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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION (Risk Placement Services, Inc.)

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18-FEB-16
All Lines Aggregate School Package Application - Main Application
C:\Users\msscarola\Downloads\ALASchool_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: 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
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
Excess Property
Excess Liability
Excess Workers' Comp
ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL
QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
18-FEB-16
All Lines Aggregate School Package Application - Main Application
C:\Users\msscarola\Downloads\ALASchool_RPS_01 Page 2 of 8
ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
E. Workers' Comp
F. Crime
G.
H.
I.
Expiring Loss Fund (if applicable)
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
Total Contents Values
Total Auto Physical Damage Values (all licensed vehicles)
Total Equipment Values
Total EDP Equipment Values
Total EDP Media Values
Total EDP Extra Expense Values
Total Accounts Receivable Values
Total Valuable Papers Values
Total Business Interruption Values
Total Extra Expense Values
Total Rental Income Values
Total Transit Values
Total Course of Construction Values
Total All Other Miscellaneous Values
Total Property Values:
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
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
[2] Brick
[3] Non-Combustible
[4] Masonry Non-Combustible
[5] Semi-Fire Resistive
[6] Fire Resistive
Any Other Classifications (describe)
Total # of Locations:
D.
Protection Details - THIS SECTION MUST BE COMPLETED IN ORDER TO SECURE A QUOTATION!
CLASSIFICATION # OF LOCATIONS % OF TOTAL
Sprinklered
Burglar Alarm - Local Sound
Central Station Alarms (both Burglar & Fire)
Security Guards
Smoke Detectors
All Other Types of Protection (describe)
18-FEB-16
All Lines Aggregate School Package Application - Main Application
C:\Users\msscarola\Downloads\ALASchool_RPS_01 Page 3 of 8
ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
Total # of Locations:
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
Senior High Students
Totals by Category:
Employees TOTAL NUMBER % OF TOTAL
Teachers
Coaches
Nurses
Nurse Practitioners
Physicians
Other (describe)
Total Employees:
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.
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:
18-FEB-16
All Lines Aggregate School Package Application - Main Application
C:\Users\msscarola\Downloads\ALASchool_RPS_01 Page 4 of 8
ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
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
Basketball
Boxing
Cheerleading
Diving
Field Hockey
Football
Golf
Gymnastics
Ice Hockey
Rugby
Soccer
Softball
Swimming
Tennis
Track & Field
Volleyball
Weight Lifting
Wrestling
All Other Athletic Activities
Total # of Participants:
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.
F. Services Questionnaire (please show receipts associated with each) FOOD LIQUOR OTHER TOTAL
Cafeterias
Restaurants
Stores
Totals:
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.)
18-FEB-16
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!!!
6) AUTOMOBILE LIABILITY
A. CATEGORY # THIS TYPE % THIS TYPE
Private Passenger Cars (up to 10,000 lbs GVW) - Non Emergency
15-Passenger Vans
Other Vans, Pickup Trucks, other Light Trucks (up to 10,000 lbs GVW)
Medium Weight Trucks (10,000 to 20,000 lbs GVW)
Heavy Trucks (20,000 to 50,000 lbs GVW)
Extra-Heavy Trucks (greater than 50,000 lbs GVW)
Motorcycles
Buses
Miscellaneous Autos
Mobile Equipment
Trailers, All Types
Total Automobiles:
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
2. Prior Fiscal Year
3. Fiscal Year Two Years Prior
ACCUMULATED SURPLUS
B. Exposure Information
1. Type Employees ACCOUNTANTS ARCHITECTS ATTORNEYS ENGINEERS ALL OTHER TOTAL
Full Time:
Part Time:
Total Employees:
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?
18-FEB-16
All Lines Aggregate School Package Application - Main Application
C:\Users\msscarola\Downloads\ALASchool_RPS_01 Page 6 of 8
ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
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
KS
IN
IA
ID
IL
GA
HI
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.
DC
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
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.
CT
DE
CA
CO
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.
AZ
AR
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.
AL
AK
STATE
POLICY APPLICATION WARNING STATEMENT
18-FEB-16
All Lines Aggregate School Package Application - Main Application
C:\Users\msscarola\Downloads\ALASchool_RPS_01 Page 7 of 8
ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
OK
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.
ND
OH
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.
NY
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
NJ
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
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.
NV
NH
MT
NE
MS
MO
MI
MN
MD
MA
LA
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
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.
KY
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.
18-FEB-16
All Lines Aggregate School Package Application - Main Application
C:\Users\msscarola\Downloads\ALASchool_RPS_01 Page 8 of 8
ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION
ALL QUESTIONS MUST BE ANSWERED IN ORDER TO SECURE A QUOTATION!!!
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:
WY
WV
WI
VA
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
All
applications for insurance must contain a statement, permanently affixed to the application, that clearly states in
subst
ance: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company
f
or the purpose of defrauding the company Penalties include imprisonment fines and denial of insurance benefits
UT
Workers' Compensation ONLY
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.
VT
TN
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
SC
SD
PA
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
OR
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.
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ALL LINES AGGREGATE SCHOOL PACKAGE APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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