Fillable Application - Tutoring36-10720

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Application - Tutoring36-10720

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TUTORING SUPPLEMENTAL
SUBMISSION REQUIREMENTS
• Currently valued insurance company loss runs for the current policy period plus three prior years
1.
2. Mailing Address
:
3. Location Address:
4.
Website Address:
Effective Date:
5.
Date business started:
6.
Has the tutoring center had any paid or reported claims in the past three years?
Yes
No
7.
Is the tutoring center part of a franchise?
Yes
No
If yes, what is the name of the franchise:
8.
Does the Applicant follow all employee policies and procedures recommended by the
franchisor?
Yes
No
9.
Do tutors have teaching credentials?
Yes
No
If no, what are the minimum qualifications for the tutors:
SECTION I - GENERAL INFORMATION
Applicant:
10.
Applicant’s pro forma financial income / loss projections for the next 3 years.
Year 1
Year 2
$
$
11.
Total number of tutors:
12.
What percentage of staff is: Employees: % Independent Contractors: %
13. Total number of students enrolled:
14.
Average daily attendance:
15.
Annual payroll: $
Annual revenue: $
16.
Where does the tutoring take place (check all that apply)
Tutoring center
Student’s home
Other (please describe):
17. If at “student’s home”, is there at least one parent present at all times? Yes No
18.
Age range of students being tutored:
19.
Is this strictly academic tutoring?
Yes
No
If no, what programs does the Applicant offer?
20.
Yes No
Are tutors allowed to transport students in their personal vehicles?
If yes, is personal insurance verified and are Motor Vehicle Reports checked?
Yes No
21. The standard General Liability limits quoted are $1,000,000/$2,000,000.
If higher General Liability limits are required by contract, please provide a copy of the contract.
Required Limits: $
22. Does the Applicant want corporal punishment coverage?
Yes No
Tutoring Supplemental
Page 1 of 4
© 2016 Philadelphia Consolidated Holding Corp.
12/2016
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Yes No
Is Umbrella coverage being requested?
If in business
les
s than
3 y
ear
s
, maximum available limit is $1,000,000
If yes, what limit is needed?
$1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000
23.
SECTION II – ABUSE & MOLESTATION
PLEASE NOTE: Standard Abuse and Molestation limits provided with proper controls in place are $100,000/$300,000
Optional Limits available: $500,000/$500,000 $1,000,000/$1,000,000
1. Yes No Do the Applicant’s contracts require a specific abuse limit?
If yes, what are the required abuse limits? (Please provide a copy of the contract.)
2. Does the Applicant’s staff (paid or volunteer) employment application include questions
about whether the individual has ever been convicted for any crime, including sex-related
or child abuse related offenses? Yes No
3. Yes No Does the Applicant’s state permit you to do criminal background investigations?
If yes, does the Applicant routinely request and receive such background investigations? Yes No
4. Are federal and state criminal background checks performed on Staff? Yes No
Volunteers? Yes No
5.
Yes No
Do any independent contractors have access to students or perform operations where
they will be physically touching another person?
If yes, please explain:
6. Does the Applicant perform background checks on hired independent contractors? Yes No
7. Is there a new employee and volunteer orientation that includes training in abuse
awareness? Yes No
8.
Does the Applicant verify employment-related references? Yes No
9.
Does the Applicant conduct personal interviews? Yes No
10.
Yes No Does the Applicant have written procedures dealing with sexual abuse?
If yes, please attach a copy.
11.
Does the Applicant have a plan of supervision that monitors staff in day-to-day
relationships with clients, both on and off premises? Yes No
12.
Does the tutoring center have specific training for the faculty on identifying and reporting
incidents of sexual abuse and molestation? Yes No
13.
Yes No Has the Applicant ever had an incident which resulted in an allegation of sexual abuse?
If yes, please describe the incident:
Yes No
Yes No
Yes No
Was a claim made against the organization?
Was the case settled?
Was the case taken to trial?
How much money was paid in damages to the victim: $
14.
Regarding coverage for Abuse & Molestation, does your current insurance program:
Yes No
Yes No
exclude coverage?
limit coverage?
If yes, please indicate limit of liability: $
neither excludes nor limits coverage? Yes No
Tutoring Supplemental
Page 2 of 4
© 2016 Philadelphia Consolidated Holding Corp.
12/2016
$
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SECTION III - PROPERTY
PLEASE NOTE: If coverage is needed for more than one location, Property ACORD applications are required.
1.
Address:
2. Square footage of your center:
3.
Construction of the building the center is in:
Frame
Joisted Masonry
Masonry Noncombustible
Fire Resistive
4.
Number of stories in this building:
5.
Year this building was built:
6. Is this tutoring center the sole occupant of this building?
Yes
No
7.
Does this tutoring center have a central station burglary alarm?
Yes
No
8.
Replacement cost of the tutoring center’s improvement and betterments: $
9.
Replacement cost of the tutoring center’s contents: $
10.
Property deductible desired:
$1,000
$2,500
$5,000
11. Do you have a plan to relocate in the event of a total loss to your Center?
Yes
No
12.
Landlord’s name and address if to be added as an Additional Insured:
13.
Loss Payee name and address if to be added for leased or financed property:
Optional Coverages (check if desired.):
Automobile Non-Owned and Hired Car (this coverage is not available for in-home tutoring).
Crime – Employee Dishonesty: $10,000; Money and Securities In & Out: $10,000; Deductible $500
Tutoring Supplemental
Page 3 of 4
© 2016 Philadelphia Consolidated Holding Corp.
12/2016
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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
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, 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 F ALSE 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 ST ATEMENT 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 FRAUDLENT 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 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
SECTION 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)
Tutoring Supplemental
Page 4 of 4
© 2016 Philadelphia Consolidated Holding Corp.
12/2016
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Completed 2 July 2020

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