motorist limit is higher than the bodily injury




                                                          All Lines Aggregate Public Entity Package Application - Uninsured / Underinsured Motorists Selection Form
                   10-MAR-07                                                 D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                          Page 12 of 31
            All Lines Aggregate Public Entity Package Application - Uninsured / Underinsured Motorists Selection Form
10-MAR-07                      D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                          Page 13 of 31
                      ALL LINES AGGREGATE PUBLIC ENTITY 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 Public Entity Package Application - Workers' Compensation Application
10-MAR-07                                                             D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                                                     Page 14 of 31
       ALL LINES AGGREGATE PUBLIC ENTITY 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?


                 Police Department
                 Is a High School Diploma or GED requirement in place?
          -      What is the number of required Academy Hours?
                 Is there an annual or continuous update to the Policies and Procedures manual?
                  If "yes", is there a Hot Pursuit policy for felony only?
                 Has there been a Jail Inspection within the last twenty-four (24) months?
                 Is there a Jail overcrowding problem?
                  If "yes", what is being done to correct the situation?
                 When was the jail built or renovated?


                 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 Public EntityPackage Application - Risk Management Practices Questionnaire
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              ALL LINES AGGREGATE PUBLIC ENTITY 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        $ Expenditures           # F/T Officers             $ Expenditures                # 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
10-MAR-07                                           D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                Page 16 of 31
                  ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                         ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                          EMERGENCY SERVICES SUPPLEMENTAL APPLICATION


            A. LAW ENFORCEMENT
                  Number of Full Time Armed Officers?                                          Number of Part Time Armed Officers?
                  Number of Full Timed Unarmed Officers?                                       Number of Part Time Unarmed Officers?
                  Number of Dispatchers?                                                       Number of Police Dogs?
                  Do District Attorney / Prosecutors have arrest authority or arrest warrant authority?
               1. Dispatching
                  a. Does the Insured handle its own dispatch?
                  b. Does the Entity dispatch for other public or private entities?
                  c. What is the total population served?
                  d. Are incoming calls to dispatchers recorded?                                                     How long are tapes maintained?
                  e. What services do you dispatch (e.g. Emergency, Fire, Police, etc.)?
               2. Policies & Procedures Manuals
                  a. Does the Insured have a policy and procedures manual?
                  b. Date of manual?                                                                                 Date of last revision / update?
                  c. Is the manual reviewed annually by legal counsel?
                  d. Is the manual distributed to all personnel?
                         Is the manual reviewed with them periodically as part of their formal training?
                  e. Does the Insured have policies governing:
                                              Use of deadly force                                                    AIDS
                                              Use of non-deadly force                                                Handling of intoxicated individuals
                                              Vehicle "hot" pursuit                                                  Ride alongs
                                              Domestic violence
                  f. Does the Insured require a report when force must be used?
               3. Education & Training Requirements
                  a. What is the minimum education requirement for hiring new officers?

                   b. Is psychological testing required before hiring?
                          Are results reviewed by a person trained in this field?
                          Is the applicant interviewed by a psychologist / psychiatrist?
                   c. What background investigations are completed prior to hiring new officers?

                   d. What training of armed street officers is required prior to any assignment where they are armed?
                        Academy Training?                                                                            Minimum # of Academy hours?
                        Other (explain)

                   e.   Is a minimum annual in service training update required?                                            Numbers of hours annually?
                   f.   Is all training documented in a training log?                                                       How long are logs kept?
                   g.   Are new officers formally assigned to work with a field training officer?
                   h.   Are officers trained and qualified before using:
                                                Baton / PR24?                                                               Control Holds?
                                                Mace / Chemicals?                                                           Stun / Laser Guns?
                   i.   How often must an officer requalify with:
                                                Service revolver?                                                           Other weapons?
                                                Personal weapon?
                   j.   What training do part-time / auxiliary officers, or reserve officers, armed and with arrest authority, receive?

                        Is this training given before duty assignment?                                                       If not, what assignments may part-time officers be given
                        prior to training?
                        What type of assignments do auxiliary officers perform?
                   k. Do all officers receive training in:           First Aid?                                              CPR?




                                                     All Lines Aggregate Public Entity Package Application - Emergency Services Supplemental Application
10-MAR-07                                                            D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                                    Page 17 of 31
                  ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                        ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                          EMERGENCY SERVICES SUPPLEMENTAL APPLICATION

                   l.Are all officers trained in vehicle operations?
                         Do all officers receive actual or simulated vehicular operations training?
                         Are officers required to complete a defensive driving training program?
                  m. Is every course completed documented to each employee and each auxiliary person's personal or training file?
               4. Underwriting Information
                  a. Does the Insured contract law enforcement services to any other public or private entity?
                  b. Is the Insured a party to any mutual aid, reciprocal, or regional task force agreements?
                  c. Does the Insured authorize employee "moonlighting"?                                       Is "moonlighting" preapproved?
                         Is "moonlighting" in bars and taverns approved?                                       If yes, please attach a copy of "moonlighting" policies.
                  d. Is the Insured currently at authorized strength?
                  e. Total full-time employees: Last Year?                                      Prior Year?                             Two Years Prior?




            B. PENAL & JAIL INSTITUTIONS - Please complete for each separate facility to be insured
               1. Is coverage for a jail premises desired?                                  If yes, does the Insured operate a:
                                                Jail?                                                                Holding Cell?
                                                Detention Home?                                                      Non-Owned facility (contractual only)?
               2. Total square footage of jail area?                                        Total square footage of jail cells only?
                      Year Built?                                      Year Renovated?                               Date of Last Inspection?
               3. Number of cells?                                     Number of beds?                               State certified capacity?
                      Average number of daily inmates?                                      Average length of stay?
               4. Are full-time jailors on duty 24 hours/day?                               Are part-time jailors used?
                      Number of jailors on duty each shift?
               5. Are the jail premises regularly inspected by:                       State Corrections Officials?                            Health Department?
                      Date of last inspection by State Corrections Officials?                                        Please list outstanding recommendations below:



               6. Are smoke detectors in the jail?                                            Method of inmate surveillance?
               7. Are there jail operations manuals covering:
                      Intake screenings and classification of inmates?                                                Storage & Administration of Medication?
                      Strip searches?                                                                                 Suicide ID Guidelines?
                      Jail evacuation?                                                                                Visual Observation of Inmates?
                      Medical treatment / sick call?
               8. Are men and women segregated?                                               If yes, in what manner?
                      Are youthful offenders (those age 18 and younger) separated from older inmates?
                          If yes, in what manner?
                      Are prisoners who have committed violent crimes segregated from those who are incarcerated for lesser offenses?
               9. Does the Insured have a contract with any other Entity for use of the jail?
                      If yes, give the name of the Entity.
               10. Has there ever been a riot or other prisoner-led disturbance?                                      If yes, please describe.



               11. In the last three years, have there been any jail suicides or attempted suicides?
                        If yes, explain and provide details and explain what has been done to prevent future suicides.



               12. Is the jail operating under a court order or Consent Decree?                                  If yes, please attach a copy with any modifications.
               13..Has the department received accreditation from the Commission on Accreditation for Law Enforcement Agencies, Inc.?
                        If yes, when?




            C. FIRE DEPARTMENT
               1. Number Paid Professionals:                                                                                Number Volunteer:
               2. Annual Calls - Emergency:                                                                                 Annual Calls - Non-Emergency:
               3. What kind of training is required?




                                                    All Lines Aggregate Public Entity Package Application - Emergency Services Supplemental Application
10-MAR-07                                                           D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                       Page 18 of 31
                ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                       ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                         EMERGENCY SERVICES SUPPLEMENTAL APPLICATION


            D. EMT's, PARAMEDICS, and NURSES / MEDICAL PROFESSIONAL LIABILITY EXPOSURES
               1. Please give the number of each of the following certified personnel:                                     # of Paid Employees           # of Volunteers
                      Certified Personnel
                      Emergency Medical Technicians
                      Paramedics
                      Nurses
                      Nurse Practitioners
                      LPNs
               2. Radius of operations?
               3. Indicate the type of training received by emergency personnel.

              4. Type of Institution and Operation ("X" if appropriate)
                                                Convalescent or Nursing Home - Please complete a nursing home supplemental application
                                                Clinic - Health Department
              5. Clinic / Nurses / Health Department
                 a. Are you approved by Medicare?
                 b. Do you comply with all federal, state or local licensing requirements?
                 c. Number of clinics
                 d. Describe operations of clinic
                 e. List all duties of the county nurses
                 f. # of patients seen each week
                 g. Describe training, licensing and certification requirements for all nurses
                 h. Do nurses work only for you?
                 i. Do you provide Home Health Care visits                                     If yes, how many visits each week
                     *Clinic visits means any outpatient visit on or off the premises involving the examination or treatment of a patient by a nurse.
                      Count only "hands-on" nurse/patient encounters, not indirect encounters for an x-ray or laboratory results interpretation.
                       A visit is a threshold crossing which may involve multiple occasions of service from more than one clinical department.



            E. COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION




                                                   All Lines Aggregate Public Entity Package Application - Emergency Services Supplemental Application
10-MAR-07                                                          D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                         Page 19 of 31
            ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                        PUBLIC WORKS SUPPLEMENTAL APPLICATION


 1) DAY CARE / DAY CAMPS
    A. Number of centers operated?
    B. Number of days open per week?
    C. Describe care provider employment requirements (experience and credentials).



    F. Number of individuals for which care is provided:                                              Children                    Adults                          Staff providing care
                                       Average # per day
                                       Maximum # per day
    G. Is transportation provided by the Entity?                                                                  If yes, please describe.




 2) TRANSPORTATION & CONVEYANCE
    A. Number of buses?                                       Radius of operation?                                                           Annual receipts?
       Average daily miles?                                   Average daily riders?

    B. Streets & Roads
       1. Roads / Highways                                      Mileage - Paved:                                                             Mileage - Unpaved:
           a. Condition of roads?
           b. Does the Entity have a regular maintenance and upkeep program?
           c. Are written records of maintenance kept?
           d. Are barricades and warnings used at road work sites?
           e. Are road signs regularly inspected for visibility or missing signs?
       2. Sidewalks
           a. How often are sidewalks inspected for defects?
           b. Are written records of inspection kept?
           c. Please describe sidewalk replacement program.

        3. Bridges
           a. How many bridges of over 20 feet in length are maintained by the Entity?
           b. Are all bridges posted for weight limits?
           c. Are there any one-lane bridges?                                                                     If so, are warning signs posted?
           d. Are any bridges closed, condemned, or structurally deficient?                                       List by bridge number and give reasons:




                  Are warning signs posted?                                                             Are barriers permanent?
           e. When was the last inspection?                                                             By whom?
                  Number of Bridges passed?                                        Have all recommendations been complied with?
        4. Describe the training of employees in the use of snow removal equipment on roadways.




                                             All Lines Aggregate Public Entity Package Application - Public Works Supplemental Application
10-MAR-07                                                 D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                                   Page 20 of 31
            ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                  ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                          PUBLIC WORKS SUPPLEMENTAL APPLICATION


 3) UTILITIES
    A. Blasting
       1. Is blasting contracted out?
       2. Are Certificates of Insurance and limits at least equal to those carried by the Entity required?
               NOTE: If 1 or 2 are answered NO, please complete the following:
           a. Please describe the types and locations of blasting.



            b. How many blasts per year?                                                                             Is the blaster certified?
            c. Please describe the precautions taken prior to blasting.




     B. Electric
        1. Annual Payroll (excl clerical)?                                                                                           Number of customers served?
        2. Does the Entity do any of the following:              Pole Erection / Wire Stringing?                                            Customer Connect?
                                                                 Transformer Installation?                                                  Meter Reading?
         3. Customer Profile:            Residential -                                   Commercial -                                       Industrial -
         4. Does the utility generate or purchase power?
               If purchased, who is the supplier?                                                                    If generated, how (steam, wind, water)?
         5. What is the Maximum Capacity?                                                                            Number of miles of high voltage lines?

     C. Landfills
        1. LOCATION of SITE                   TOTAL ACRES               ACRES in USE            ACRES FENCED                 #YRS in OPS        CONTROL of LANDFILL*   DNA EPA ID




                                                      * A = Abandoned, C = Closed, E = Entity Operated, S = Subcontracted Out
         2. In what type of area is/are the landfill(s) located?
                Please describe adjacent properties.
         3. Do employees monitor attendance when the site is open?
                Is each site fenced with a locked gate when closed?
         4. How close is the nearest surface water?                                                          Drinking water?
         5. Describe any test(s), system(s), or equipment used to monitor this site(s).



         6. What type and form of waste goes into each site?              TYPE                     FORM
              Location 1.                                                                                            TYPE = Household, Commercial, Industrial, Organic
              Location 2.                                                                                            FORM = Solid, Liquid, Sludge
              Location 3.
              Location 4.
              Location 5.




                                                All Lines Aggregate Public Entity Package Application - Public Works Supplemental Application
10-MAR-07                                                    D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                               Page 21 of 31
            ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                         PUBLIC WORKS SUPPLEMENTAL APPLICATION

        7. Is any hazardous waste handled at any site?                                                               If yes, please describe material and handling at any site.



        8. Is the Entity aware of any prior activities which involved hazardous wastes?                                                         If yes, please describe.



        9. If there are any abandoned or closed sites, please describe closure plans.



        10. Are there Methane Gas Escape Vents?
        11. Is the landfill covered each night per EPA standards?

    D. Sewer
       1. Is a sewage disposal plan maintained?                                                                      If yes, please give payroll.
       2. Number of miles of sewer lines maintained?
       3. Percentage of work, such as laying of sewers, removal of sludge, etc., is
              Undertaken directly by Entity?                                                                         Performed by Independent Contractors?

    E. Water
       1. Annual Payroll (excl clerical)?                                                  Gallons per year?                                    Miles of Pipe?
       2. Type of pipe used?
       3. Percentage of work, such as laying of waterlines, etc., that is:
             Undertaken directly by Entity?                                                Performed by Independent Contractors?
       4. Source of water supply?                                                          Age of the system?                                   Date upgraded?
             How often is drinking water tested?                                                                     By whom?
       5. Does Entity have water supply tanks?                                             If yes, please list below
                                       CONSTRUCTION          TYPE                               CAPACITY (gal)                              DATE LAST INSPECTED




        6. Type of public protection around the tank base(s) (fencing, lighting, aircraft warning lights, runoff channels, etc.)

        7. Are tanks inspected by qualified engineers?                              How often?
        8. Does the system comply with current local and federal standards for hygiene and metals content?




                                                All Lines Aggregate Public Entity Package Application - Public Works Supplemental Application
10-MAR-07                                                    D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                                      Page 22 of 31
            ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                  ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                          PUBLIC WORKS SUPPLEMENTAL APPLICATION


 3) DAMS / DIKES / LEVEES / RESERVOIRS / SPILLWAYS (any barrier built to impound water that, if it broke, would release water in a floodlike manner )
    This supplement must be completed for each Dam/Dike/Levee/Reservior or Spillway - please copy this section again below this one for each additional structure.
    A. Dam / Dike / Levee / Reservoir / Spillway
       1. General Information
           a) Structure Name:                                                              Structure Location:
           b) Year built:                                                            Type (e.g. Dam, Dike, Levee, Reservoir, Spillway):
           c) General Condition & Maintenance:                                             (Excellent, Good, Fair, or Poor)
           d) Built under the Direction of:                                                (Owner, Corps of Engineers, Dept of Interior, Dept of Agriculture, Bureau of Reclamation)
           e) Purpose(s):              Agriculture                                                                 Power*
                                       Flood Control                                                               Water Supply
                                       Industrial
                 *if Power, describe alternate source in event of power failure:
           f) Hazard Code:                                     (I, II, III, IV - see below)                        Safety:                                          (Safe or Unsafe)
           g) Construction:                                    (Concrete, Earthen, Steel, or Timber) - if Other, Please Specify:
           h) Dimensions:              Height                                              Top Width                                       Base Width
           i) Name of Tributary Rivers:                        Upstream
                                                               Downstream
           j) Normal Pond Measurements:                        # of Acres                                                        Storage Capacity (Acres / Feet)
               Is additional storage available in Flood State?                             If Yes, please describe
           k) Water Level Control: Gates?                                                  Other? (describe)
               If Gates, what Type?
               How are they Operated?
               By Whom?
       2. Upstream Exposures - Are there any Exposures to any of the Following?
              Structures, Industrial Complexes, Housing?                                                           If "Yes", please describe & be specific (include distances, etc.)

                 Recreational Areas (e.g. swimming, boating, camping)                                                If "Yes", please describe & be specific

                 Bridges
                 Lower Dams                                                                                          If "Yes", please give Names

               Highways
               Railroads
               Agricultural Areas                                                                                    If "Yes", is there an exposure to:
                 Livestock
                 Crops
                 Dwellings
                 Barns / Sheds
         3. Downstream Exposures
               Type                                 Distance     Description
               Housing
               Other Structures
               Industrial Complexes
               Pumping Stations
               Lower Dams
               Recreational Areas
               Bridges
               Highways
               Railroads
               Agricultural Areas




                                                All Lines Aggregate Public Entity Package Application - Public Works Supplemental Application
10-MAR-07                                                    D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                             Page 23 of 31
            ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                        PUBLIC WORKS SUPPLEMENTAL APPLICATION

        4. Dam Inspection
              How often:                                      By Whom:
              Has risk been included in the National Program for Dam Inspection?
                                     If "Yes", please attach a copy of the most recent inspection report and responses to recommendations
                                     If "No", please attach a copy of the most recent independent inspection report
        5. Losses - please describe any losses or pending suits which have occurred involving the dam or reservoir; include the amount of damages paid and amounts in reserve.




        Please attach a copy of Emergency Procedures / Plan. If you have more than one dam / dike / levee / reservoir / spillway, please complete one questionnaire for each.

        HAZARD CODES:
        Class I                      Dams which, should they fail, would likely cause loss of life.
        Class II                     Dams which, should they fail, would likely cause substantial downstream property damage, but are not considered to be a threat to life.
        Class III                    Dams which would cause little or no downstream damage should they fail.
        Class IV                     Dams which are less than 15 feet in height, impound less than 15 acre feet of water to the top of the dam, and drain less than 150 acres.
                                      No dam may be included in the Class IV category if failure of the dam could cause downstream property damage or loss of life.



 4) COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION




                                              All Lines Aggregate Public Entity Package Application - Public Works Supplemental Application
10-MAR-07                                                  D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                            Page 24 of 31
             ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                   ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                     PARKS & RECREATION SUPPLEMENTAL APPLICATION


 1) RECREATIONAL FACILITIES
    A. Fireworks
       1. Please list the types of events and scheduled dates.




        2. Are displays conducted by licensed pyrotechnicians?
               If no, please explain (e.g. who will set up & launch? experience? etc.)

        3.   Where is the display held (e.g. river, park, open field, etc.)?
        4.   How long will the display last?
        5.   Will emergency vehicles be on the premises?
        6.   Please give the approximate distance from the crowd.
        7.   Please give the approximate distance to the nearest structure.

    B. Parks & Recreation Facilities
       1. Parks & Recreation Areas
          a. How many parks are owned by the Entity?                                                                                               # of Acres?
          b. Is playground equipment inspected?                                                                                                    How often?
                 Is corrective action on equipment documented?
                 How is equipment anchored?
          c. Number of Golf Courses?                                                        Annual Receipts?                                       Liquor Receipts?
          d. Number of Swimming Pools?                                                      Wading Pools?                                          Wave Pools?
                 Are all depths marked?
          e. Any diving boards 3 meters or over?
                 Are diving wells 12 feet or deeper?                                        Is the area surrounding the pool(s) fenced?
                    If no, what is the depth?                                               Are pools drained in the off season?
          f. Are Certified Lifeguards on duty at all times the pool is open?
                 Please describe type of Certification.                                                               Number of Lifeguards on duty?
          g. Are pool regulations posted?
                 Are employees trained for the use of chlorine?                                                       Is chlorine stored in locked facilities?
          h. Are there any waterslides?
                 If yes, give height, length, and number of curves.                                                                                Depth of entry well?
                 Describe supervision in detail.



             i.   If you have an ice skating rink, please answer the following:
                      Type of rink?                                                                                   Size of rink(s)?
                      Is the area lighted?                                                                            Is skating supervised?
                      Please describe controls, if lake or pond:




                                               All Lines Aggregate Public Entity Package Application - Parks Recreation Supplemental Application
10-MAR-07                                                     D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                             Page 25 of 31
            ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                  ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                    PARKS & RECREATION SUPPLEMENTAL APPLICATION

            j.   Describe location and size of beach areas.



               Is swimming allowed?                                                                                  Is the swimming area roped off?
                   Are Certified Lifeguards on duty during swimming hours?                                           Number of Lifeguards on duty?
                   Is any boating permitted near the swimming area?
                   Are scheduled swimming hours clearly posted?                                                      Is the area fenced?
                   Are there any diving platforms or rafts in any part of the swimming area?
               If no swimming is allowed, or no Lifeguards on duty, are warning signs posted?
                   Is the beach patrolled regularly during evening hours?
        2. Athletic Participants
           a. Please attach a list of all athletic activities sponsored and number of participants.
           b. Is a signed consent form required from parents/guardians?

    C. Marinas, Watercraft, Wharves, Piers, Docks
       1. How many piers, docks, or wharves are owned by the Entity?                                                 Area of each (in sq ft)?
               Use of each?
       2. Are there boat slips?                                                                                      If yes, how many?
       3. How many piers / docks are anchored?
       4. Is there a regular maintenance and upkeep program for the piers / docks?                                                                Please describe.

        5. How often are the piers / docks inspected?
        6. Is there a marina exposure?                                                                               If yes, please describe all operations.

                 Receipts                                        Are there any operations subcontracted out?                                      If yes, describe.

        7. List owned watercraft, including length, usage, and horsepower of each.

        8. Is there any boat rental conducted by the Entity?                                                                                      Receipts?
                If yes, describe the boat operation in detail.



    D. Zoo
       1. Number of acres?                                                                                           Hours of Operation?
       2. List number and type of animals

        3. Can the public feed, pet, or ride any of the animals?                                                     If yes, describe in detail.

        4. How is the public protected from the animals?

        5. Are there any rides through open animal ranges?




 2) COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION




                                              All Lines Aggregate Public Entity Package Application - Parks Recreation Supplemental Application
10-MAR-07                                                    D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                          Page 26 of 31
                 ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                                                ALL QUESTIONS MUST BE ANSWERED

                               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"?
            H. Is the Sexual Harassment policy understandable (i.e. clear and concise)?




                                                      All Lines Aggregate Public Entity Package Application - Sexual Harassment Coverage Application
10-MAR-07                                                           D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                                  Page 27 of 31
                 ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                                                ALL QUESTIONS MUST BE ANSWERED

                               SEXUAL HARASSMENT COVERAGE APPLICATION

            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 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 Public Entity Package Application - Sexual Harassment Coverage Application
10-MAR-07                                                           D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                                             Page 28 of 31
                           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 Public Entity Package Application - Terrorism Activities Questionnaire
10-MAR-07                                                               D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                                     Page 29 of 31
                 ALL LINES AGGREGATE PUBLIC ENTITY 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         PUB OFF    WORKERS'      TOTAL
                   CATEGORY         LIABILITY     PHYS DAM                                LIABILITY           LIABILITY         & IN MARINE       E&O 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
                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 Public Entity Package Application - Multi-Year Loss Summary
10-MAR-07                                                         D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                             Page 30 of 31
                    ALL LINES AGGREGATE PUBLIC ENTITY 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 Public Entity Package Application - Claims in Excess of $25,000
 10-MAR-07                                                  D:\Docstoc\Working\pdf\372fb13f-147e-468a-a832-847ec6d765a2.xls                                                Page 31 of 31

								
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