Fillable Application - Educational Institutions Security Supplement36-8721

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Application - Educational Institutions Security Supplement36-8721

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EDUCATIONAL INSTITUTIONS SUPPLEMENT - SECURITY
GENERAL APPLICANT INFORMATION
Applicant:
Mailing Address:
Website Address:
Effective Date:
SECTION I – SECURITY
1. Are there security guards at the school daily?
Yes
No
2. Indicate the number of personnel providing security services.
Employed: Unarmed Security: Armed Security:
Contracted: Unarmed Security: Armed Security:
3. When security is contracted to a third party, is the contractor’s general liability / law enforcement
professional liability policy required to name the educational institution as an additional insured?
Yes
No
If yes, does the third party maintain a minimum limit of liability coverage and indemnify the
educational institution?
Yes
No
If yes, indicate the minimum limit of liability of general / policy professional liability coverage your
institution requires: $
4. Do security personnel have arresting authority?
Yes
No
5. If there is employed armed security, are they trained and/or re-certified annually to the
standards required for public sector law enforcement personnel within the political subdivision
for use of weapons?
Yes
No
6. Are criminal background checks and psychological reviews provided for all employed security?
Yes
No
If yes, how often are these checks and reviews conducted: Every Months
If no, explain:
7. Is the Applicant’s security department accredited by the International Association of Campus
Law Enforcement Admi
nistration (IACLEA)?
Yes
No
8.
Does a mutual aid agreement exist with local city or county police?
Yes
No
9.
Does the Applicant permit staff, volunteers, or visitors to carry open or concealed firearms on
your premises?
Yes
No
10.
If the Applicant does not permit open and/or concealed carry of firearms on any premises for
which you are requesting insurance coverage do all locations have signage which
conspicuously identifies the building as a Gun Free Zone?
Yes
No
11.
Do security personnel store weapons on premises?
Yes
No
12.
Do faculty, staff, or employees store weapons on premises?
Yes
No
13.
Does the Applicant’s Weapons Ban Policy have any exceptions?
Yes
No
14.
Does the Applicant have emergency call boxes located throughout the campus that are
connected directly to campus security or policy?
Yes
No
15.
Does the Applicant provide after-hours security escort service for students?
Yes
No
Educational Institutions Security Supplement
Page 1 of 2
©2013 Philadelphia Consolidated Holding Corp.
09/2013
Print Application
FRAUD NOTICE STATEMENTS
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 AND
SUBJECTS THAT PERSON TO CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A
FRAUDULENT INSURANCE ACT WHICH MAY BE A C RIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL
PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS ($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION).
(NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN, NM, OK, RI, TN, VA, VT, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A L OSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE
INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN
PRISON.
APPLICABLE IN COLORADO: 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.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE PRESENTED OR
PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER OR ANY
AGENT THEREOF, ANY WRITTEN STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE
RATING OF AN INSURANCE POLICY FOR PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT
PURSUANT TO AN INSURANCE POLICY FOR COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN
MATERIALLY FALSE INFORMATION CONCERNING ANY FACT MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING,
INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: IT IS A C RIME 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.
Name (Please Print/Type) Title
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR
EXECUTIVE DIRECTOR)
____________________________________________________
Signature Date
The above signed warrants that he/she is authorized and has the power to complete and execute this Application, including the
Warranty Statement on behalf of the Applicant and their respective Directors, Officers or other insured persons.
Produced By: (Section to be completed by Producer/Broker)
Producer Agency
Producer License Number Agency Taxpayer ID or SS Number
Address (Street, City, State, Zip)
Educational Institutions Security Supplement
Page 2 of 2
©2013 Philadelphia Consolidated Holding Corp.
09/2013
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