Certificate of Insurance General Liability Hartford

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Certificate of Insurance General Liability Hartford Powered By Docstoc
					          ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!




PRODUCER NAME:                    Robert S. Bookhammer III, ARM-P                                             DATE APPLICATION COMPLETED:
AGENCY NAME:                      Wachovia Insurance Services, Inc.                                           DATE QUOTE NEEDED TO AGENT:
AGENCY LOCATION:                  5956 Sherry Lane #2000, Dallas TX 75225                                     DATE COVERAGE TO INCEPT:                  07/01/2006
AGENCY WEB SITE:                  www.wachovia.com                                                            E MAIL ADDRESS:   bob.bookhammer@wachovia.com



1) NAMED INSURED:                 Plano Independent School District                                           CONTACT NAME: Raymond Weaver
   STREET ADDRESS:                2700 W. 15th Street                                                         PUBLIC or PRIVATE SCHOOL?                  Public
   CITY:                          Plano                                                           STATE:      TX                        ZIP CODE:        75075



2) PROPOSED PLAN - Please enter limits and retentions desired. Insert "NA" if coverage is not desired.
     NOTE: PROTECTED CELLS AUTOMATICALLY PULL DATA FROM THE SCHEDULE SHOWN IN SECTION 4)


   A. Coverage I (Property - Real & Pers, Auto PhysDam, Bus Inc & Ext Exp, Prop in Transit and Data Proc Media & Equip - MAXIMUM LIMIT $1,000,000 INCLUSIVE OF SIR )
         ?                         Per Loss Limit                                                                                 Proposed SIR:               $25,000
                                   Quake (Annual Aggregate) Sublimit                                                                          NOTE: $25,000 minimum
                                   Flood (Annual Aggregate) Sublimit
   B. Coverage II (General Liability) - MAXIMUM LIMIT $10,000,000 INCLUSIVE OF SIR )                                              Proposed SIR:               $50,000
                   $1,000,000 Liability Per Occurrence                                   $2,000,000 Liability Policy Aggregate                NOTE: $50,000 minimum
                      $10,000 Premises Medical Payments                                  $2,000,000 Products / Completed Operations

   C. Coverage III (Automobile Liability - MAXIMUM LIMIT $10,000,000 INCLUSIVE OF SIR )                                                  Proposed SIR:               $50,000
                    $1,000,000 Liability Per Accident                                                         No-Fault Coverage/PIP                  NOTE: $50,000 minimum
                                  Un/Underinsured Motorists                                        $5,000     Auto Medical Payments

   D. Coverage IV (CLAIMS MADE School Board Legal Liability - MAXIMUM LIMIT $10,000,000 INCLUSIVE OF SIR )                  Proposed SIR:               $50,000
                             Liability Per Claim                                                Liability Policy Aggregate              NOTE: $50,000 minimum
                             Sexual Harassment Per Claim                                        Sexual Harassment Policy Aggregate
                             Sexual Abuse Per Claim                                             Sexual Abuse Policy Aggregate

   E. Coverage V (Workers' Compensation - MAXIMUM LIMIT $200,000 EXCESS OF SIR )                                                         Proposed SIR:             $100,000
                               Workers Compensation                                                                                                 NOTE: $100,000 minimum
                               Employer's Liability

   F. Coverage VI (Crime - MAXIMUM LIMIT $500,000 INCLUSIVE OF SIR )                                                                      Proposed SIR:               $25,000
                    $500,000 Employee Dishonesty                                                $500,000      Money Orders & Counterfeit Currency     NOTE: $25,000 minimum
                    $500,000 Money & Securities (Inside Premises)                               $500,000      Depositors Forgery
                    $500,000 Money & Securities (Outside Premises)

   G. Any other coverage required (please attach additional information as necessary):
         Requested Limit                                                                                                                             Proposed Underlying Limit
                                 Excess Property
                                 Excess Liability
                                 Excess Workers' Comp




                                                          All Lines Aggregate School Package Application - Main Application
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         ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
               ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!


3) CURRENT PROGRAM INFORMATION
      COVERAGE TYPE        CARRIER NAME                                                            LIMITS               RETENTION           RETRO DATE                 PREMIUM
   A. Property (incl APD)
   B. General Liability    Hartford                                                  1 Mil/2 mill agg          none                                                     $176,635
   C. Automobile Liability Hartford                                                            $1,000,000      none                                                     $508,879
   D. School Board Legal
   E. Workers' Comp
   F. Crime                Travelers                                                             $500,000                      $5,000                                     $9,298
   G.
   H.
   I.
                                                                       Expiring Loss Fund (if applicable)                                                               $694,812



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                                                                                                                                                0.0%
     Total Contents Values                                                                                                                                                0.0%
     Total Auto Physical Damage Values (all licensed vehicles)                                                                                 $13,539,599              100.0%
     Total Equipment Values                                                                                                                                               0.0%
     Total EDP Equipment Values                                                                                                                                           0.0%
     Total EDP Media Values                                                                                                                                               0.0%
     Total EDP Extra Expense Values                                                                                                                                       0.0%
     Total Accounts Receivable Values                                                                                                                                     0.0%
     Total Valuable Papers Values                                                                                                                                         0.0%
     Total Business Interruption Values                                                                                                                                   0.0%
     Total Extra Expense Values                                                                                                                                           0.0%
     Total Rental Income Values                                                                                                                                           0.0%
     Total Transit Values                                                                                                                                                 0.0%
     Total Course of Construction Values                                                                                                                                  0.0%
     Total All Other Miscellaneous Values                                                                                                                                 0.0%
                                                                                                             Total Property Values:            $13,539,599              100.0%

  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
                                                                                                                                                                           0.0%
                                                                                                                                                                           0.0%
                                                                                                                                                                           0.0%

  C. Construction Details - THIS SECTION MUST BE COMPLETED IN ORDER TO SECURE A QUOTATION!
     ISO CLASSIFICATION                                                                                                                   # OF LOCATIONS            % OF TOTAL
     [1] Frame or Brick Veneer                                                                                                                                              NA
     [2] Brick                                                                                                                                                              NA
     [3] Non-Combustible                                                                                                                                                    NA
     [4] Masonry Non-Combustible                                                                                                                                            NA
     [5] Semi-Fire Resistive                                                                                                                                                NA
     [6] Fire Resistive                                                                                                                                                     NA
     Any Other Classifications (describe)                                                                                                                                   NA
                                                                                       Total # of Locations:                                             0                  NA




                                                           All Lines Aggregate School Package Application - Main Application
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         ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
               ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!


  D. Protection Details - THIS SECTION MUST BE COMPLETED IN ORDER TO SECURE A QUOTATION!
     CLASSIFICATION                                                                                                                       # OF LOCATIONS            % OF TOTAL
     Sprinklered                                                                                                                                                            NA
     Burglar Alarm - Local Sound                                                                                                                                            NA
     Central Station Alarms (both Burglar & Fire)                                                                                                                           NA
     Security Guards                                                                                                                                                        NA
     Smoke Detectors                                                                                                                                                        NA
     All Other Types of Protection (describe)                                                                                                                               NA
                                                                                      Total # of Locations:                                              0                  NA



5) GENERAL LIABILITY
     NOTE: YOU MUST FORWARD COMPLETE FINANCIAL INFORMATION WITH THIS APPLICATION !


  A. GL Rating Information
                                                                                                                  AVERAGE DAILY             ABSENTEEISM                TRUANCY
      CATEGORY                                                                            ENROLLMENT                ATTENDANCE                     RATE                   RATE
      Pupils
         Elementary & Junior High Students                                                          38,058                     38,058                0.000
         High School Students                                                                        7,970                      7,970                0.000
         Senior High Students                                                                        7,175                      7,175                0.000
                                                           Totals by Category:                      53,203                     53,203                0.000                      NA

      Employees                                                                                                                            TOTAL NUMBER              % OF TOTAL
        Teachers                                                                                                                                   3,745                   55.8%
        Coaches                                                                                                                                      230                    3.4%
        Nurses                                                                                                                                        73                    1.1%
        Physicians                                                                                                                                                          0.0%
        Other (describe)                                  Non-instructional                                                                          2,662                 39.7%
                                                                                                                   Total Employees:                  6,710               100.0%

      Stadiums / Exhibition Centers                       USAGE                                                  CONSTRUCTION           SEATING CAPACITY               RECEIPTS
      1. Kimbrough Stadium                                Sports activities                                                                         9,603
      2. Clark Stadium                                    Sports activities                                                                        14,224
      3. Williams Stadium                                 Sports activities                                                                         3,500
      4. 3 atheltic fields                                Sports activities                                                                         2,550
      5. Total Receipts                                                                                                                                                    $673,576

      Swimming Pools                                       OPEN TO PUBLIC?       # LIFEGUARDS               POOL DEPTH          # DIVING BOARDS             BOARD HEIGHT
      1. Indoor                                                      Yes   2-3 when open to public     2 ft to 11 1/2 depth                2 slides
      2. Indoor                                                      Yes   2-3 when open to public     2 ft to 11 1/2 depth                       1          3/4 quarter meter
      3.
      4.
      5.
         Please describe required lifeguard training & certification:         The pools are owned by the city on district property. The city provides training for all lifeguards. Lifeguards are

  B. Lead Exposure Questionnaire
     1. Does School have any procedures for testing lead exposure levels in paint, dust, drinking water and soil at any buildings built prior to 1980?                No
        Explain.

      2. Have there been any adverse results arising out of the testing procedures described in B.1. above?                                     No           Please explain.




                                                           All Lines Aggregate School Package Application - Main Application
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        ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
              ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!


     3. Describe follow-up / abatement procedures.        n/a




 C. Independent Contractor Operations Questionnaire
    1. Does the School ever make use independent contractors?                                Yes              If yes, please describe the contractor types used & purposes:
        Various services other than transporting students.

     2. Does the School require the following:
                Yes            Certificate of Insurance?
                Yes            Limits at least equal to those carried by the School (if general contractor)?
                Yes            Is the School named as an Additional Insured on the contractor's policy?
                Yes            Are there Hold Harmless Agreements used in all of the School's contracts?
     3. Do you hold any special events in which you do not transfer liability to the contractor performing the special event?                  No

 D. Athletic Participants Questionnaire
    1. Is a signed consent form from parents or guardians required and kept on file? (If "Yes", please attach a copy)                                          Yes
    2. Are medical exams required and copies of doctors' permission forms kept on file for all athletes?                                                       Yes
    3. Are certified trainers and coaches used in the athletic program?                                                                                        Yes
    4. Is there a physician in attendance at all sporting events?                                                                                              Yes
    5. Is applicant securing AD&D / sports excess medical insurance on its participants?                                                                       Yes
                                 If so, what carrier, limits, and coverage are in place?                  Texas Monarch, AIG, $10,000 Death, $20,000 Dismemberment
    6. Number of trampolines?                                                                                                                                          -
    7. Ratable athletic activities:                                                                                                                    # of PARTICIPANTS
                                 Baseball                                                                                                                              225
                                 Basketball                                                                                                                            540
                                 Boxing                                                                                                                                   0
                                 Cheerleading                                                                                                                          205
                                 Diving                                                                                                                                  20
                                 Field Hockey                                                                                                                             0
                                 Football                                                                                                                            2,450
                                 Golf                                                                                                                                  100
                                 Gymnastics                                                                                                                               0
                                 Ice Hockey                                                                                                                               0
                                 Rugby                                                                                                                                    0
                                 Soccer                                                                                                                                330
                                 Softball                                                                                                                              120
                                 Swimming                                                                                                                              170
                                 Tennis                                                                                                                                180
                                 Track & Field                                                                                                                       2,070
                                 Volleyball                                                                                                                            296
                                 Weight Lifting                                                                                                                        178
                                 Wrestling                                                                                                                             220
                                 All Other Athletic Activities                                                                                                            0
                                                                                                                              Total # of Participants:               7,104

 E. Living Quarters / Dormitories Questionnaire              BUILDING                           AGE of                 NUMBER of       SPRINKLERED?              SMOKE / FIRE
                          NUMBER of RESIDENTS              CONSTRUCTION                       BUILDING                   FLOORS          (Yes / No)              DETECTORS?
    1.                                          N/A
    2.
    3.
    4.
    5.




                                                          All Lines Aggregate School Package Application - Main Application
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          ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!


   F. Services Questionnaire (please show receipts associated with each)                             FOOD                       LIQUOR              OTHER                     TOTAL
         Cafeterias                                                                                                                                                         1,177,959
         Restaurants                                                                                                                                                               n/a
         Stores                                                                                                                                                                    n/a
                                                                      Totals:                              0                         0                     0                1,177,959

   G. Other Questions
      1. Do you operate a day care facility?             No, Preschool Center           Daily Attendance? 20 student each class                        Staff?
                                                                                                                                                # Care1 Director and 3 student interns
      2. Please attach additional information regarding extracurricular activities (e.g. newspapers, yearbooks, radio stations, etc.)



6) AUTOMOBILE LIABILITY

   A. CATEGORY                                                                                                                                 # THIS TYPE             % THIS TYPE
         Private Passenger Cars (up to 10,000 lbs GVW) - Non Emergency                                                                                    8                    2.0%
         15-Passenger Vans                                                                                                                                0                    0.0%
         Other Vans, Pickup Trucks, other Light Trucks (up to 10,000 lbs GVW)                                                                           137                   33.9%
         Medium Weight Trucks (10,000 to 20,000 lbs GVW)                                                                                                 30                    7.4%
         Heavy Trucks (20,000 to 50,000 lbs GVW)                                                                                                          3                    0.7%
         Extra-Heavy Trucks (greater than 50,000 lbs GVW)                                                                                                                      0.0%
         Motorcycles                                                                                                                                                           0.0%
         Buses                                                                                                                                           195                  48.3%
         Miscellaneous Autos                                                                                                                                                   0.0%
         Mobile Equipment                                                                                                                                 11                   2.7%
         Trailers, All Types                                                                                                                              20                   5.0%
                                                                                                                  Total Automobiles:                     404                 100.0%

   B. Underwriting Criteria for Buses ONLY (if applicable)
      1. Is the bus service contracted?                             No                                      Name of Company used:
                                                 Company's Insurance Carrier:                                                                 Limits Carried:
                                                  Insurance Certificate on File?                                      Is School named an Additional Insured?

      2. Describe operations of any passenger vans or buses (including radius, frequency, receipts, etc.):
         80 regular routes - total annual distance 1,237,334; 35 special ed routes - total annual distance 543,492.

      3. Describe operations of any trucking exposures (including radius, frequency, receipts, etc.):
         None

      4. Describe any vehicles modified to handle handicapped or wheelchair passengers:
         Plano ISD does not make any modifications to any buses or any other vehicles owned by the school district. All of our buses and other equipmnt is orderd to specifications from the facto

      5. Please advise in which state the Insured has Automobile operations / exposure:
         Texas

                                                                                 Plano
      6. Please attach a copy of the policy on personal use of owned or leased vehicles.ISD does not allow the used of owned or leased vehicles for personal use.



7) SCHOOL BOARD LEGAL LIABILITY - this coverage is provided on a CLAIMS-MADE basis                              N/A
                                                                                                                                                                        SURPLUS or
   A. Budget (last three years)                             BOND RATING                             YEAR                 REVENUES          EXPENDITURES                 DEFICIT (+/-)
      1. Current Fiscal Year                                AAA                                    2004-05               594,883,144           575,545,945                19,337,199
      2. Prior Fiscal Year                                                                         2003-04                                                                          0
      3. Fiscal Year Two Years Prior                                                               2002-03                                                                          0
                                                                                                                                   ACCUMULATED SURPLUS




                                                            All Lines Aggregate School Package Application - Main Application
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           ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!


   B. Exposure Information
      1. Type Employees             ACCOUNTANTS                 ARCHITECTS                 ATTORNEYS              ENGINEERS                ALL OTHER                       TOTAL
                    Full Time:                                                                                                                                                N/A
                   Part Time:                                                                                                                                                 N/A
            Total Employees:                         0                         0                     0                     0                           0                        0
      2. Have any of the following occurred within the past three years?
         a. Have you had a strike, slowdown, or other employee disruption?                                                                                           No
         b. Has there been a layoff of employees or reductions in service?                                                                                           Yes
         c. Have there been any disputes or suits involving voting or voting rights violations?                                                                      No
         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?                                                                    Yes
      3. Does your School administer or act in a fiduciary capacity for any employment benefit or any self-insurance fund?                                           Yes
      4. Does your School follow a formal, written procedure for employee disputes / complaints?                                                                     Yes



8) COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION
   Auto - Include Hired, Borrowed, Non-owned. Include Defense Outside the Limits. Include Broad Form Named Insured Endorsement, 90 Day Notice of Cancellation, Governmental
   Bodies Amendatory Endorsement, Supplementary Death Benefit, Mexico Coverage, Governmental Immunity Endorsement, Public Transportation Autos, Fleet Automatic Physical
   Damage, Governmental Units, Inadvertent E&O, Notice of Occurrence, Additional Insured - Lessor Endorsement, Delete Fellow Employee Exclusion-Incl all emps at or above supvr.
   Employee Benefits Liability - 12/31/91 Retro Date
   GL - Expanded definition of insured endorsement, PI/AI-delete exclusion 2.b(4) that pertains to liability assumed under any contract or agreement, Amend Fellow Employee Excl as above,
   Automatic Addl Insds, delayed notice of occurrence, include punitive damages, and other chagnes as indicated in specifications provided.




9) FRAUD WARNING REQUIREMENTS

 STATE             STATUTORY REFERENCE                                                         POLICY APPLICATION WARNING STATEMENT
   AL                      NONE
  AK                       NONE
   AZ                      NONE
  AR                   IC § 23-66-503                   The following statement must be included on applications for insurance: Any person who knowingly presents a false
                                                        or fraudulent claim for payment of a loss or benefit or knowingly presents false information on an application for
                                                        insurance is guilty of a crime and may be subject to fines and confinement in prison.
   CA                         NONE
   CO                     IC § 10-1-127                 The following statement must be permanently affixed to all printed applications for insurance: It is unlawful to knowingly
                                                        provide false, incomplete, or misleading facts or information to an insurance company for the purpose of
                                                        defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of
                                                        insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly
                                                        provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
                                                        defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable
                                                        from insurance proceeds shall be reported to the Colorado division of insurance within the department of
                                                        regulatory agencies.
   CT                         NONE
   DE                         NONE
   DC                    IC § 22-3255.09                The following statement must be conspicuously included on all insurance application forms: WARNING: It is a crime to
                                                        provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other
                                                        person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
                                                        false information materially related to a claim was provided by the applicant.

    FL             IC § 817.234;Inf Bulletin 96-1       The following statement must be included on all application forms: Any person who knowingly and with intent to
                                                        injure, defraud, or deceive any insurer files a statement of claim or an application containing any false,
                                                        incomplete, or misleading information is guilty of a felony of the third degree.
   GA                         NONE




                                                           All Lines Aggregate School Package Application - Main Application
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        ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
             ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!


  HI               IC § 431:10C-307.7            The following statement must be included on all motor vehicle application forms: For your protection, Hawaii law
                                                 requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime
                                                 punishable by fines or imprisonment, or both.
  ID                      NONE
  IL                      NONE
  IN                      NONE
  IA                      NONE
  KS                      NONE
  KY                 IC § 304.47-030             The following statement must be included on all applications: Any person who knowingly and with intent to defraud
                                                 any insurance company or other person files an application for insurance containing any materially false
                                                 information or conceals, for the purpose of misleading, information concerning any fact materially 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 sugject to fines and confinement in
                                                 prison.

 ME                  IC 24-A § 2186              The following statement must be permanently affixed to all applications: It is a crime to knowingly provide false,
                                                 incomplete, or misleading information to an insurance company for the purpose of defrauding the company.
                                                 Penalties may include imprisonment, fines, or a denial of insurance benefits.
 MD                      NONE
 MA                      NONE
 MI                      NONE
 MN                      NONE
 MS                      NONE
 MO                      NONE
 MT                      NONE
 NE                      NONE
 NV                      NONE
 NH                      NONE
 NJ         NJAC § 11:16-1.2;N.J.S.A. 17:33A-6   The following statement must be prominently and clearly included on all application forms: Any person who includes
                                                 any false or misleading information on an application for an insurance policy is subject to criminal and civil
                                                 penalties.
 NM                  IC § 59A-16C-8              The following statement must be permanently affixed to all applications for insurance: ANY PERSON WHO KNOWINGLY
                                                 PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY
                                                 PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE
                                                 SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

 NY                  11 NYCRR 86.4               The following statement must be included on all insurance applications for commercial insurance and accident and health
                                                 insurance except automobile insurance:
                                                 Any person who knowingly and with intent to defraud any insurance company or other person files an
                                                 application for insurance or statement of claim containing any materially false information, or conceals for the
                                                 purpose of mmisleading, information concerning any fact material thereto, commits a fraudulent insurance act,
                                                 which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated
                                                 value of the claim for each such violation.
                                                 The following statement must be included on all insurance applications for automobile insurance:
                                                 Any person who knowingly and with intent to defraud any insurance company or other person files an
                                                 application for commercial insurance or a statement of claim for any commercial or personal insurance benefits
                                                 containing any materially false information, or conceals for the purpose of misleading, information concerning
                                                 any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or
                                                 knowingly assists, abets, solicits, or conspires with another to make a false report of
                                                 the theft, destruction, damage, or conversion of any motor vehicle to a law enforcement agency, the department
                                                 of motor vehicles
                                                 or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject to a
                                                 civil penalty not to
                                                 exceed five thousand dollars and the value of the subject motor vehicle or stated claim for each violation.
 NC                       NONE
 ND                       NONE




                                                   All Lines Aggregate School Package Application - Main Application
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          ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!


 OH                       IC § 3999.21                 The following statement must be included on or attached as an addendum to all applications for insurance: Any person
                                                       who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or
                                                       files a claim containing a false or deceptive statement is guilty of insurance fraud.
 OK                      IC 36 § 3613.1                The following statement must be included either on or attached as an addendum to every insurance policy or application:
                                                       WARNING: Any person who knowingly, and with intent to injury, defraud, or deceive any insurer, makes any
                                                       claim for the proceeds of an insurance policy containing any false, incomplete, or misleading information is
                                                       guilty of a felony.

 OR                       Bulletin 98-5                Warning statements are not mandatory, but may be included on applications. The following is the suggested language:
                                                       Any person who knowingly and with intent to defraud or solicit another to defraud an insurer; (1) by submitting
                                                       an application, or (2) by filling a claim containing a false statement as to any material fact, may be violating state
                                                       law.
  PA                  75 Pa. C.S.A. § 1822             The following statement must be included on all applications for insurance: Any person who knowingly and with intent
                                                       to injure or defraud any insurer files an application or claim containing any false, cincomplete, or misleading
                                                       information shall, upon conviction, be subject to imprisonment for up to seven years and payment of a fine of up
                                                       to $15,000.

 RI                           NONE
 SC                           NONE
 SD                           NONE
 TN               IC § 56-47-112;IC § 56-53-111        The following statement must be permanently affixed to all applications for insurance: It is a crime to knowingly provide
                                                       false, incomplete, or misleading information to an insurance company for the purpose of defrauding the
                                                       company. Penalties include imprisonment, fines, and denial of insurance benefits.
  TX                         NONE
  UT                    IC § 34-2-110 -                The following statement must be prominently displayed or printed on all applications for Workers' Compensation
                  Workers' Compensation ONLY           insurance: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be
                                                       filed false or fraudulent report or billing for health care fees or other professional services is guilty of a crime
                                                       and may be subject to fines and confinement in state prison.

  VT                         NONE
  VA                       RL § 52-40                  The following statement must be permanently affixed to or included as part of all insurance applications: It is a crime to
                                                       knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of
                                                       defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits.
 WA                          NONE
 WV                          NONE
 WI                          NONE
 WY                          NONE


 COVERAGE NOTICE
 If this account meets our underwriting standards, liability coverage will be quoted as follows:
        * Automobile Liability, General Liability and Law Enforcement Liability will be quoted on an OCCURRENCE basis.
        * School Board Legal Liability will be quoted on a CLAIMS-MADE basis.

 The information provided in this application and all schedules are true and correct to the best of my knowledge.



       Signed:                                                                                                Signed:

                                  Date:                                                                                            Date:



       Named Insured:                                                                                         Agent/Broker Name:




                                                          All Lines Aggregate School Package Application - Main Application
01-NOV-05                                                D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                              Page 8 of 21
             ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION


          UNINSURED / UNDERINSURED MOTORISTS SELECTION FORM


Uninsured motorists insurance provides protection for damages as a result of bodily injury and/or property damage caused by a negligent motorist who has no insurance
to pay for the damages caused.

Underinsured motorists insurance provides protection for damages as a result of bodily injury and/or property damage caused by a negligent motorist who does not have
enough liability insurance to pay for the damages caused. Underinsured motorists coverage will apply only if your own underinsured motorist limit is higher than the bodily injury
limit of the negligent motorists.

You have the right to reject Uninsured/Underinsured Motorists coverage or to select a limit shown below.

                                                            I want to REJECT Uninsured/Underinsured Motorists coverage completely.
                                                            Not allowed in - CT, DC, IL, KS, ME, MD, MA, MN, MO, NE, NH, NJ, NY, ND, OR, SC, SD, UT, VT, VA, WI, WV

             Alabama                                        I want to select limits of   $ 40,000
             Alaska                                         I want to select limits of   $ 125,000
             Arizona                                        I want to select limits of   $ 30,000
             Arkansas                                       I want to select limits of   $ 25,000    / $ 50,000 / $ 25,000
             California                                     I want to select limits of   $ 35,000
             Colorado                                       I want to select limits of   $ 25,000    / $ 50,000
             Connecticut                                    I want to select limits of   $ 40,000
             Delaware                                       I want to select limits of   $ 15,000    / $ 30,000 / $ 10,000
             DC                                             I want to select limits of   $ 25,000    / $ 50,000 / $ 5,000
             Florida                                        I want to select limits of   $ 20,000    VLFL02 (06-04) will need to be signed upon binding
             Georgia                                        I want to select limits of   $ 75,000
             Hawaii                                         I want to select limits of   $ 20,000    / $ 40,000
             Idaho                                          I want to select limits of   $ 50,000
             Illinois                                       I want to select limits of   $ 40,000
             Indiana                                        I want to select limits of   $ 60,000
             Iowa                                           I want to select limits of   $ 20,000    / $ 40,000
             Kansas                                         I want to select limits of   $ 50,000
             Kentucky                                       I want to select limits of   $ 60,000
             Lousiana                                       I want to select limits of   $ 10,000    / $ 20,000 for vehicles under 20,000lbs
                                                                                         $ 25,000    / $ 50,000 for vehicles 20,000lbs-50,000lbs
                                                                                         $ 100,000   / $300,000 for vehicles >50,000lbs
                                                                                                     VLLA03 (06-04) & VLLA04 (06-04) will need to be signed upon binding
             Maine                                          I want to select limits of   $ 100,000
             Maryland                                       I want to select limits of   $ 55,000
             Massachusetts                                  I want to select limits of   $ 20,000 /     $ 40,000
             Michigan                                       I want to select limits of   no minimum
             Minnesota                                      I want to select limits of   $ 50,000
             Mississippi                                    I want to select limits of   $ 10,000 /     $ 20,000 / $ 5,000
             Missouri                                       I want to select limits of   $ 50,000
             Montana                                        I want to select limits of   $ 25,000 /     $ 50,000
             Nebraska                                       I want to select limits of   $ 50,000
             Nevada                                         I want to select limits of   $ 15,000 /     $ 30,000
             New Hampshire                                  I want to select limits of   $ 25,000 /     $ 50,000
             New Jersey                                     I want to select limits of   $ 35,000
             New Mexico                                     I want to select limits of   $ 60,000
             New York                                       I want to select limits of   $ 25,000 /     $ 50,000
             North Carolina                                 I want to select limits of   $ 85,000
             North Dakota                                   I want to select limits of   $ 50,000
             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




                                                  All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
   01-NOV-05                                                      D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                                    Page 9 of 21
        Rhode Island                    I want to select limits of   $ 75,000
        South Carolina                  I want to select limits of   $ 40,000
        South Dakota                    I want to select limits of   $ 25,000 / $ 50,000
        Tennessee                       I want to select limits of   $ 60,000
        Texas                           I want to select limits of   $ 55,000
        Utah                            I want to select limits of   $ 25,000 / $500,000 for Schools & Governmental Entities
        Vermont                         I want to select limits of   $ 100,000 VLVT01 (05-04) will need to be singed upon binding
        Virginia                        I want to select limits of   $ 70,000
        Washington                      I want to select limits of   $ 60,000
        West Virginia                   I want to select limits of   $ 50,000
        Wisconsin                       I want to select limits of   $ 100,000
        Wyoming                         I want to select limits of   $ 50,000

                                        I want to select limits equal to policy limits for Automobile Bodily Injury




                         Signature                                                           Date




                              All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
01-NOV-05                                     D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                       Page 10 of 21
                            ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                             ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                       WORKERS' COMPENSATION APPLICATION


            1) NAMED INSURED:                 Plano Independent School District                                           CONTACT NAME:               Raymond Weaver
               ADDRESS:                       2700 W. 15th Street
               CITY:                          Plano                                                           STATE:      TX                                  ZIP CODE:      75075



            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)                           6,710                  TOTALS                               0                      0                         0

            4) UNDERWRITING
               a. Federal Employers Identification Number (FEIN)
               b. Date applicant qualified as a Self-Insured:
               c. Does applicant have any employees who may be subject to the Longshoremen and Harbor Workers Act, Jones Act, or Federal Employee's Liability Act?
                      If "Yes", describe
               d. Do the operations of the applicant include volunteer or donated labor?
                      If "Yes", describe
               e. Provide details of any OSHA or State OSHA violation within the past 5 years.




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




                                                             All Lines Aggregate School Package Application - Workers' Compensation Application
01-NOV-05                                                             D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                                                  Page 11 of 21
          ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                                   ALL QUESTIONS MUST BE ANSWERED

                   RISK MANAGEMENT PRACTICES QUESTIONNAIRE



   NAMED INSURED: Plano Independent School District                                             Contact Name              Raymond Weaver
   Address             2700 W. 15th Street
   City                Plano                                             State                        TX                          Zip Code                 75075




                       Risk Management
             Yes       Does the Insured have a Full Time Risk Management Program in place?
             22         If "yes", how long has the Risk Management Program been in place?
             22         If "yes", how long has the Risk Manager been in place?
             Yes       Does the entity have a loss control safety and procedures manual?
             No        If "yes", is it distributed to all employees?
             No        Does the entity have an employee procedures manual?
             No         If "yes", is it distributed to all employees?
             Yes       Are formal safety meetings conducted?
          Varies       If "yes", how often are they held?
                       How are losses reported?          Burglary, vandalism losses, etc reported to Benefits and Risk Managemnt and Safety and Security by each building.
                        How
30+ health & workers' comp long has the account been Self Insured?


                       Auto
                       What are requested UM limits?
             Yes       Are MVRs checked annually for regular drivers?


                       Stability of Entity
          Growth       Is the entity in a growth mode, or has population been steady over the years?
             Yes       Does the entity have a master plan for their growth?
                       What is the entity's zoning process?        The attendance zones within the district are still experiencing a growth mode. The district utilizes a five year enrollmnt p


                       Additional Comments




                                           All Lines Aggregate School Package Application - Risk Management Practices Questionnaire
  01-NOV-05                                            D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                        Page 12 of 21
                   ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                   ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                  EXPOSURE HISTORY COMPARISON


                     Property / APD       GL                      LAW                       E&O                          AL                 WC          Crime
                         $ TIV         #Students             # F/T Officers               #Teachers                   # Vehicles         $ Payroll   # Employees


  9th year prior
  8th year prior
  7th year prior
  6th year prior
  5th year prior
  4th year prior
  3rd year prior
  2nd year prior
  1st year prior
     current
   prospective                                53,203      100 Contracted                                                           373                         6,763




                                          All Lines Aggregate Public Entity Package Application - Exposure History Comparison
01-NOV-05                                          D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                      Page 13 of 21
                            ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                                                            ALL QUESTIONS MUST BE ANSWERED

                           CAMPUS SECURITY SUPPLEMENTAL QUESTIONNAIRE - SCHOOLS


                                                                                                                                                                       YES / NO
 1.   Do you use metal detectors on any School Grounds?                                                                                                           Yes hand held models
 2.   Are City or County Police contacted when a situation occurs on any School Grounds?                                                                                  Yes
 3.   Do you have armed Police or Security Officers on any school grounds?                                                                                                Yes
 4.   Do you use Police-trained dogs on School Grounds for bomb or drug searches that are conducted by your Police or Security Officers?                                  Yes
 5.   Do officers have arrest authority?                                                                                                                                  Yes
 6.   Do you have a policy and procedures manual for the Police or Security Officers?                                                                                     Yes
 7.   If you have a policy and procedures manual, when was it last updated?                                                                                              Feb-06
 8.   Are your Police and Security Officers Employees or Independent Contractors?                                                                            Independent Contractors
 9.   Please give the number of Full-Time Officers.                                                                                                                    Approx 100
10.   Please give the number of Part-Time Officers.
11.   Please describe personnel screening measures prior to hiring.
      Background and criminal history checks are done on all employees. Drivers must maintain CDL, have 20 classroom and 6 behind wheel hours, MVR checks.

12. Please describe training requirements prior to hiring.
    5 class room driver training hours and 8 refresher hours every three years for CDL holders.

13. Please describe continuing education requirements for Employees.
    Professional staff must reeive 30 hours per contract year. Othr employees licensed by state agencies must meet those requirements.

      If "YES" to any of the above answers, please provide a five-year loss history.




                                                           All Lines Aggregate School Package Application - Campus Security Supplemental Questionnaire
       01-NOV-05                                                         D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                           Page 14 of 21
          ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
               ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

             SEXUAL ABUSE & MOLESTATION COVERAGE APPLICATION
                                                                                                                                       N/a

1) NAMED INSURED:                  Plano Independent School District                                          CONTACT NAME:            Raymond Weaver
   ADDRESS:                        2700 W. 15th Street
   CITY:                           Plano                                                           STATE: TX                                    ZIP CODE: 75075



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

                     $1,000,000 Limit Per Occurrence                                           $2,000,000 Policy Aggregate                   Proposed SIR:                $50,000



3) HAS ANY INSURER EVER CANCELLED OR NON-RENEWED THIS TYPE OF COVERAGE? (if YES, please explain)




4) UNDERWRITING & RISK MANAGEMENT - SEXUAL ABUSE INFORMATION
   A. Any clients with:                     Handicaps?               Yes                   Emotional?                                     Physical?
                                    Special Education?               Yes
   B. Do all employees complete an employment application?
   C. Does pre-employment background checks include the following:
                                 Personal References?                Yes               Police Record?            Yes          Education Verification?
   D. Are records kept documenting this investigation as part of each employee's personnel file?
   E. Is an application obtained on volunteers?                     Yes           Does background check include obtaining police records?                           Yes
   F. Are child abuse and neglect laws reviewed with new employees and volunteers?                                                                                  Yes
   G. Does the facility have written policies that include physical or sexual abuse?                                                                                Yes
        Are these policies reviewed with employees and volunteers?                                                                                                  Yes
   H. Are clients in your care overnight?                                                                                                                           No
   I. Are procedures in place that more than one employee or volunteer is present at all times when a client is in your care?                                       Yes
   J. Are services to clients subcontracted to others?                                                                                                              No
   K. Are your clients instructed to report possible instances of sexual misconduct or abuse?                                                                       Yes
   L. Are known or suspected molestation or abuse incidents reported by your organization to proper police authorities?                                             Yes
        Are employees and volunteers advised of this procedure?                                                                                                     Yes



5) LOSS HISTORY
   A. Please furnish first dollar loss history, for the past five years, for all sexual abuse and/or molestation claims:
             Date of Claim          Claimant's Name             $ Defense Amount $ Indemnity Amount $ Reserve (if open)                Status (open/closed) Nature of Claim




                                           All Lines Aggregate School Package Application - Sexual Abuse Molestation Coverage Application
 01-NOV-05                                                D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                          Page 15 of 21
           ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

              SEXUAL ABUSE & MOLESTATION COVERAGE APPLICATION
                                                                                                                                        N/a

   B. 1.     Are there any unknown or suspected cases reported to date?
      2.     Are you aware of any occurrences that could lead to or result in claims concerning sexual abuse or misconduct being made against you?
      3.     Have any claims concerning sexual abuse or misconduct been filed against you or your organization?
      4.     Have any public authorities investigated your operation relating to sexual abuse or misconduct?
      5.     Have any parents, guardians, or others alleged sexual abuse in connection with your premises or operations?
      6.     Please describe any unknown or suspected claims reported to date:




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




The application further warrants that if the information supplied on the application changes between the date of this application and the inception date of the policy period, it
 will immediately notify Alternative Market Specialists of such change. Signing of this application does not bind the Company to offer or the Applicant to accept insurance,
         but it is agreed that this application shall be the basis of the insurance contract and will be attached and made part of the policy should a policy be issued.




                                  NAMED INSURED AUTHORIZED SIGNATURE                                                                TITLE




                                                                                                          DATE




                                            All Lines Aggregate School Package Application - Sexual Abuse Molestation Coverage Application
 01-NOV-05                                                 D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                         Page 16 of 21
                   ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                        ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                           SEXUAL HARASSMENT COVERAGE APPLICATION n/a


      1) NAMED INSURED:                   Plano Independent School District                                          CONTACT NAME:              Raymond Weaver
         ADDRESS:                         2700 W. 15th Street
         CITY:                            Plano                                                           STATE: TX                                     ZIP CODE: 75075



      2) PROPOSED PLAN - Enter limits and retentions desired. Insert "NA" if coverage is not desired.                N/A

                             $1,000,000 Limit Per Occurrence                                           $2,000,000 Policy Aggregate                    Proposed SIR:                   $50,000



      3) HAS ANY INSURER EVER CANCELLED OR NON-RENEWED THIS TYPE OF COVERAGE? (if YES, please explain)                                                                          No




      4) EMPLOYEE INFORMATION
         A. Number of FULL-time employees                                                                                                       N/A
         B. Number of PART-time employees                                                                                                       N/A
         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?
               Human Resource Director                           2700 West 15th Street                           Plano, TX 750275
               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)                                Yes



      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)                                               Yes




            B. Is there a hiring / screening process for new employees?                                                                                                         Yes
            C. Is there a policy/procedure concerning employee background (including criminal) checks?                                                                          Yes
            D. Are Human Resources files maintained in a central location?
            E. Are policies and procedures in place concerning Sexual Harassment, Discrimination, Equal Opportunity, etc.? (if "Yes" please provide a copy)
            F. Does the Sexual Harassment policy include a clear and open reporting procedure?
            G. Is the Sexual Harassment policy "Zero Tolerance"?




                                                      All Lines Aggregate School Package Application - Sexual Harassment Coverage Application
01-NOV-05                                                         D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                                       Page 17 of 21
                   ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                         ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                            SEXUAL HARASSMENT COVERAGE APPLICATION n/a

            H. Is the Sexual Harassment policy understandable (i.e. clear and concise)?
            I. Are new employees provided with a copy of the Sexual Harassment policies and procedures at orientation?
            J. Are policies and procedures disseminated to all employees?
            K. Is training on the Sexual Harassment policies and procedures offered to all employees?
            L. Is training documented in the employee's personnel files?
            M. Is training provided for all supervisory personnel?
            N. Is training documented in the supervisory personnel's personnel files?
            O. Does top management support the Sexual Harassment policies and procedures?
            P. Has legal counsel reviewed the Sexual Harassment policy? (If "yes, provide date of latest review; if "no", describe the review process)




      7) LOSS HISTORY
         A. Please furnish first dollar loss history, for the past five years, for all Sexual Harassment claims:
                    Date of Claim          Claimant's Name               $ Defense Amount        $ Indemnity Amount       $ Reserve (if open)     Status (open/closed)   Nature of Claim




            B. 1. Are you aware of any occurrences that could lead to or result in claims being made against you?
               2. Please describe any unknown or suspected claims reported to date:




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




        The application further warrants that if the information supplied on the application changes between the date of this application and the inception date of the policy period, it wil
            immediately notify Alternative Market Specialists of such change. Signing of this application does not bind the Company to offer or the Applicant to accept insurance,
                  but it is agreed that this application shall be the basis of the insurance contract and will be attached and made part of the policy should a policy be issued.




                                          NAMED INSURED AUTHORIZED SIGNATURE                                                                 TITLE




                                                                                                                   DATE




                                                        All Lines Aggregate School Package Application - Sexual Harassment Coverage Application
01-NOV-05                                                           D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                                        Page 18 of 21
                            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)?                                                           No
      2. Does the Insured have any Bridges greater than 300 feet in length?                                                                                                               No
      3. Does the Insured own, lease or operate any Convention / Exhibition Centers / Theatres / Concert Halls with seating >10,000?                                                      No
      4. Does the Insured own, lease or operate any Dams greater than 300 feet in length, with a downstream population >25,000?                                                           No
      5. Does the Insured provide Emergency Services (e.g. Police, Fire, EMTs) in cities where the population is greater than 250,000?                                                    No
      6. Does the insured own or lease space in any Federal and/or State Government Buildings, and/or National Landmarks?                                                                 No
      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?                                          No
      8. Does the Insured own or manage space in any Office Buildings greater than 25 stories in height?                                                                                  No
      9. Does the Insured own, lease or operate/manage any Residential Buildings greater than 25 stories in height?                                                                       No
     10. Does the Insured operate or have any Port / Transit Authorities?                                                                                                                 No
     11. Does the Insured operate or have any Railroads? (not including sidetrack agreements)                                                                                             No
     12. Does the Insured operate a Public School District within cities where the population is greater than 250,000?                                                                    Yes
     13.   Does the Insured own, lease or operate any Stadiums/Sports arenas with seating capacities greater than 10,000?                                                                 Yes
     14.   Does the Insured have any Tunnels greater than 300 feet in length?                                                                                                             No
     15.   Does the Insured operate any Universities?                                                                                                                                     No
     16.   Does the Insured own, lease or operate any Utilities (e.g. electric, gas, water & sewer) with greater than 250,000 customers?                                                  No
     17. Does the insured own or lease any gas or oil pipelines?                                                                                                                          No
     18. Is your entity's population greater than 250,000?                                                                                                                                No
           If you answered yes on #18 - Do you provide emergency services (ie. Police, firefighters, EMTs)?                                                                               No
     19. Do you employ any Architects or Engineers?                                                                                                                                       No
     20. Do you have a Seaport or Maritime operation, or do you operate any Commuter Ferries?                                                                                             No



     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
           12 - Population of Plano is 222,030 as of 2000 census.
           13. The district owns Clark Stadium which seats more than 10,000




                                                                 All Lines Aggregate School Package Application - Terrorism Activities Questionnaire
01-NOV-05                                                                D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                                        Page 19 of 21
                           ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                                           LOSS SUMMARY
                                          (All losses should include the deductible part of the loss)


                  DESCRIPTION or           AUTO           AUTO                CRIME            GENERAL           LAW ENFRC            PROPERTY      SCH BOARD    WORKERS'      TOTAL
                      CATEGORY          LIABILITY     PHYS DAM                                 LIABILITY           LIABILITY         & IN MARINE    LEGAL LIAB      COMP    ALL LINES

                            Current
            Loss Run Valuation Date                                                                                                                                               NA
                    Total Incurred $          $0              $0                   $0                   $0                   $0                $0           $0         $0         $0
                    Total Reserve $                                                                                                                                               $0
                        Total Paid $                                                                                                                                              $0
                    Total Incurred #           0                0                    0                   0                    0                 0            0          0          0
                      Total Open #                                                                                                                                                 0
                     Total Closed #                                                                                                                                                0

                     1st year prior
            Loss Run Valuation Date                                                                                                                                               NA
                    Total Incurred $          $0              $0                   $0                   $0                   $0                $0           $0         $0         $0
                    Total Reserve $                                                                                                                                               $0
                        Total Paid $                                                                                                                                              $0
                    Total Incurred #           0                0                    0                   0                    0                 0            0          0          0
                      Total Open #                                                                                                                                                 0
                     Total Closed #                                                                                                                                                0

                    2nd year prior
            Loss Run Valuation Date                                                                                                                                               NA
                    Total Incurred $          $0              $0                   $0                   $0                   $0                $0           $0         $0         $0
                    Total Reserve $                                                                                                                                               $0
                        Total Paid $                                                                                                                                              $0
                    Total Incurred #           0                0                    0                   0                    0                 0            0          0          0
                      Total Open #                                                                                                                                                 0
                     Total Closed #                                                                                                                                                0

                     3rd year prior
            Loss Run Valuation Date                                                                                                                                               NA
                    Total Incurred $          $0              $0                   $0                   $0                   $0                $0           $0         $0         $0
                    Total Reserve $                                                                                                                                               $0
                        Total Paid $                                                                                                                                              $0
                    Total Incurred #           0                0                    0                   0                    0                 0            0          0          0
                       Total Open #                                                                                                                                                0
                     Total Closed #                                                                                                                                                0

                     4th year prior
            Loss Run Valuation Date                                                                                                                                               NA
                    Total Incurred $          $0              $0                   $0                   $0                   $0                $0           $0         $0         $0
                    Total Reserve $                                                                                                                                               $0
                        Total Paid $                                                                                                                                              $0
                    Total Incurred #           0                0                    0                   0                    0                 0            0          0          0
                       Total Open #                                                                                                                                                0
                     Total Closed #                                                                                                                                                0

                     5th year prior
            Loss Run Valuation Date                                                                                                                                               NA
                    Total Incurred $          $0              $0                   $0                   $0                   $0                $0           $0         $0         $0
                    Total Reserve $                                                                                                                                               $0
                        Total Paid $                                                                                                                                              $0
                    Total Incurred #           0                0                    0                   0                    0                 0            0          0          0
                       Total Open #                                                                                                                                                0
                     Total Closed #                                                                                                                                                0

                    Total all years
            Loss Run Valuation Date           NA              NA                   NA                  NA                   NA                 NA          NA         NA          NA
                    Total Incurred $          $0              $0                   $0                  $0                   $0                 $0          $0         $0          $0
                    Total Reserve $           $0              $0                   $0                  $0                   $0                 $0          $0         $0          $0
                        Total Paid $          $0              $0                   $0                  $0                   $0                 $0          $0         $0          $0
                    Total Incurred #           0               0                    0                   0                    0                  0           0          0           0
                      Total Open #             0               0                    0                   0                    0                  0           0          0           0
                     Total Closed #            0               0                    0                   0                    0                  0           0          0           0




                                                                    All Lines Aggregate School Package Application - Multi-Year Loss Summary
01-NOV-05                                                               D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                             Page 20 of 21
                                ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                                  ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                     CLAIMS IN EXCESS OF 50% OF PROPOSED SIRs or $25,000 (whichever is less)


            POLICY     DATE     COV    CLAIM            CLAIMANT                       TOTAL CLAIM $           TOTAL CLAIM $           TOTAL CLAIM $   O
     #      PERIOD    OF LOSS   TYPE   NUMBER           NAME                            PAID TO DATE              RESERVED                INCURRED     C   CLAIM DESCRIPTION

     1                                                                                                                                            $0
     2                                                                                                                                            $0
     3                                                                                                                                            $0
     4                                                                                                                                            $0
     5                                                                                                                                            $0
     6                                                                                                                                            $0
     7                                                                                                                                            $0
     8                                                                                                                                            $0
     9                                                                                                                                            $0
    10                                                                                                                                            $0
    11                                                                                                                                            $0
    12                                                                                                                                            $0
    13                                                                                                                                            $0
    14                                                                                                                                            $0
    15                                                                                                                                            $0
    16                                                                                                                                            $0
    17                                                                                                                                            $0
    18                                                                                                                                            $0
    19                                                                                                                                            $0
    20                                                                                                                                            $0
    21                                                                                                                                            $0
    22                                                                                                                                            $0
    23                                                                                                                                            $0
    24                                                                                                                                            $0
    25                                                                                                                                            $0




                                                             All Lines Aggregate School Package Application - Claims in Excess of $25,000
01-NOV-05                                                          D:\Docstoc\Working\pdf\3fc48658-c09d-4c5b-a11e-8c6f35697c2e.xls                                             Page 21 of 21

				
DOCUMENT INFO
Description: Certificate of Insurance General Liability Hartford document sample