Livery Drivers Contracts

Document Sample
Livery Drivers Contracts Powered By Docstoc
					                              PUBLIC EDUCATORS ASSOCIATION OF TEXAS
                                NEW BUSINESS SCHOOL APPLICATION
                                                         Proposed Effective Date
                                                         Proposed Expiration Date
                                                         Date Quote is Needed
                                                         Bid Date

       This application includes all coverages offered. This General Information section is mandatory

General Information
  1.   Name of District
  2.   Physical address:
  3.   Mailing address (if different):
  4.   City:                                                   State:                        Zip
  5.   County:
  6.   Contact Person:
  7.   Title:                                                             Phone:
  8.   Do you have a risk manager?                 Yes        No        Full time?                 Part time?
  9.   Name of Risk Manager:

Agency and Agent Information
  1.   Name of Agent
  2.   Name of Agency
  3.   Address:
  4.   City:                                                   State:                       Zip:
  5.   Phone:                                                                Fax:
  6.   Email Address:

Expiring Coverage
       Line of Business                  Carrier                Premium                      Limits              Deductible
  Property - Inland Marine
  General Liability
  Auto Liability
  Auto Physical Dmg.
  School Board Legal
  Law Enforcement
  Excess Liability

Coverage Requested
       Line of Business             Requested?               Occurrence Limit            Aggregate Limit         Deductible
  Property - Inland Marine          Yes       No          Per Property Schedule                N/A
  General Liability                 Yes       No         $              1,000,000    $               2,000,000
  Auto Liability                    Yes       No                                               N/A
  Auto Physical Damage              Yes       No             Per Auto Schedule                 N/A
  Crime                             Yes       No             See Crime Section                 N/A
  School Board Legal                Yes       No         $              1,000,000    $               1,000,000
  Law Enforcement                   Yes       No         $              1,000,000    $               1,000,000
  Excess Casualty Liability         Yes       No                                     $                       -      N/A

       PEAT NB App (0209)
                             NEW BUSINESS SCHOOL APPLICATION

Submission Requirements
  5 years currently valued loss runs
  Current excel Statement of Values
  Current excel Auto Schedule

  The undersigned being authorized by , and acting on behalf of, the applicant and all persons or concerns seeking insurance,
  has read and understands this application, and declares that all statements set forth herein are true, complete and accurate.
  The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy
  applied for, which may render inaccurate, untrue or incomplete any statement made herein will immediately be reported in
  writing to the POOL. The undersigned acknowledges and agrees that the applicant's submission and POOL's receipt of such
  written report, prior to the inception of the policy applied for, is a condition precedent to coverage.

  The signing of this application does not bind the undersigned to purchase the insurance, nor does review of the application
  bind the insurance company to issue a policy. The applicant does hereby agree that this policy, if issued, is issued in reliance
  upon the truth of this application, including all requested attachments, which will be incorporated into and made a part of this
  coverage document.

  WARNING: Any person who knowingly and with intent to defraud the pool or other person files an application for coverage or
  statement of claim containing materially false information, or conceals for the purpose of misleading, information concerning
  any fact material thereto, commits a fraudulent act, which is a crime.

  Applicant's Authorized Signature                      Title                                            Date

     PEAT NB App (0209)
0                                                                        Premium/Loss Recap
Carrier loss runs for current and prior 4 years, valued within the last six months, must be provided to the Fund for review. Give details on large losses below.
Current Year                          Prop. B&C   B&M        Crime       Gen Liab Law(if any)      E/O        Auto-Liab   Auto-PD     Subtotal     Excess       TOTAL
Beginning:      Premium                                                                                                                       0                           0
     2008       Deductibles
Valuation Date: Paid Losses                                                                                                                   0                          0
                Total Incurred                                                                                                                0                          0
Company:        Occurrences                                                                                                                   0                          0
                Loss Ratio                                                                                                              #DIV/0!                    #DIV/0!

1st Prior                      Prop. B&C          B&M        Crime       Gen Liab Law(if any)      E/O        Auto-Liab   Auto-PD     Subtotal     Excess       TOTAL
     2007       Premium                                                                                                                       0                           0
Valuation Date: Paid Losses                                                                                                                   0                           0
                Total Incurred                                                                                                                0                           0
Company:        Occurrences                                                                                                                   0                           0
                Loss Ratio                                                                                                            #DIV/0!                   #DIV/0!

2nd Prior                      Prop. B&C          B&M        Crime       Gen Liab Law(if any)      E/O        Auto-Liab   Auto-PD     Subtotal     Excess       TOTAL
     2006       Premium                                                                                                                       0                           0
Valuation Date: Paid Losses                                                                                                                   0                           0
                Total Incurred                                                                                                                0                           0
Company:        Occurrences                                                                                                                   0                           0
                Loss Ratio                                                                                                            #DIV/0!                   #DIV/0!

3rd Prior                      Prop. B&C          B&M        Crime       Gen Liab Law(if any)      E/O        Auto-Liab   Auto-PD     Subtotal     Excess       TOTAL
     2005       Premium                                                                                                                       0                           0
Valuation Date: Paid Losses                                                                                                                   0                           0
                Total Incurred                                                                                                                0                           0
Company:        Occurrences                                                                                                                   0                           0
                Loss Ratio                                                                                                            #DIV/0!                   #DIV/0!

4th Prior                      Prop. B&C          B&M        Crime       Gen Liab Law(if any)      E/O        Auto-Liab   Auto-PD     Subtotal     Excess       TOTAL
     2004       Premium                                                                                                                       0                           0
Valuation Date: Paid Losses                                                                                                                   0                           0
                Total Incurred                                                                                                                0                           0
Company:        Occurrences                                                                                                                   0                           0
                Loss Ratio                                                                                                            #DIV/0!                   #DIV/0!

     Total                            Prop. B&C   B&M        Crime       Gen Liab Law(if any)      E/O        Auto-Liab   Auto-PD     Subtotal     Excess       TOTAL
                     Premium                                                                                                                  0                          0
   Four Year Paid Losses                                                                                                                      0                          0
   Summary           Total Incurred                                                                                                           0                          0
  (Excluding the     Average Loss                                                                                                             0                          0
current policy year) Occurrences              0         0            0           0           0            0           0           0           0             0            0
                     Ave Frequency            0         0            0           0           0            0           0           0           0             0            0
                     Loss Ratio                                                                                                        #DIV/0!                     #DIV/0!
Large Loss Details
Please provide details of any General Liability or E/O losses over $10,000 and any over $50,000 for other lines

   Date of         Line of
    Loss          Business Incurred Details and Status of Loss
                                                                                                             Property Schedule

District Name:                                     0
Protection Class
 Building   Building                                                                                                   Construction          Year     Year
 Location   Number             Occupancy                  Address              City          State          Zip           Type               Built   Upgrade   Area Sq Ft   Stories   Contents       Buildings       Total Value
                       Add More Rows by Selecting this Row and the Number of Rows Needed then Insert/Rows (Copy Formulas in Column L Down)
                                                                                                                                                                                                 0               0                 0

Authorized Applicant Signature                                                            Title                                                      Date
                                                Property & Inland Marine

Property and Inland Marine
Building and Contents Coverage Limits and Deductibles:
     (Values are automatically filled from Property Statement of Values totals on the previous worksheet)

General Coverage                                                                            Limit                   Deductible
     1.   Total Building Values:                                                  $                         -
     2.   Total Content Values:                                                   $                         -
     3.   Total Values:                                                           $                         -   $                    -
     4.   Flat Wind & Hail                                                                 Included
     5.   Business Income                                                                                       72 hours
     6.   Flood (excluding zones A,V)
     7.   Earthquake (excluding zones 1,2)

Optional Higher Limits                                                                          Standard
(Please indicated if Higher limits are preferred)                                                Limits  Optional Limits
     1.   Accounts Receivable                                                                  $     100,000
     2.   Band Equipment and Uniforms                                                          $     250,000
     3.   Communications Equipment, Computers and Media                                        $     500,000
     4.   Extra Expense                                                                        $     250,000
     5.   Fine Arts                                                                            $      25,000
     6.   Miscellaneous Equipments                                                             $     100,000
     7.   Mobile, Portable or Contractors Equipment                                            $     100,000
     8.   Personal Property in Transit (from Transportation)                                   $     100,000
     9.   Valuable Papers and Records - Cost of Research                                       $     100,000

Underwriting Questions, Loss Control, Risk Management
     1. Is there any 100 year flood plain exposure within the boundaries of the entity?                              Yes     No
     2. Names of rivers, streams, lakes within 1 mile of any locations.

     3. Is there National Flood Insurance Program Coverage in place?                                                 Yes     No
             If yes, what is the limit?
     4. Has school ever been cited for violation of building codes?                                                  Yes     No
             If yes, explain.
     5. Are any school buildings now or scheduled to be vacant?                                                      Yes     No
             If yes, provide location(s).
     6. Is there any woodworking or spray painting done on premises?                                                 Yes     No
             If yes, explain.
     7. Are any of the buildings sprinklered?                                                                        Yes     No
             If yes, please provide a list of locations along with addresses.
                                              General Liability

General Liability
Coverages                                                                                           Limit
   1.   Each Occurrence Limit                                                                       $       1,000,000
   2.   Products - Completed Operations - Aggregate                                                 $       1,000,000
   3.   Personal & Advertising - Injury Limit                                                       $       1,000,000
   4.   Employee Benefits Liability                                                                 $       1,000,000
   5.   General Aggregate Limit (Other than products / completed ops)                               $       2,000,000
   6.   Damage to premises rented to you limit - any one premises                                   $          50,000
   7.   Medical Expense Limit - any one claim
   8.   GL Deductible                                                                               $                 -

Detail Questions
   1.   Number of Employees?
   2.   Average Daily Attendance
   3.   Full-Time Enrollment (Community College only)
   4.   Part-Time Enrollment (Community College only)
   5.   Number of Teachers?
   6.   Number of school nurses?
   7.   Number of grandstands?
   8.   Any grandstands with capacity over 5,000?
        a. If so how many?                                                                              Yes     No

Underwriting Questions, Loss Control, Risk Management
   1. Does the entity have legal counsel review all contracts prior to execution?                       Yes     No
   2. Are students allowed to use specialized machinery in unsupervised situation?                      Yes     No
          If yes, explain.
   3. Are all pieces of equipment and machinery equipped with appropriate safeguards?                   Yes     No
   4. Is there a drivers education course offered?                                                      Yes     No
   5. Does the applicant use, have or provide lessons for aircraft or watercraft?                       Yes     No
   6. List athletic programs sponsored by the school.
                        Football     Yes      No       Swimming           Yes     No  Baseball          Yes     No
                      Volleyball     Yes      No           Tennis         Yes     No    Track           Yes     No
                        Hockey       Yes      No       Basketball         Yes     No   Softball         Yes     No

   7. Are trampolines used?             Yes    No                                       How many?
   8. Is there a policy regarding visitor check in?                                                     Yes     No
       a. Sign in/out of main office?                                                                   Yes     No
       b. Are signs posted relating to this procedure?                                                  Yes     No
   9. Does the school have a "zero tolerance" plan in place regarding violent behavior?                 Yes     No
   10. Is applicant in compliance with the State and Federal asbestos standards?                        Yes     No
   11. Does the applicant have a swimming pool?                          Yes     No     How many?
       a. Does the applicant allow public use?                                                          Yes     No
       b. Are signs posted relating to this procedure?                                                  Yes     No
       c. Height of diving boards
       d. Number of lifeguards?                                                                         Yes     No
       e. Are the lifeguards certified?                                                                 Yes     No
   12. Does the school provide dormitories?                                                             Yes     No
            If so, how many?
   13. Is there a hazing policy in force?                                                               Yes     No
                                    Auto Schedule

                                                      Vehicle Type         B = Bus
                                                                           T = Truck / Van
                                                                           P = Private Passenger
District Name:           0                                                 TR = Trailer

 Vehicle Number   Year       Make      Vehicle Type           Vehicle ID         Cost New

Total                                                                                              0
                                          Auto Liability & Auto PD


Auto Liability Coverage                                                                   Limit
     1.   Auto Liability Limits                                                            $                          -
     2.   Auto Medical Payments Limits
     3.   Uninsured / Underinsured Limits
     4.   Garagekeepers Liability Limits
     5.   Garagekeepers Liability Deductible
     6.   Hired/non-owned auto requested ?                                                        Yes         No

     7. Auto Liability Deductible

Auto Physical Damage
          Collision Coverage Deductible
          Comprehensive Coverage Deductible

Additional Coverage Provided
          Hired Physical Damage Limit                                                      $                  50,000
          Hired Physical Damage Deductible                                                 $                   1,000

Underwriting Questions, Loss Control, Risk Management
     1. Are all owned or leased vehicles covered under this program?                                Yes       No
     2. Describe any location(s) with a concentration of stored vehicles whose total values exceed $500,000
                                            Location                                        Total Value (s)

     3. Do all bus drivers have a Commercial Drivers License (CDL)?                               Yes         No
     4. Does the school employ drivers under the age of 25?                                       Yes         No
     5. Is there a vehicle maintenance program in place?                                          Yes         No
     6. Are buses parked in a secure, well-lit area?                                              Yes         No
     7. Are buses used for student trips?                                                         Yes         No
             If yes, what is the radius of operation?
     8. Are buses used for non-student or livery activities?                                      Yes         No
              If yes, describe activities.
     9. Do you sponsor a Driver Education program?                                                Yes         No
             If so, are your vehicles equipped with dual controls?                                Yes         No
                                            Crime Coverage


Crime Coverage                                                 Limits   Deductible
     1.   Employee Dishonesty
     2.   Money & Securities Inside
     3.   Money & Securities Outside
     4.   Forgery or Alteration
     5.   Computer Fraud

Underwriting Questions, Loss Control, Risk Management
     1. Number of employees handling money?
     2. Are Countersignatures required?                                  Yes    No
     3. Have you ever had a loss due to employee dishonesty?             Yes    No
            If yes, please describe.
     4. Do you reconcile bank accounts?                                  Yes    No
            If no, explain.
     5. Are two signatures required on all checks?                       Yes    No
            If no, explain.
     6. Separate persons making deposits and withdrawals?                Yes    No
     7. Do you have an outside CPA conduct an audit?                     Yes    No
            How often?
                                        School Board Legal Liability

School Board Legal Liability
General Information
    1. Have you had on-site monitoring visits by State or Federal Regulatory Agencies?                  Yes     No
          If yes, provide name of agency and purpose of visit. Forward any written evaluations or
          reports of the agency findings.

    2. Has the district been criticized by the State Board of Education?                                Yes     No
           If yes, provide details.
    3. How many Board members are to be elected or appointed to office this year?
                                                   Single Member
           If elected, are they elected by:               Districts                         At large
    4. What is your enrollment?                                                       Currently        Last Year
       a. Average Daily Attendance
       b. Full time students:
       c. Part time students:
    5. What is the percentage of students for the following:
                     Special Education?                                         Disabled Students?
    6. Do you have your own Law Enforcement or Security Department?                                     Yes     No
       a. If not, do you contract with an outside agency for these services?                            Yes     No
       b. If so, with what entity?
    7. Are bus drivers...                             Employees?       Yes   No         Contracted?     Yes     No

Financial / Bond Information
    1.   Current Budget:                                 Revenue                       Expenditures
    2.   Total accumulated surplus/deficit
    3.   Explain any surplus or deficit
    4.   What is entity's current bond rating? (Moody's or Standard & Poor's)
    5.   Do you expect budget reductions?                                                               Yes     No

Insurance Information
    1. Does your current Educators Legal Liability coverage have a Retroactive Date?                    Yes     No
          If so, what is it?
    2. Does your current policy provide coverage for employment related practices?                      Yes     No
    3. Has your Educators Legal Liability coverage ever been denied, canceled or non-renewed?           Yes     No
          If so, please explain.

Institution Profile
    1. Are any new school campuses opening in the next 24 months?                                       Yes     No
    2. Any school closings or school mergers expected in the next 12 months?                            Yes     No
    3. Do you expect staff reductions?                                                                  Yes     No
            If yes, has your attorney reviewed the plans for staff reductions?                          Yes     No
    4. Are any campus closing expected in the next 24 months?                                           Yes     No
    5. Did any of following take place last year:
       a. Strike, slowdown or other disruptions?                                                        Yes     No
       b. Layoff or staff reductions?                                                                   Yes     No
       c. Has any employee been suspended, dismissed demoted, transferred or tenure contract            Yes     No
           Explain any "yes" answers.
                                       School Board Legal Liability

   6. Has any person alleged sexual molestations/abuse against any:
       a. student?                                                                                        Yes     No
       b. employee?                                                                                       Yes     No
       c. other?                                                                                          Yes     No
   7. How many EEOC or similar state hearings have taken place in the last 12 months?
   8. How many special education hearings have taken place in the last 12 months?
   9. Do you have policies and procedures for drug testing:
       a. students?                                                                                       Yes     No
       b. bus drivers?                                                                                    Yes     No
           other employees?
       c. other employees                                                                                 Yes     No
           If yes responses and policy has been updated since last year's application, attach a copy.
   10. Do you have a policy concerning:                                                                   Yes     No
       a. students use of lockers                                                                         Yes     No
       b. parking facilities                                                                              Yes     No
   11. Do you allow strip searches of students                                                            Yes     No
           If yes do you have a written policy?                 If yes attach a copy                      Yes     No
   12. When did you last update your policies and procedures?
   13. How many administrative hearings or appeals have taken place in the past 12 months
   14. What is your average class size?
   15. For which services does your entity contract with independent contractors?
                                     Food        Yes      No                  Accounting / Financial      Yes     No
                            Transportation       Yes      No                  Specialized Education       Yes     No
                      Custodial / Janitorial     Yes      No                 Clerical / Administrative    Yes     No
                    Medical / Health Care        Yes      No                Extracurricular activities    Yes     No

   16. Do you require all subcontractors to carry their own liability coverage?                           Yes     No
   17. Do you require all subcontractors to include you as an Additional Insured?                         Yes     No
   18. Do you conduct background investigations on all employees before employment?                       Yes     No

ATTACHMENT: Please provide a copy of your current student handbook.
ATTACHMENT: Please provide copy of your current employment manual including policies and procedures
pertaining to sexual harassment, discrimination, and employee grievances, and your current EEOC log.

Loss History
   1. Does any board member, employee or volunteer have any knowledge of any negligent act,               Yes     No
      error, omissions, or breach of duty which may reasonably be expected to give rise to a claim?

   2. Has any person, former employee or job applicant made a threat of claim alleging unfair or          Yes     No
      improper treatment regarding hiring, salary, advancement, demotion, suspensions or
   3. Have you received any employment-related inquiry, complaint or charge from any municipal,           Yes     No
       state or federal regularity authority or governmental entity?

ATTACHMENT: Please provide a currently valued copy of your Educational Institutions and Employment
Practices Liability Loss Runs for the past 5 years. NOTE: Your current and previous carriers are obligated and
required to forward currently valued loss runs at your request.
                                              Law Enforcement Liability

Law Enforcement Liability
NOTE: Complete this portion of the application only if you have an exposure for law enforcement related
activities and wish to secure Law Enforcement Liability Coverage for the district and your officers. Otherwise
skip to the next section.

General Information
     1. Do you currently carry law enforcement liability coverage?             If so please specify:      Yes    No
        a. Carrier
        b. Expiration date
        c. Limits
        d. Deductible
        e. Occurrence or Claims Made
        f. Retroactive Date if any
     2. When was your law enforcement agency established?
     3. Do you authorize off-duty employment?                                                             Yes    No
            If so, who authorizes?
            Is there any moonlighting in bars or taverns?                                                 Yes    No
     4. Do you want coverage for moonlighting?                                                            Yes    No
            If yes, please attach a list of all authorized employers
     5. Are you party to any Mutual Aid Agreements?                                                       Yes    No
            If yes, with whom?

Positions To Be Insured (This section must be completed)                                                  Number
Please complete the following by accounting for each employee only once in their primary classification
     1.   Chief (Department Head)
     2.   Other ranking officers (Captains, Lieutenants)
     3.   Full-time armed officers with arrest authority (non-ranking)
     4.   Armed Part-time, auxiliary, or reserve officers
              For your PT officers, what is the average number of hours per officer/per week?
     5.   Canines (provide certification of training for both dog and handler)
     6.   Unarmed part-time, auxiliary or reserve officers
     7.   What is the average number of hours per officer/per week?
     8.   School crossing guards

Hiring and Training
     1. What are the minimum educational requirements for applicants?
        a. High School                                                                                    Yes    No
        b. GED                                                                                            Yes    No
        c. 30 or more hours of college?                                                                   Yes    No
        d. 60 or more hours of college?                                                                   Yes    No
        e. Bachelor's Degree?                                                                             Yes    No
     2. Which of the following are included in your selection process prior to employment?
        a. Written Exam                                                                                   Yes    No
        b. Psychological Exam                                                                             Yes    No
        c. Professional Psychological Evaluation                                                          Yes    No
        d. Background & Employment Investigation                                                          Yes    No
     3. Do all law enforcement officers meet your state's minimum standards for training and              Yes    No
        receive certification prior to assignment to regular street duty?
                                       Law Enforcement Liability

  4. If answer to #3 is "No", please explain:
  5. Do you follow written policies regarding in-service training or continuing education for all    Yes      No
          If yes, how many hours per year?
  6. Is all employee training, both past and present, documented and kept on file?                   Yes      No
  7. Are officers required to complete training in the use of:
     a. Baton / PR 24 / ASP?                                                      Yes       No      Not Authorized
     b. Chemical Irritants?                                                       Yes       No      Not Authorized
     c. Stun gun / Taser?                                                         Yes       No      Not Authorized
     d. Carotid Control Hold?                                                     Yes       No      Not Authorized
  8. How often are officers re-certified for their firearms?
  9. Do all officers receive training in:
     a. First Aid?                                                                Yes       No      Not Authorized
     b. CPR?                                                                      Yes       No      Not Authorized
     c. Use of defibrillators?                                                    Yes       No      Not Authorized

Policies and Procedures
  1.   Do you maintain a formal Policies and Procedures Manual?                                      Yes      No
  2.   Do all employees maintain their own copy?                                                     Yes      No
  4.   When was your manual originally assembled?
  5.   When was your manual last updated?
  6.   Is your manual regularly reviewed by competent legal counsel?                                 Yes      No
  7.   By whom?
  8.   Do you have formal written policies and procedures pertaining to the following:              Date Updated
       a. Use of deadly force?                                                    Yes       No
       b. Use of non deadly force?                                                Yes       No
       c. Search and seizure?                                                     Yes       No
       d. Intoxicated arrestees?                                                  Yes       No
       e. Off-duty employment?                                                    Yes       No

Loss History
  1. Has any claim been made against the entity, or any person in their capacity as an official      Yes      No
     or employee of the entity, in the last 5 years? If yes, please attach a narrative summary
     with details and status
  2. Does any official or employee have any knowledge of any fact, circumstance or situation         Yes      No
     which might reasonably be expected to give rise to a claim? If yes, please attach a
     narrative summary with details.
                                          Excess Liability

Excess Liability Coverages

                                                                                           Total Underlying
                                                                       Excess Limit        and Excess Limit
  Underlying Coverages                         Underlying Limit         Requested             Combined
  1. General Liability                         $     1,000,000                             $      1,000,000
  2. Auto Liability                            $     1,000,000
  3. Educators Legal Liability                 $     1,000,000
  4. Law Enforcement Liability                 $     1,000,000

  Notes:   $1,000,000 Underlying limit is required for excess liability limits.
           Excess Liability does not cover over uninsured/underinsured motorist coverage

Shared By:
Description: Livery Drivers Contracts document sample