Fillable Abuse And Molestation Liability Application (Risk Placement Services, Inc.)

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Abuse And Molestation Liability Application (Risk Placement Services, Inc.)

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MP 5005 06 14
Copyright, American Alternative Insurance Corporation, 2013
.
Page 1 of 6
Abuse And Molestation Liability Application
THIS APPLICATION IS ON AN OCCURRENCE COVERAGE BASIS.
THIS APPLICATION IS ON A CLAIMS-MADE COVERAGE BASIS.
NOTICE: THIS APPLICATION IS FOR A COVERAGE PART WRITTEN ON A CLAIMS-MADE BASIS. "CLAIMS"
MUST BE FIRST MADE AGAINST ANY INSURED DURING THE POLICY PERIOD OR ANY APPLICABLE
EXTENDED REPORTING PERIOD, AND REPORTED TO US AS SOON AS PRACTICABLE DURING THE POLICY
PERIOD, ANY SUBSEQUENT RENEWAL OF THE POLICY OR ANY APPLICABLE EXTENDED REPORTING
PERIOD. THE INSURANCE FOR WHICH THIS APPLICATION IS MADE APPLIES ONLY IF THE "WRONGFUL ACT"
OUT OF WHICH THE "CLAIM" AROSE OCCURRED ON OR AFTER THE RETROACTIVE DATE, IF ANY, SHOWN IN
THE DECLARATIONS AND BEFORE THE END OF THE POLICY PERIOD.
THIS APPLICATION IS ON A DEFENSE WITHIN LIMITS BASIS.
NOTICE: "DEFENSE EXPENSES" ARE PAYABLE WITHIN, NOT IN ADDITION TO, THE LIMIT OF LIABILITY.
NAMED INSURED & ADDRESS POLICY EFFECTIVE DATE
A) L
IMITS REQUESTED: ____________________________
B) E
XPOSURE DATA
Number of full-time
employees: _________________
Number of part-time employees: _______________
Annual number of volunteers: _______________
Number of students: _________________
Average daily number of children for all operations listed on page 1: ____________
C) R
ISK MANAGEMENT
1.
Is there a Sexual Abuse Prevention Program in effect? Yes No
2.
Has a written policy been established clearly expressing management’s commitment to
sexual abuse prevention?
Yes No
3.
Have written procedures encompassing rules, a code of conduct and disciplinary
measures been established for all staff and/or volunteers, which clearly define the
policy and consequences of non-adherence?
Yes No
MP 5005 06 14
Copyright, American Alternative Insurance Corporation, 2013
.
Page 2 of 6
4. Has a mechanism been developed to ensure that sexual abuse prevention policies and
procedures are implemented and enforced throughout the organization?
Yes No
5.
Is there a Sexual Abuse Prevention Coordinator that reports to a member of
management?
Yes No
6.
Are management/staff trained in policies and procedures relating to the Sexual Abuse
Prevention Program?
Yes No
7.
Are volunteers trained in policies and procedures relating to the Sexual Abuse
Prevention Program?
Yes No
8.
Do policies and procedures include an incident reporting and follow-up mechanism? Yes No
9.
Are standard applications used for all prospective employees or volunteers? Yes No
10.
Is there a minimum of two background checks for prospective employees with
documentation maintained in file?
Yes No
11.
Do background checks include checks with “Sex Offender Hot-lines,” State Police,
State Department of Social Services, or similar public agencies? (where applicable)
Yes No
12.
In the past five years have any employees or officers been terminated for cause related
to sexually abusive behavior?
Yes No
13.
Are records maintained documenting adherence to all applicable policies and
procedures, e.g., hiring and screening, code of conduct, training, incident and follow-
up procedures?
Yes No
14.
Are you aware of any circumstances that may result in a sexual abuse claim? If Yes,
explain on a separate sheet.
Yes No
15.
Have any members of the staff been transferred because allegations of sexual abuse? Yes No
D) Coverage History
SEXUAL ABUSE AND MOLESTATION COVERAGE
(CURRENT YEAR & PRIOR FIVE YEARS)
Policy Term:
Carrier:
Limit/SIR:
Claims Made/Occurrence:
Aggregate:
Retro Date:
Defense Inside/
Outside Limit/SIR:
Policy Premium:
Has any ins
u
rer ever cancelled or non-renewed coverage?
Yes No
If Yes, pl
ease explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
MP 5005 06 14
Copyright, American Alternative Insurance Corporation, 2013
.
Page 3 of 6
E) L
OSS HISTORY – FURNISH LOSS HISTORY FOR CURRENT AND PRIOR FIVE YEARS FOR ALL SEXUAL ABUSE CLAIMS,
INCID
ENTS WITH NO CLAIMS
, OR ALLEGATIONS WITH NO CLAIMS, WHETHER OR NOT INSURED.
Policy
Term
#
Claims
Open or
Closed
# Incidents/Allegations
with no Claims
Total Paid
Indemnity/Expenses
Total Incurred
Indemnity/Expenses
Have
all known claims, incidents with no claim, occurrences involving minors or allegations with no claims been
reported?
Yes No
On a separate document, please provide the following information for any individual claim with a Total Incurred
Amount in excess of $10,000:
1. Date of alleged or actual
initial abuse
2. Date claim was brought
3. Description of loss or alleged abuse
4. Total Paid
5. Total Incurred
6. Open or closed
7. Valuation date
MP 5005 06 14
Copyright, American Alternative Insurance Corporation, 2013
.
Page 4 of 6
NOTICE TO APPLICANT
–
PLEASE READ CAREFULLY
FOR THE PURPOSE OF THIS APPLICATION, THE UNDERSIGNED, AS AUTHORIZED AGENT FOR
ALL PERSONS AND ENTITIES PROPOSED FOR THIS INSURANCE, DECLARES THAT TO THE BEST
OF HIS/HER KNOWLEDGE THE STATEMENTS HEREIN ARE TRUE AND COMPLETE. THE
INSURER IS AUTHORIZED TO MAKE ANY INQUIRY IN CONNECTION WITH THIS APPLICATION.
SIGNING THIS APPLICATION DOES NOT BIND THE INSURER TO ISSUE, OR THE APPLICANT TO
PURCHASE, ANY INSURANCE POLICY.
THE INFORMATION CONTAINED IN AND SUBMITTED WITH THIS APPLICATION IS ON FILE WITH
THE INSURER. THE INSURER WILL HAVE RELIED UPON THE STATEMENTS MADE IN THIS
APPLICATION AND ATTACHMENTS IN ISSUING THIS COVERAGE PART.
IF THE INFORMATION IN THIS APPLICATION MATERIALLY CHANGES PRIOR TO THE EFFECTIVE
DATE OF THE COVERAGE PART, THE APPLICANT MUST NOTIFY THE INSURER, WHO MAY
MODIFY OR WITHDRAW THE QUOTATION.
THE UNDERSIGNED, AS THE AUTHORIZED REPRESENTATIVE OF THE INSURED
ACKNOWLEDGES THAT THEY HAVE BEEN ADVISED THAT:
A. THIS POLICY APPLIES ONLY TO "CLAIMS" FIRST MADE OR DEEMED MADE AGAINST THE
"INSUREDS" DURING THE "POLICY PERIOD" OR BASIC EXTENDED REPORTING PERIOD.
B. IF THE DEFENSE WITHIN LIMITS BASIS BOX IS SELECTED, THE LIMIT OF LIABILITY IS
REDUCED BY AMOUNTS INCURRED AS "DEFENSE EXPENSES" AND SUCH EXPENSES
WILL BE SUBJECT TO THE DEDUCTIBLE AMOUNT
.
(WORDS WITHIN QUOTATION MARKS ARE DEFINED IN THE COVERAGE FORM.)
FRAUD STATEMENT
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.
FRAUD STATEMENT TO ALABAMA APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents
false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in
prison, or any combination thereof.
FRAUD STATEMENT TO ARKANSAS APPLICANTS
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.
FRAUD STATEMENT TO COLORADO APPLICANTS
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 settlement or award payable from insurance proceeds shall be reported
to the Colorado division of insurance within the department of regulatory agencies.
FRAUD STATEMENT TO DISTRICT OF COLUMBIA APPLICANTS
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.
FRAUD STATEMENT TO FLORIDA APPLICANTS
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.
FRAUD STATEMENT TO KENTUCKY APPLICANTS
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.
MP 5005 06 14
Copyright, American Alternative Insurance Corporation, 2013
.
Page 5 of 6
FRAUD STATEMENT TO LOUISIANA APPLICANTS
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.
FRAUD STATEMENT TO MAINE APPLICANTS
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.
FRAUD STATEMENT TO MARYLAND APPLICANTS
Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or who
knowingly and willfully presents false information in an application for insurance is guilty of a crime and may be subject to
fines and confinement in prison.
FRAUD STATEMENT TO NEW JERSEY APPLICANTS
Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal
and civil penalties.
FRAUD STATEMENT TO NEW MEXICO APPLICANTS
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.
FRAUD STATEMENT TO NEW YORK APPLICANTS
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.
FRAUD STATEMENT TO OHIO APPLICANTS
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.
FRAUD STATEMENT TO OKLAHOMA APPLICANTS
WARNING: Any person who knowingly, and with intent to injure, 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.
FRAUD STATEMENT TO OREGON APPLICANTS
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents
materially false information in an application for insurance may be guilty of a crime and may be subject to fines and
confinement in prison.
FRAUD STATEMENT TO PENNSYLVANIA APPLICANTS
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 subjects such
person to criminal and civil penalties.
FRAUD STATEMENT TO RHODE ISLAND APPLICANTS
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, including failing to disclose whether the applicant or applicants have been
convicted of any degree of the crime of arson, is guilty of a crime and may be subject to fines and confinement in prison.
FRAUD STATEMENT TO TENNESSEE APPLICANTS
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.
MP 5005 06 14
Copyright, American Alternative Insurance Corporation, 2013
.
Page 6 of 6
FRAUD STATEMENT TO VERMONT APPLICANTS
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 may be a crime and subjects
such person to criminal and civil penalties.
FRAUD STATEMENT TO VIRGINIA APPLICANTS
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.
FRAUD STATEMENT TO WASHINGTON APPLICANTS
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.
FRAUD STATEMENT TO WEST VIRGINIA APPLICANTS
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.
______________________________________________ _______/_______/_______
Signature of Applicant Date
______________________________________________
Name and Title
INSURANCE AGENT INFORMATION:
Agency name: __________________________________________________________________________________
Contact person: __________________________________________________________________________________
Agency address: __________________________________________________________________________________
____________________________________________________________________________________________________
Telephone number: _____________________________ Fax number: ____________________________
E-mail address: __________________________________________________________________________________
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Abuse And Molestation Liability Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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