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ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION MAIN (Risk Placement Services, Inc.)

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1
8-FEB-16
All Lines Aggregate Public Entity Package Application - Main Application
C:\Users\msscarola\Downloads\ALAPublicEntity_RPS_01 Page 1 of 8
PRODUCER NAME: DATE APPLICATION COMPLETED:
AGENCY NAME: DATE QUOTE NEEDED TO AGENT:
AGENCY LOCATION: DATE COVERAGE TO INCEPT:
AGENCY WEB SITE: E MAIL ADDRESS:
1) NAMED INSURED: CONTACT NAME:
STREET ADDRESS:
CITY: STATE: ZIP CODE:
PHONE:
2) PROPOSED PLAN - Please enter limits and retentions desired. Insert "NA" if coverage is not desired.
A.
Coverage I (Property - Real & Pers, Auto PhysDam, Bus Inc & Ext Exp, Prop in Transit and Data Proc Media & Equip - MAXIMUM LIMIT $1,000,000 INCLUSIVE OF SIR
)
Per Loss Limit Proposed SIR: $25,000
Quake (Annual Aggregate) Sublimit NOTE: $25,000 minimum
Flood (Annual Aggregate) Sublimit
B.
Coverage II (General Liability and Law Enforcement Liability) - MAXIMUM LIMIT $1,000,000 INCLUSIVE OF SIR )
Proposed SIR: $50,000
Liability Per Occurrence Liability Policy Aggregate NOTE: $50,000 minimum
Law Enforcement Liability Products / Completed Operations
Premises Medical Payments
C.
Coverage III (Automobile Liability - MAXIMUM LIMIT $1,000,000 INCLUSIVE OF SIR
)
Proposed SIR: $50,000
Liability Per Accident No-Fault Coverage/PIP NOTE: $50,000 minimum
Un/Underinsured Motorists
Auto Medical Payments
D.
Coverage IV (CLAIMS MADE Public Officials Errors & Omissions Liability - MAXIMUM LIMIT $1,000,000 INCLUSIVE OF SIR
Proposed SIR: $50,000
Liability Per Claim Liability Policy Aggregate NOTE: $50,000 minimum
Sexual Harassment Per Claim Sexual Harassment Policy Aggregate
E.
Coverage V (Workers' Compensation - MAXIMUM LIMIT $250,000 EXCESS OF SIR)
Proposed SIR: $100,000
Workers Compensation
NOTE: $100,000 minimum
Employer's Liability
F.
Coverage VI (Crime - MAXIMUM LIMIT $500,000 INCLUSIVE OF SIR )
Proposed SIR: $25,000
Employee Dishonesty Money Orders & Counterfeit Currency NOTE: $25,000 minimum
Money & Securities (Inside Premises) Depositors Forgery
Money & Securities (Outside Premises)
G. Any other coverage required (please attach additional information as necessary):
Requested Limit Proposed Underlying Limit
Excess Workers' Comp
Excess Property
Excess Liability
ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
MAIN APPLICATION
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All Lines Aggregate Public Entity Package Application - Main Application
C:\Users\msscarola\Downloads\ALAPublicEntity_RPS_01 Page 2 of 8
A. Property (incl APD)
B. General Liability
C. Law Enforcement Liability
D. Automobile Liability
E. Pub Off E&O Liability
F. Workers' Comp
G. Crime
H.
I.
J.
Expiring Loss Fund (if applicable) Total Premiums: $0
CURRENT THIRD PARTY ADMINISTRATOR:
TPA CONTACT NAME: TPA CONTACT PHONE NUMBER:
4)
PROPERTY INFORMATION
PROTECTION CLASS
NOTE: YOU MUST FORWARD A COMPLETE PROPERTY SCHEDULE WITH THIS APPLICATION!
APPRAISAL DATE
A.
Values - IMPORTANT THAT 100% REPLACEMENT COST VALUES BE SHOWN
$ VALUES % OF TOTAL
Total Building Values NA
Total Contents Values NA
Total Auto Physical Damage Values (all licensed vehicles) NA
Total Equipment Values NA
Total EDP Equipment Values NA
Total EDP Media Values NA
Total EDP Extra Expense Values NA
Total Accounts Receivable Values NA
Total Valuable Papers Values NA
Total Business Interruption Values NA
Total Extra Expense Values NA
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 (prefix 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
3) CURRENT PROGRAM INFORMATION
COVERAGE TYPE CARRIER NAME LIMITS RETENTION RETRO DATE PREMIUM
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Total # of Locations: 0 NA
D.
Protection Details - THIS SECTION MUST BE COMPLETED IN ORDER TO SECURE A QUOTATION!
CLASSIFICATION # OF LOCATIONS % OF TOTAL
Sprinklered NA
Burglar Alarm - Local Sound NA
Central Station Alarms (both Burglar & Fire) NA
Security Guards NA
Smoke Detectors NA
All Other Types of Protection (describe) NA
Total # of Locations: 0 NA
5) GENERAL LIABILITY
NOTE: YOU MUST FORWARD COMPLETE FINANCIAL INFORMATION WITH THIS APPLICATION
!
A.
Entity Information: Does the public entity own or operate any of the following? (Please Answer Yes / No ):
Airports (ALA policy excludes) Hospitals
Amusement Park, Carnival, Circus Housing Authority, Projects
Athletic Participants Independent Contractors
Beaches, Lakes Jail or Detention Facilities
County Homes Landfills
Blasting Operations Law Enforcement Activities
Bleachers, Arenas, Stadiums Marinas
Cemeteries Nursing Homes
Dams, Reservoirs Racing / Rodeo Exhibitions
Day Care Centers or Day Camps Recreational Facilities (Parks, Camps, etc.)
Electric Utility Schools and Colleges
EMT's, Paramedics, Nurses Sewer Utility
Fairs, Festivals Ski Facility
Fire Department Streets, Roads, Highways, Bridges
Fireworks Displays Transportation System (Buses, Rail Service or Subways)
Garbage Collection Water Utility
Gas Utility Watercraft
Golf Course Wharves, Piers, Docks
Health Department Zoo
Any additional exposures not mentioned in the checklist above:
Any exposures checked yes above that insured elsewhere or subcontracted out to others:
B. General Information
Population
Employee Count
Total Payroll
D. Independent Contractor Operations Questionnaire
1. Does the Entity ever make use independent contractors? If yes, please describe the contractor types used & purposes:
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Certificate of Insurance?
Limits at least equal to those carried by the Entity (if general contractor)?
Is the Entity named as an Additional Insured on the contractor's policy?
Are there Hold Harmless Agreements used in all of the Entity's contracts?
3. Do you hold any special events in which you do not transfer liability to the contractor performing the special event?
6) AUTOMOBILE LIABILITY
A. CATEGORY # THIS TYPE % THIS TYPE
Private Passenger Cars (up to 10,000 lbs GVW) - Non Emergency NA
Private Passenger Cars (up to 10,000 lbs GVW) - Emergency (e.g. Fire, Police) NA
15-Passenger Vans NA
Other Vans, Pickup Trucks, other Light Trucks (up to 10,000 lbs GVW) NA
Medium Weight Trucks (10,000 to 20,000 lbs GVW) NA
Heavy Trucks (20,000 to 50,000 lbs GVW) NA
Extra-Heavy Trucks (greater than 50,000 lbs GVW) NA
Fire Trucks NA
Ambulances NA
Motorcycles NA
Buses NA
Miscellaneous Autos NA
Mobile Equipment NA
Trailers, All Types NA
Total Automobiles: 0 NA
B. Underwriting Criteria
1. Describe operations of any passenger vans or buses (including radius, frequency, receipts, etc.):
2. Describe any vehicles modified to handle handicapped or wheelchair passengers:
7) PUBLIC OFFICIALS' ERRORS AND OMISSIONS LIABILITY - this coverage is provided on a CLAIMS-MADE basis
SURPLUS or
A. Budget (last three years) BOND RATING YEAR REVENUES EXPENDITURES DEFICIT (+/-)
1. Current Fiscal Year 0
2. Prior Fiscal Year 0
3. Fiscal Year Two Years Prior 0
ACCUMULATED SURPLUS
4.
The following rating information is to be taken from the applicant's most recent fiscal year budget.
Please complete all items, then attach a scanned copy,or mail a photocopy, of the most current budget when you return this application.
5. Please explain any deficit postions.
BUDGETED EXPENDITURES EXPENDITURES FOR SEPARATELY RATED EXPOSURES
General Fund Airports
Special Revenue Fund EMT's Paramedics
Other Special Funds or Accounts Golf Courses
Total Budgeted Operating Expenditures 0 Hospitals / Clinics
2. Does the Entity require the following:
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All Lines Aggregate Public Entity Package Application - Main Application
C:\Users\msscarola\Downloads\ALAPublicEntity_RPS_01 Page 5 of 8
Housing Projects
Less: Items to be paid out in current year Lakes / Dams / Reservoirs
Capital Improvements Nursing Home
Debt Service Funds Penal Institutions
Other Indebtedness Police
Independent Contractors Schools
Insurance Costs Utility - Electric
OPERATING EXPENDITURES 0 Utility - Gas
Utility - Water / Sewer
Wharves / Piers / Docks / Marinas
Operating Expenditures
0 Zoos / Ski Facilities
TOTAL EXPENDITURES 0
Less Separately Rated Exposure Expenditures 0
Net Operating Expenditures (Rating Base) 0
6. Type Employees ACCOUNTANTS ARCHITECTS ATTORNEYS ENGINEERS ALL OTHER TOTAL
Full Time: 0
Part Time: 0
Total Employees: 0 0 0 0 0 0
7. Indicate elected (E) or appointed (A) officials:
Mayor President / Chair of County Commission
City Manager or Administrator County Commissioner / Supervisor
City / County Clerk Personnel Director
City Council Members
8. Have any of the following occurred within the past three years?
a. Have you had a strike, slowdown, or other employee disruption?
b. Has there been a layoff of employees or reductions in service?
c. Have there been any disputes or suits involving voting or voting rights violations?
d. Has any person, former employee, or job applicant made claim alleging unfair or improper treatment
regarding employee hiring, remuneration, advancement, or termination of employment?
9. Does your entity administer or act in a fiduciary capacity for any employment benefit or any self-insurance fund?
10.
Does the Insured have a zoning commission?
11. Does your entity follow a formal, written procedure for employee disputes / complaints?
12. Does the Insured administer a centralized emergency dispatch system for other entities?
If yes, please submit a copy of the current contract.
8) COMMENTS - PLEASE USE THIS AREA TO ELABORATE ON ANY INFORMATION PROVIDED ELSEWHERE IN THIS APPLICATION
9) FRAUD WARNING REQUIREMENTS
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STATE
AL
DE
DC
FL
GA
HI
ID
AK
AZ
AR
CA
CO
CT
ME
MD
MA
MI
MN
MS
IL
IN
IA
KS
KY
LA
MO
MT
STATUTORY REFERENCE
NONE
NONE
NONE
IC § 23-66-503
NONE
IC § 10-1-127
NONE
NONE
NONE
NONE
NONE
IC § 304.47-030
IC R.S. § 40:1424
NONE
IC § 22-3255.09
IC § 817.234;Inf Bulletin 96-1
NONE
IC § 431:10C-307.7
NONE
NONE
NONE
IC 24-A § 2186
NONE
NONE
NONE
NONE
NONE
POLICY APPLICATION WARNING STATEMENT
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.
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.
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.
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.
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.
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.
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.
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.
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NC
ND
OH
OK
NE
NV
NH
NJ
TX
OR
PA
RI
SC
SD
TN
NM
NY
NONE
NONE
NONE
NJAC § 11:16-1.2;N.J.S.A. 17:33A-6
NONE
Bulletin 98-5
75 Pa. C.S.A. § 1822
IC § 59A-16C-8
11 NYCRR 86.4
NONE
NONE
NONE
NONE
NONE
IC § 56-47-112;IC § 56-53-111
IC § 3999.21
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.
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.
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.
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.
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.
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.
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.
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.
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COVERAGE NOTICE
If this account meets our underwriting standards, liability coverage will be quoted as follows:
* Automobile Liability, General Liability and Law Enforcement Liability will be quoted on an OCCURRENCE basis.
* Public Officials' Errors and Omissions Liability will be quoted on a CLAIMS-MADE basis.
The information provided in this application and all schedules are true and correct to the best of my knowledge.
Signed: Signed:
Date: Date:
Named Insured: Agent/Broker Name:
WI
WY
UT
VT
VA
WA
WV
NONE
IC § 34-2-110 -
Workers' Compensation ONLY
NONE
RL § 52-40
NONE
NONE
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.
The following statement must be prominently displayed or printed on all applications for Workers' Compensation
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.
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.
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ALL LINES AGGREGATE PUBLIC ENTITY PACKAGE APPLICATION MAIN (Risk Placement Services, Inc.)

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Completed 30 July 2020

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