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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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  • 88 check-boxes
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C‐APP036‐0815Page1of4
COLONY INSURANCE COMPANY – COLONY SPECIALTY INSURANCE COMPANY
PELEUS INSURANCE COMPANY
CONTRACT DIVISION - SCHOOLS - SUPPLEMENTAL APPLICATION
ACORD Application also required - Check all applicable checkboxes below
General Agent:
Date:
Insured:
Insured Mailing Address:
Insured’s Web Address:
Insured Contact Name:
Phone Number:
PROHIBITED (check all that apply to your operations)
Armed security unless off-duty certified peace officers
Boarding schools, Charter schools
Developmentally disabled or handicapped acceptable if incidental. If the school specializes in these kinds of
students the risk should be submitted to Allied Medical
Emotionally challenged student exposures
Student housing
Schools for:
Aviation, flight training, parachuting schools
Cheerleading, gymnastics
Firearms or weapons training
Health/Medical (acupuncture, homeopathic, CPR, EMT, Fire/Rescue, Life Safety, Lamaze, Mommy & Me)
Heavy equipment, heavy machinery, rigging, welding
Racing or stunt
Recreational vehicles including but not limited to: ATV’s, motorcycles, 3 wheelers, jet skis, watercraft
Veterinary
YEARS IN BUSINESS / EXPERIENCE
_____ Years in business as the ‘Named Insured’ indicated on this application
_____ Years’ experience in the operations indicated on this application - Attach resumes if available
Has applicant had an insurance policy cancelled or non-renewed in past 3 years? If yes, explain.
(Missouri Applicants - Do not answer this question)
Applicant in receivership
Bankruptcy (Chapter 7, 11 or 13) has been filed in past 5 years
LICENSING
Licenses and certifications, as required by state and/or locality are all in place
License Number: _______________________________________________
C‐APP036‐0815Page2of4
SCHOOLS - SUPPLEMENTAL APPLICATION
LOSS HISTORY
Three years of loss history information provided on ACORD application or attached to this application
There has been a claim due to sexual misconduct or molestation. If yes (explain):
OPERATIONS / EXPOSURES / CONTROLS
Type of School:
_______ Ages of those taught
_______ Total number of students
_______ Total number of teachers (including volunteer teachers)
OPERATIONS / EXPOSURES / CONTROLS
Field Trips:
Number of field trips per month on average_________
Permission slips (signed) are required in order to go on field trip
Trips may include visits to a beach, lake or swimming pool
Trips may include visits to amusement facilities
Trips may include visits to zoos
Trips to destinations not listed above include (describe below):
Medical / Emergencies
Authorization procedure in place if student not released to custodial parent or legal guardian
Emergency evacuation plan in place, posted and all employees trained and aware of the plan
Exclusion criteria in place for sick students and students without certain immunizations
Immunization records obtained for each child enrolled
Health records are obtained for each child that is enrolled including immunization records and dietary issues
Medicines and first aid equipment are stored out of reach of children
Medicines only dispensed if parent/legal guardian provides written permission and written instructions
School nurse (if any) is licensed and insured elsewhere
Overnight:
Over-night or Over-stay exposures. If yes, explain:
Premises:
Carbon monoxide detectors in place
Doors are equipped with panic bars
Exits clearly marked, lighted and free of obstructions
Fire extinguishers on premises and have current inspection tags
No smoking signs posted and strict no smoking policy enforced
Playground equipment (describe):
Playground equipment was installed professionally by a company certified in playground safety
Playground equipment does not have any primary platforms are higher than 8 feet
Play area(s) if outdoors are fully fenced with self-locking gates for grades K thru 5
Play area(s) if outdoors have an artificial soft-surface material installed
Play area(s) meet all safety requirements specified by the Consumer Products Safety Commission
Smoke detectors in place: Battery Hardwired
C‐APP036‐0815Page3of4
SCHOOLS - SUPPLEMENTAL APPLICATION
OPERATIONS / EXPOSURES / CONTROLS (continued)
Sports facilities (describe):
Bleachers (if any) above 4 tiers in height all have backs to prevent falls
Fenced if used by children 10 years old or younger
Swimming Pool(s) Number of swimming pools: _______
Depths marked, Life safety equipment placed in pool area, Rules posted
Competitions Diving Teams Swimming Instruction
Fenced completely with self-latching gate(s), if pool is outdoors
Life guards CPR trained Subcontracted out
Slides or diving boards Maximum height: _____ feet
SUBCONTRACTORS / INDEPENDENT CONTRACTORS
Uninsured subcontractors are not acceptable
Risk Transfer – Subcontractors:
Additional Insured – Status granted to you on the subcontractor’s policy
Certificates of Insurance - Always obtained from a subcontractor prior to any work being done for you
Limits of Liability - Subcontractors are required to carry limits equal or above your own
EMPLOYEES / VOLUNTEERS
Certifications (as required) in place for all teachers
Criminal background checks performed on all employees At time of hire only Annually
CPR trained staff member (at least one) is always on duty during hours of operation
Drug testing of all employees
Training (at least once annually) of all staff regarding child abuse and sexual abuse
Volunteers go through a formal application process, and background check performed (if student contact)
RATING BASIS
All Operations
$
Number of Children
Number of Days per Week
PLANNED EXPANSION OR NEW ACTIVITIES IN COMING POLICY TERM
New activities or expansion is anticipated (describe):
C‐APP036‐0815Page4of4
SCHOOLS - SUPPLEMENTAL APPLICATION
COVERAGE OPTIONS - LIABILITY (check if you would like a quote on any of the following)
Abuse and Molestation: $25,000 Limit $50,000 limit $100,000 limit
Employee Benefit Liability – U058
High Limits General Liability
Identity Recovery – i.e. Identity Theft – U651
Medical Expense Limit of $10,000 rather than $5,000
Stop Gap Liability – U066
COVERAGE OPTIONS - PROPERTY (check if you would like a quote on any of the following)
Building Ordinance or Law (Increased Cost of Construction) – U750
Equipment Breakdown – U522 & U523
Property Coverage Enhancement:
Bronze – U777C, Silver – U777B or Gold – U777A
Signs (Outdoor) – CP1440
Water Back Up and Sump Overflow – U548
GENERAL FRAUD STATEMENT (Not applicable in all states.)
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, may be committing a fraudulent insurance act, and may be subject to
a civil penalty or fine.
The undersigned is an authorized representative of the applicant and certifies that reasonable inquiry has been made to
questions on this application. He/She certifies:
The answers are true, correct and complete to the best of his/her knowledge.
They agree to the Privacy and Fraud provisions found in the ACORD-125 (Commercial Insurance Application)
and understand those provisions also apply to this supplemental application.
SIGN AND DATE
PRODUCER’S SIGNATURE DATE
APPLICANT’S PRINTED NAME DATE
APPLICANT’S SIGNATURE DATE
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COLONY INSURANCE COMPANY COLONY SPECIALTY INSURANCE COMPANY PELEUS (Strickland Insurance Brokers)

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Completed 17 July 2021

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