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Residential Lease to Own Agreements Georgia

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Residential Lease to Own Agreements Georgia Powered By Docstoc
					          ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!




PRODUCER NAME:                                                                                                DATE APPLICATION COMPLETED:
AGENCY NAME:                                                                                                  DATE QUOTE NEEDED TO AGENT:
AGENCY LOCATION:                                                                                              DATE COVERAGE TO INCEPT:
AGENCY WEB SITE:                                                                                              E MAIL ADDRESS:



1) NAMED INSURED:                                                                                             CONTACT NAME:
   STREET ADDRESS:                                                                                            PUBLIC or PRIVATE SCHOOL?
   CITY:                                                                                          STATE:                                    ZIP CODE:



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


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

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

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

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

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

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




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


3) CURRENT PROGRAM INFORMATION
      COVERAGE TYPE        CARRIER NAME                                                            LIMITS              RETENTION          RETRO DATE                   PREMIUM
   A. Property (incl APD)
   B. General Liability
   C. Automobile Liability
   D. School Board Legal
   E. Workers' Comp
   F. Crime
   G.
   H.
   I.
                                                                       Expiring Loss Fund (if applicable)                                                                      $0



4) PROPERTY INFORMATION                                                                                                               PROTECTION CLASS
     NOTE: YOU MUST FORWARD A COMPLETE PROPERTY SCHEDULE WITH THIS APPLICATION !                                                        APPRAISAL DATE

  A. Values - IMPORTANT THAT 100% REPLACEMENT COST VALUES BE SHOWN                                                                             $ VALUES             % OF TOTAL
     Total Building Values                                                                                                                                                 NA
     Total Contents Values                                                                                                                                                 NA
     Total Auto Physical Damage Values (all licensed vehicles)                                                                                                             NA
     Total Equipment Values                                                                                                                                                NA
     Total EDP Equipment Values                                                                                                                                            NA
     Total EDP Media Values                                                                                                                                                NA
     Total EDP Extra Expense Values                                                                                                                                        NA
     Total Accounts Receivable Values                                                                                                                                      NA
     Total Valuable Papers Values                                                                                                                                          NA
     Total Business Interruption Values                                                                                                                                    NA
     Total Extra Expense Values                                                                                                                                            NA
     Total Rental Income Values                                                                                                                                            NA
     Total Transit Values                                                                                                                                                  NA
     Total Course of Construction Values                                                                                                                                   NA
     Total All Other Miscellaneous Values                                                                                                                                  NA
                                                                                                             Total Property Values:                     $0                 NA

  B. If flood coverage is requested, provide details of the flood exposure. List property values (Real & Personal) within Federally-defined flood plains (A & V):
     LOCATION ADDRESS & DESCRIPTION                                                                                            $ VALUES @ LOCATION                  % OF TOTAL
                                                                                                                                                                            NA
                                                                                                                                                                            NA
                                                                                                                                                                            NA

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




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


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



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


  A. GL Rating Information
                                                                                                                AVERAGE DAILY           ABSENTEEISM                    TRUANCY
      CATEGORY                                                                           ENROLLMENT               ATTENDANCE                   RATE                       RATE
      Pupils
         Elementary & Junior High Students                                                                                                           NA
         Senior High Students                                                                                                                        NA
                                                           Totals by Category:                           0                     0                     NA                         NA

      Employees                                                                                                                        TOTAL NUMBER                  % OF TOTAL
        Teachers                                                                                                                                                            NA
        Coaches                                                                                                                                                             NA
        Nurses                                                                                                                                                              NA
        Nurse Practitioners                                                                                                                                                 NA
        Physicians                                                                                                                                                          NA
        Other (describe)                                                                                                                                                    NA
                                                                                                                 Total Employees:                        0                  NA

      Stadiums / Exhibition Centers                       USAGE                                                CONSTRUCTION         SEATING CAPACITY                   RECEIPTS
      1.
      2.
      3.
      4.
      5.

      Swimming Pools                                       OPEN TO PUBLIC?              # LIFEGUARDS                POOL DEPTH       # DIVING BOARDS             BOARD HEIGHT
      1.
      2.
      3.
      4.
      5.
         Please describe required lifeguard training & certification:

  B. Lead Exposure Questionnaire
     1. Does School have any procedures for testing lead exposure levels in paint, dust, drinking water and soil at any buildings built prior to 1980?
        Explain.

      2. Have there been any adverse results arising out of the testing procedures described in B.1. above?                                                  Please explain.




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


     3. Describe follow-up / abatement procedures.




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



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

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

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




                                                          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                                                                                                                                                      0
         Restaurants                                                                                                                                                     0
         Stores                                                                                                                                                          0
                                                                      Totals:                              0                       0                      0              0

   G. Other Questions
      1. Do you operate a day care facility?                                            Daily Attendance?                                      # Care Staff?
      2. Please attach additional information regarding extracurricular activities (e.g. newspapers, yearbooks, radio stations, etc.)



6) AUTOMOBILE LIABILITY

   A. CATEGORY                                                                                                                                # THIS TYPE      % THIS TYPE
         Private Passenger Cars (up to 10,000 lbs GVW) - Non Emergency                                                                                                  NA
         15-Passenger Vans                                                                                                                                              NA
         Other Vans, Pickup Trucks, other Light Trucks (up to 10,000 lbs GVW)                                                                                           NA
         Medium Weight Trucks (10,000 to 20,000 lbs GVW)                                                                                                                NA
         Heavy Trucks (20,000 to 50,000 lbs GVW)                                                                                                                        NA
         Extra-Heavy Trucks (greater than 50,000 lbs GVW)                                                                                                               NA
         Motorcycles                                                                                                                                                    NA
         Buses                                                                                                                                                          NA
         Miscellaneous Autos                                                                                                                                            NA
         Mobile Equipment                                                                                                                                               NA
         Trailers, All Types                                                                                                                                            NA
                                                                                                                  Total Automobiles:                      0             NA

   B. Underwriting Criteria for Buses ONLY (if applicable)
      1. Is the bus service contracted?                                                                    Name of Company used:
                                                 Company's Insurance Carrier:                                                                Limits Carried:
                                                  Insurance Certificate on File?                                     Is School named an Additional Insured?

      2. Describe operations of any passenger vans or buses (including radius, frequency, receipts, etc.):



      3. Describe operations of any trucking exposures (including radius, frequency, receipts, etc.):



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



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



      6. Please attach a copy of the policy on personal use of owned or leased vehicles.



7) SCHOOL BOARD LEGAL LIABILITY - this coverage is provided on a CLAIMS-MADE basis
                                                                                                                                                               SURPLUS or
   A. Budget (last three years)                             BOND RATING                              YEAR               REVENUES          EXPENDITURES         DEFICIT (+/-)
      1. Current Fiscal Year                                                                                                                                               0
      2. Prior Fiscal Year                                                                                                                                                 0
      3. Fiscal Year Two Years Prior                                                                                                                                       0
                                                                                                                                ACCUMULATED SURPLUS




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


  B. Exposure Information
     1. Type Employees             ACCOUNTANTS                 ARCHITECTS                 ATTORNEYS              ENGINEERS           ALL OTHER                      TOTAL
                   Full Time:                                                                                                                                           0
                  Part Time:                                                                                                                                            0
           Total Employees:                         0                         0                     0                     0                      0                      0
     2. Have any of the following occurred within the past three years?
        a. Have you had a strike, slowdown, or other employee disruption?
        b. Has there been a layoff of employees or reductions in service?
        c. Have there been any disputes or suits involving voting or voting rights violations?
        d. Has any person, former employee, or job applicant made claim alleging unfair or improper treatment
             regarding employee hiring, remuneration, advancement, or termination of employment?
     3. Does your School administer or act in a fiduciary capacity for any employment benefit or any self-insurance fund?
     4. Does your School follow a formal, written procedure for employee disputes / complaints?



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




9) FRAUD WARNING REQUIREMENTS

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

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




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


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

  LA                IC R.S. § 40:1424            The following statement must either be permanently affixed to or included as part of all applications: Any person who
                                                 knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
                                                 information in an application for insurance is guilty of a crime and may be subject to fines and confinement in
                                                 prison.

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

 NY                  11 NYCRR 86.4               The following statement must be included on all insurance applications for commercial insurance and accident and
                                                 health insurance except automobile insurance:
                                                 Any person who knowingly and with intent to defraud any insurance company or other person files an
                                                 application for insurance or statement of claim containing any materially false information, or conceals for the
                                                 purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act,
                                                 which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated
                                                 value of the claim for each such violation.
                                                 The following statement must be included on all insurance applications for automobile insurance:
                                                 Any person who knowingly and with intent to defraud any insurance company or other person files an
                                                 application for commercial insurance or a statement of claim for any commercial or personal insurance benefits
                                                 containing any materially false information, or conceals for the purpose of misleading, information concerning
                                                 any fact material thereto, and any person who, in connection with such application or claim, knowingly makes or
                                                 knowingly assists, abets, solicits, or conspires with another to make a false report of the theft, destruction,
                                                 damage, or conversion of any motor vehicle to a law enforcement agency, the department of motor vehicles,
                                                 or an insurance company, commits a fraudulent insurance act, which is a crime, and shall also be subject
                                                 to a civil penalty not to exceed five thousand dollars and the value of the subject motor vehicle or stated claim
                                                 for each violation.



 NC                       NONE
 ND                       NONE




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


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

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

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

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


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

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



       Signed:                                                                                               Signed:

                                  Date:                                                                                            Date:



       Named Insured:                                                                                        Agent/Broker Name:




                                                         All Lines Aggregate School Package Application - Main Application
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         UNINSURED / UNDERINSURED MOTORISTS SELECTION FORM


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

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

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

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

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



                                           All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
   10-MAR-07                                               D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                         Page 9 of 23
        Ohio                              I want to select limits of   $ 12,500    / $ 25,000
        Oklahoma                          I want to select limits of   $ 50,000
        Oregon                            I want to select limits of   $ 60,000
        Pennsylvania                      I want to select limits of   $ 35,000
        Rhode Island                      I want to select limits of   $ 75,000
        South Carolina                    I want to select limits of   $ 40,000
        South Dakota                      I want to select limits of   $ 25,000    / $ 50,000
        Tennessee                         I want to select limits of   $ 60,000
        Texas                             I want to select limits of   $ 55,000
        Utah                              I want to select limits of   $ 25,000     / $500,000 for Schools & Governmental Entities
        Vermont                           I want to select limits of   $ 100,000   VLVT01 (05-04) will need to be singed upon binding
        Virginia                          I want to select limits of   $ 70,000
        Washington                        I want to select limits of   $ 60,000
        West Virginia                     I want to select limits of   $ 50,000
        Wisconsin                         I want to select limits of   $ 100,000
        Wyoming                           I want to select limits of   $ 50,000

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




                         Signature                                                             Date




                         All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
10-MAR-07                                D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                Page 10 of 23
sts coverage will apply only if your own underinsured motorist limit is higher than the bodily injury




                                                             All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
                   10-MAR-07                                                 D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                      Page 11 of 23
            All Lines Aggregate School Package Application - Uninsured / Underinsured Motorists Selection Form
10-MAR-07                   D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                      Page 12 of 23
                            ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                             ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                       WORKERS' COMPENSATION APPLICATION


            1) NAMED INSURED:                 0                                                                           CONTACT NAME:               0
               ADDRESS:                       0
               CITY:                          0                                                               STATE:      0                                     ZIP CODE:      00000



            2) GROSS PAYROLL DISTRIBUTION BY CLASSIFICATION CODE
                                                                        prosective policy           current year              1st prior year              2nd prior year          3rd prior year
                            WC CODE           CLASSIFICATION              ESTIMATED                 ESTIMATED                  AUDITED                      AUDITED                 AUDITED




                                                    TOTALS                                  0                        0                            0                        0                         0
                                  EXPERIENCE MODIFICATIONS

            3) CONCENTRATION OF RISK                                                                                                                                            prospective policy
                    LOC ADDR                  CONSTRUCTION           OCCUPANCY                       ZIP CODE              # EMPL ALL SHIFT # EMPL IN MAX SHIFT                  EST PAYROLL




                       TOTAL # OF EMPLOYEES (from Main App)                                 0                TOTALS                               0                        0                         0

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




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




                                                             All Lines Aggregate School Package Application - Workers' Compensation Application
10-MAR-07                                                            D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                                                     Page 13 of 23
          ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                              ALL QUESTIONS MUST BE ANSWERED

              RISK MANAGEMENT PRACTICES QUESTIONNAIRE



NAMED INSURED: 0                                                                             Contact Name              0
Address         0
City            0                                                    State                          0                            Zip Code     0




                Risk Management
                Does the Insured have a Full Time Risk Management Program in place?
          -      If "yes", how long has the Risk Management Program been in place?
          -      If "yes", how long has the Risk Manager been in place?
                Does the entity have a loss control safety and procedures manual?
                If "yes", is it distributed to all employees?
                Does the entity have an employee procedures manual?
                 If "yes", is it distributed to all employees?
                Are formal safety meetings conducted?
                If "yes", how often are they held?
                How are losses reported?
          -     How long has the account been Self Insured?


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


                Stability of Entity
                Is the entity in a growth mode, or has population been steady over the years?
                Does the entity have a master plan for their growth?
                What is the entity's zoning process?


                Additional Comments




                                      All Lines Aggregate School Package Application - Risk Management Practices Questionnaire
 10-MAR-07                                       D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                            Page 14 of 23
                   ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                   ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                                  EXPOSURE HISTORY COMPARISON


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


  9th year prior
  8th year prior
  7th year prior
  6th year prior
  5th year prior
  4th year prior
  3rd year prior
  2nd year prior
  1st year prior
     current
   prospective




                                          All Lines Aggregate Public Entity Package Application - Exposure History Comparison
10-MAR-07                                         D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                 Page 15 of 23
                            ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                                                             ALL QUESTIONS MUST BE ANSWERED

                           CAMPUS SECURITY SUPPLEMENTAL QUESTIONNAIRE - SCHOOLS


                                                                                                                                                               YES / NO
 1.   Do you use metal detectors on any School Grounds?
 2.   Are City or County Police contacted when a situation occurs on any School Grounds?
 3.   Do you have armed Police or Security Officers on any school grounds?
 4.   Do you use Police-trained dogs on School Grounds for bomb or drug searches that are conducted by your Police or Security Officers?
 5.   Do officers have arrest authority?
 6.   Do you have a policy and procedures manual for the Police or Security Officers?
 7.   If you have a policy and procedures manual, when was it last updated?
 8.   Are your Police and Security Officers Employees or Independent Contractors?
 9.   Please give the number of Full-Time Officers.
10.   Please give the number of Part-Time Officers.
11.   Please describe personnel screening measures prior to hiring.



12. Please describe training requirements prior to hiring.



13. Please describe continuing education requirements for Employees.



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




                                                             All Lines Aggregate School Package Application - Campus Security Supplemental Questionnaire
       10-MAR-07                                                          D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                  Page 16 of 23
          ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
               ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

             SEXUAL ABUSE & MOLESTATION COVERAGE APPLICATION


1) NAMED INSURED:                  0                                                                          CONTACT NAME:            0
   ADDRESS:                        0
   CITY:                           0                                                               STATE: 0                                    ZIP CODE: 00000



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

                                   Limit Per Occurrence                                                       Policy Aggregate              Proposed SIR:



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




4) UNDERWRITING & RISK MANAGEMENT - SEXUAL ABUSE INFORMATION
   A. Any clients with:                     Handicaps?                                     Emotional?                                     Physical?
                                    Special Education?
   B. Do all employees complete an employment application?
   C. Does pre-employment background checks include the following:
                                 Personal References?                                  Police Record?                         Education Verification?
   D. Are records kept documenting this investigation as part of each employee's personnel file?
   E. Is an application obtained on volunteers?                                   Does background check include obtaining police records?
   F. Are child abuse and neglect laws reviewed with new employees and volunteers?
   G. Does the facility have written policies that include physical or sexual abuse?
        Are these policies reviewed with employees and volunteers?
   H. Are clients in your care overnight?
   I. Are procedures in place that more than one employee or volunteer is present at all times when a client is in your care?
   J. Are services to clients subcontracted to others?
   K. Are your clients instructed to report possible instances of sexual misconduct or abuse?
   L. Are known or suspected molestation or abuse incidents reported by your organization to proper police authorities?
        Are employees and volunteers advised of this procedure?



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




                                           All Lines Aggregate School Package Application - Sexual Abuse Molestation Coverage Application
 10-MAR-07                                               D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                           Page 17 of 23
           ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                 ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

              SEXUAL ABUSE & MOLESTATION COVERAGE APPLICATION


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




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




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




                                  NAMED INSURED AUTHORIZED SIGNATURE                                                                TITLE




                                                                                                          DATE




                                            All Lines Aggregate School Package Application - Sexual Abuse Molestation Coverage Application
 10-MAR-07                                                D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                           Page 18 of 23
                   ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                        ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                               SEXUAL HARASSMENT COVERAGE APPLICATION


      1) NAMED INSURED:                    0                                                                           CONTACT NAME:              0
         ADDRESS:                          0
         CITY:                             0                                                                STATE: 0                                    ZIP CODE: 00000



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

                                           Limit Per Occurrence                                                        Policy Aggregate               Proposed SIR:



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




      4) EMPLOYEE INFORMATION
         A. Number of FULL-time employees                                                                                                                          0
         B. Number of PART-time employees                                                                                                                          0
         C. For each of the past five years, what has been your annual percentage turnover rate of employees?
                                                  5th year prior        4th year prior          3rd year prior                  2nd year prior         1st year prior


            D. Percentage of employees with salaries less than $100,000
               Percentage of employees with salaries between $100,000 & $360,000
               Percentage of employees with salaries greater than $360,000



      5) CLAIMS HANDLING INFORMATION
         A. 1. Who in the Applicant Organization has been designated to handle claims?


                  NAME                                              ADDRESS                                          CITY, STATE, ZIP                                   PHONE
               2. With respect to claims incidents, etc., do you have a written procedure for obtaining information? (if YES, please attach a copy)



      6) UNDERWRITING & RISK MANAGEMENT - SEXUAL HARASSMENT INFORMATION
         A. Does the Applicant have a Human Resources or Personnel Department? (if NO, please describe handling of this function)




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




                                                        All Lines Aggregate School Package Application - Sexual Harassment Coverage Application
10-MAR-07                                                          D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                              Page 19 of 23
                   ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
                         ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!

                               SEXUAL HARASSMENT COVERAGE APPLICATION

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




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




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




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




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




                                          NAMED INSURED AUTHORIZED SIGNATURE                                                                 TITLE




                                                                                                                   DATE




                                                        All Lines Aggregate School Package Application - Sexual Harassment Coverage Application
10-MAR-07                                                          D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                                         Page 20 of 23
                           ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
                                                           ALL QUESTIONS MUST BE ANSWERED

                                               TERRORISM ACTIVITIES QUESTIONNAIRE


    Please list every location where that location's Total Insured Values (inclusive of ALL coverages, e.g. Business Interruption, Extra Expense, etc.) is GREATER THAN $50 Million
          LOCATION ADDRESS & DESCRIPTION                                                                                                                                 $ TIV        % OF TOTAL
     1.
     2.
     3.



                                                                                                                                                                                      YES / NO
     1. Does the Insured own or operate any Airports and/or Airline Companies (including Flight Schools and/or Crop Dusting)?
     2. Does the Insured have any Bridges greater than 300 feet in length?
     3. Does the Insured own, lease or operate any Convention / Exhibition Centers / Theatres / Concert Halls with seating >10,000?
     4. Does the Insured own, lease or operate any Dams greater than 300 feet in length, with a downstream population >25,000?
     5. Does the Insured provide Emergency Services (e.g. Police, Fire, EMTs) in cities where the population is greater than 250,000?
     6. Does the insured own or lease space in any Federal and/or State Government Buildings, and/or National Landmarks?
     7. Does the Insured own or operate any Hospitals with a bed count greater than 300 in cities where the population is greater than 250,000?
     8. Does the Insured own or manage space in any Office Buildings greater than 25 stories in height?
     9. Does the Insured own, lease or operate/manage any Residential Buildings greater than 25 stories in height?
    10. Does the Insured operate or have any Port / Transit Authorities?
    11. Does the Insured operate or have any Railroads? (not including sidetrack agreements)
    12. Does the Insured operate a Public School District within cities where the population is greater than 250,000?
    13.   Does the Insured own, lease or operate any Stadiums/Sports arenas with seating capacities greater than 10,000?
    14.   Does the Insured have any Tunnels greater than 300 feet in length?
    15.   Does the Insured operate any Universities?
    16.   Does the Insured own, lease or operate any Utilities (e.g. electric, gas, water & sewer) with greater than 250,000 customers?
    17. Does the insured own or lease any gas or oil pipelines?
    18. Is your entity's population greater than 250,000?
          If you answered yes on #18 - Do you provide emergency services (ie. Police, firefighters, EMTs)?
    19. Do you employ any Architects or Engineers?
    20. Do you have a Seaport or Maritime operation, or do you operate any Commuter Ferries?



    Please mark Yes even if the exposure is insured elsewhere.

          FOR ANY QUESTION ANSWERED "YES", YOU ARE REQUIRED TO PROVIDE ADDITIONAL DETAILS & INFORMATION ABOUT YOUR ANSWER




                                                                All Lines Aggregate School Package Application - Terrorism Activities Questionnaire
10-MAR-07                                                               D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                                     Page 21 of 23
                           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
10-MAR-07                                                              D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                              Page 22 of 23
                                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
10-MAR-07                                                         D:\Docstoc\Working\pdf\5919a43f-a1a8-4eb1-a405-7e6a64122d34.xls                                              Page 23 of 23

				
DOCUMENT INFO
Description: Residential Lease to Own Agreements Georgia document sample