Fillable Application - Educators Professional Select Renewal PIIC - FL36-10925

Fill Online, Printable, Fillable, Blank Application - Educators Professional Select Renewal PIIC - FL36-10925 Form

Use Fill to complete blank online PHILADELPHIA INSURANCE COMPANIES pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Application - Educators Professional Select Renewal PIIC - FL36-10925

On average this form takes 22 minutes to complete

The Application - Educators Professional Select Renewal PIIC - FL36-10925 form is 4 pages long and contains:

  • 0 signatures
  • 0 check-boxes
  • 89 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Philadelphia Insurance Companies forms online.

BROWSE PHILADELPHIA INSURANCE COMPANIES FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
EDUCATORS PROFESSIONAL SELECT RENEWAL APPLICATION
THIS IS AN APPLICATION FOR CLAIMS MADE POLICY.
PLEASE CONSULT WITH YOUR AGENT FOR ANY QUESTIONS.
SECTION I – GENERAL INFORMATION
This application must be signed and dated by the Executive Officer of the Educational Institution or by a member of its
Governing Board.
Educational Institution:
Mailing Address:
City:
State:
Zip Code:
1.
Student Enrollment Profile:
Has enrollment increased or decreased more than 10% from the prior year?
No
If yes, please explain:
Current Enrollment
Full Time
Part Time
K - 8
9 - 12
2 or 4 year undergraduate
Graduate
Other:
Total
SECTION II – EDUCATORS LEGAL LIABILITY
For all Yes answers provide explanation on page 3 of this application.
2.
Have there been any acquisitions, mergers, or new entities created in the past year?
No
Are any planned within the next 12 months?
No
3.
Are all entities requesting coverage still recognized as 501(c)(3), tax exempt organizations by the
Internal Revenue Service?
No
4.
Is the Educational Institution projecting a budget deficit for the coming fiscal year?
No
If a deficit, provide details about the reason(s) for the deficit and the Educational Institution’s plans
to fund the deficit.
5.
In the past 12 months, have there been any changes to the Educational Institution’s governing
board or to senior management (other than health reasons, death, retirement, or term expiration)?
No
6.
In the past 12 months, have there been changes to the Educational Institution’s bylaws or an
operating agreement?
No
7.
In the last 12 months, has the Educational Institution eliminated or closed any academic
programs, including music, arts or athletic programs?
No
8.
In the next 12 months, does the Educational Institution anticipate eliminating or closing any
academic programs?
No
9.
Has the educational institution or any of the Educational Institution’s academic programs ever lost
accreditation, been placed on probation or become unable to gain accreditation?
No
10.
In the last 12 months, has the Educational Institution made any changes to its student handbook
or policies?
No
Educators Professional Select
Renewal PIIC - FL
Page 1 of 4
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
Clear Application
Print Application
For Charter Schools Only
11.
What is the current percentage of students in the Educational Institution that have IEPs
(individualized education plans): %
12.
How many IEP due process hearings has the Educational Institution had in the past 12 months?
SECTION III – EMPLOYMENT PRACTICES LIABILITY
For all Yes answers provide explanation on page 3 of this application
13.
Please indicate the number of employees in the following categories:
Full Time
Part Time
a.
Total Number of Employees
b.
Certified Teaching Faculty
c.
Non-certified Teaching Faculty
d.
Administration
e.
Counselors / Psychologists
f.
Volunteers
g.
Security / Law Enforcement
h.
Other:
14.
In the last 12 months, has the Educational Institution implemented any new or eliminated any
existing employment or human resources policies or procedures?
No
15.
Has the Educational Institution had any school closings, layoffs or restructuring resulting in workforce
reduction in the past 12 months?
No
16.
Does the Educational Institution anticipate any school closings, layoffs or restructuring resulting
in workforce reduction in the next 24 months?
No
17.
Have staffing totals increased or decreased more than 10% from the prior years?
No
18.
Over the last 12 months, how many teaching, professional and senior administration individuals
have left the Educational Institution’s employ due to the following?
Prior 12 months
Involuntary terminations
Resignations (other than retirement)
Layoffs / Downsizing
SECTION V - NOTICES
The information requested in this application is for underwriting purposes only and does not constitute notice to the
Company under any policy of a claim or potential claim. All such notices must be submitted to the Company
pursuant to the terms of the policy.
Material Change
This application does not create a binding contract as to the Educational Institution or the Company. If there is any
material change in the answers to the questions in this application prior to the policy inception date, the
Educational Institution shall notify the Company in writing. The undersigned acknowledges and agrees that the
Company’s receipt of such written report, prior to inception date of the proposed coverage, is a condition precedent
to any offer of coverage.
Educators Professional Select
Renewal PIIC - FL
Page 2 of 4
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
Clear Application
Print Application
ADDITIONAL INFORMATION
This
page may be used to provide additional information to any question on the application. Please identify the
question number to which you are referring.
Educators Professional Select
Renewal PIIC - FL
Page 3 of 4
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
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 CRIME 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, PA, 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 LOSS 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: AN ACT COMMITTED BY 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, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR 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.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
_____
________________________________________________________
SIGNATURE DATE
SE
CTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Educators Professional Select
Renewal PIIC - FL
Page 4 of 4
© 2017 Philadelphia Consolidated Holding Corp.
06/2017
Clear Application
Print Application
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Application - Educators Professional Select Renewal PIIC - FL36-10925

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 2 July 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document