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EDUCATORS MANAGEMENT LIABILITY APPLICATION (Risk Placement Services, Inc.)

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EDUCATORS MANAGEMENT LIABILITY APPLICATION
THIS APPLICATION IS FOR A CLAIMS-MADE POLICY. "CLAIMS" MUST BE FIRST
MADE AGAINST AN "INSURED PERSON" 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.
1. Name of Educational Organization:________________________________________
Date incorporated or otherwise legally created: ______________________________
2. Principal address: _______________________________________________________
City: _____________________________ State: Zip:__________________
3. Do you have a full-time Risk Manager? Yes No
Risk Manager’s name:____________________________________________________
4. Website address:_________________________________________________________
Phone number :___________________________ FEIN:_______________________
5. Type of Educational Organization (c
heck all boxes that
apply):
Public School Communit
y
Colle
g
e
Special Ed Facilit
y
State
Private For Profi
t
Public
K
-12
Vocational/Technical
Count
y
Private Not for Profi
t
Independent School
Pre-School
Municipal
Please attach copies of the following:
Audited financial statement for the most recent available fiscal year;
Minimum of last three years of current and prior insurers’ loss runs (five years
desired);
Current employee handbook, including procedures on sexual harassment,
discrimination and employee grievances;
Current student handbook;
Complete list of all Directors or Trustees including their name, position, term of office,
and affiliation with any other outside organizations
Complete list of all Officers including their name, position, and affiliation with any
other outside organizations
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 2 of 10
Multi-District Coop Charter School
Private School
Special District
Colle
g
e / Universit
y
Other (Explain)
6. IRS Tax Status:
501 (c) (3) Public Entity Other_____________
7. Number of board members:
a. Are board members: Elected Appointed Length of Term:
b. If board members are appointed, by whom are they appointed?
c. Do board members serve on rotating or staggered basis? Yes No
d. If elected, are board members elected:
At large Single member districts
8. Enrollment and employment information:
E
NROLLMENT
C
URRENT YEAR LAST YEAR
2
ND
PRIOR
YEAR
Full Time Students
Part Time Students
Special Education Students
Other
Total
E
MPLOYMENT
CURRENT YEAR LAST YEAR
2
ND
PRIOR
YEAR
Full Time Faculty / Instructors
Part Time Faculty / Instructors
Non-Certified Staff
Administrative Personnel,
including officials, principals,
administrators, etc
Other Professional Staff
Volunteers
Total
9. Have you had any staff reductions in the past 24 months?
Yes No
a. Were faculty members involved in this reduction in force?
Yes No
10. a. In the last 3 years, have you been involved in any school mergers/closings or plan
to do so in the next 18 months?
Yes No
If yes, please explain ____________________________________________________
________________________________________________________________________
b. Any anticipated openings in the next year?
Yes No
If yes, please explain _____________________________________
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 3 of 10
FINANCIAL
1. a. Fiscal year end date:
b. Budget for current and prior fiscal years:
C
URRENT
YEAR
L
AST YEAR PREVIOUS YEAR
Revenues
Expenditures
Budget Surplus (Deficits)
Accumulated Budget
Deficit/Surplus
c. Provide an explanation for any budget deficits in the past three years and
anticipated steps to address accumulated deficits.
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
2. Amount of outstanding bonds: $ _____________
3. Has the applicant been in default on principal or interest on any bond?
Yes No If yes, please explain:
OPERATIONS AND POLICY
1. Accreditation is provided by which body:_________________________
Date of last accreditation:
2. Does the Educational Organization have a disaster planning document in place and
in practice for natural disasters, terrorist acts, acts of violence or unauthorized
intrusions?
Yes No
3. Do you perform background checks on all employees before offering employment?
Yes No If no, please explain: __________________________________________
a. Are Volunteers subject to the same background checks?
Yes No
4. Which of the following processes and policies have you adopted?
a. As pertains to teachers:
i. Student suspensions or expulsions Yes No
In Writing
ii.
Use of corporal punishment Yes No
In Writing
iii.
Disciplinary action Yes No
In Writing
iv.
Testing standards Yes No
In Writing
v.
Teacher/student relationships Yes No
In Writing
vi.
Sexual harassment/molestation Yes No
In Writing
vii.
Drug testing Yes No
In Writing
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 4 of 10
b. As pertains to Students:
i. Suspension/expulsion Yes No
In Writing
ii. Corporal punishment Yes No
In Writing
iii. Possession of weapons Yes No
In Writing
iv. Drug testing and searches Yes No
In Writing
v. Internet access Yes No
In Writing
vi. Students with disabilities Yes No
In Writing
vii. Special education Yes No
In Writing
viii. Public displays of affection Yes No
In Writing
c. Have the above policies and procedures been
reviewed by counsel?
Yes No
Some
EMPLOYMENT PRACTICES LIABILITY
1. During the last three years has any Educational Organization or unit thereof been
involved in any employment or labor related litigation?
Yes No
2. During the last three years has any Educational Organization or unit thereof been
involved in any administrative proceedings with:
a. the Equal Employment Opportunity Commission?
Yes No
b. the U.S. Department of Labor?
Yes No
c. any state or local government agency whose purpose is to address employee-
related claims?
Yes No
If the answer to any question in one and two above is ‘yes’, please state the type and number
of each proceeding and, for each proceeding which has or is expected to exceed $75,000 in loss
(including claims expenses), attach full details.
3. Have there been any strikes, slowdowns or disruptions in the past five years?
Yes No
If yes, please explain: _______________________________
4. Provide your percentage of employee turnover: Current Year __________%
Last year______________%
5. Who is responsible for providing employment counsel for employment advice?
Outside Legal Counsel Name of Firm ________________________
Inside Legal Counsel
Other, Please explain _______________________________________________
6. a. How often are Educational Organization’s human resources documents, policies,
guidelines, and procedures reviewed?
Annually Semi-Annually Other
b. What was the date of the most recent comprehensive review of such documents,
policies, guidelines, and procedures? _________________________________
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 5 of 10
c. Who was responsible for the review?
Outside Legal Counsel Name of Firm: _________________________
Other ____________________________________
7. Does the Educational Organization have written guidelines, policies or
procedures for addressing human resources or personnel management in the
following areas:
a. Hiring / Interviewing? Yes No
b. Employee at will statement and employee contract disclaimer? Yes No
c. Performance appraisals? Yes No
d. Discipline? Yes No
e. Discharge? Yes No
f. Accommodating the disabled? Yes No
g. Non-union grievance procedures? Yes No
h. Sexual harassment? Yes No
i. Use of Educational Organization’s electronic mail, voice mail and
Internet access?
Yes No
Do all employees receive a copy of these guidelines, policies or procedures, and
acknowledge such receipt in writing?
Yes No
8. Does the Educational Organization have a full-time human resources manager?
Yes No
If not, who is responsible for human resources? ________________________________
9. When an employee is discharged:
a. Is officer approval required and are human resources personnel
directly involved?
Yes No
b. Is an attorney consulted prior to discharging an employee? Yes No
INSURANCE INFORMATION
1. Please provide Educators Legal Liability & Employment Practices Liability policy
information:
C
URRENT & LAST
FOUR
YEARS
P
ROFESSIONAL LIABILITY
CARRIER
L
IMITS
D
EDUCTIBLE /
RETENTION
P
REMIUM
Current Year
Prior Year
2
nd
Prior Yr
3
rd
Prior Yr
4
th
Prior Yr
2. Current Claims Made Retroactive Date: ________________________________
3. Current general liability carrier and limits:
4. Has any insurance been declined, cancelled or not renewed in the past five years?
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 6 of 10
Yes No If yes, please explain: ___________________________________________
___________________________________________________________________________
Missouri Applicants are not required to answer this question.
5.Limit of Liability requested:
$ 100,000 $ 250,000 $ 500,000
$ 1,000,000
$ 2,000,000 $ 3,000,000 $ 4,000,000
Other $____________
6.Deductible requested:
COV A:
$ 10,000 $15,000
$20,000
$25,000 $50,000 Other $______
COV B:
$ 5,000 $10,000
$15,000
$25,000 $50,000 Other $______
CLAIMS EXPERIENCE
1. Do any principals, directors, officer, partners, professional employees or
independent contractors of the Educational Organization have knowledge or
information of any act or omission which might reasonably be expected to give rise
to a claim?
Yes No
It is agreed by all concerned that if any such person has any such knowledge or
information, whether or not described above, any claim emanating therefrom shall
be excluded from coverage under this Policy.
2. Has the Educational Organization, or any of its predecessors in business,
subsidiaries or affiliates, or any of its principals, directors, officers, partners,
professional employees or independent contractors, ever been the subject of a
disciplinary action as a result of professional activities?
Yes No
3. During the past five years, have any claims been made or suits brought against the
Educational Organization, any predecessors in business, subsidiaries, or affiliates
of any principal, director, officer or professional employee?
Yes No
4. Has the Educational Organization reported the matters listed in response to
questions one through three, above, inclusive, to its current or any former insurance
carrier?
Yes No
If any response to questions one through four, above, inclusive, was yes, please attach a detailed
explanation including date of circumstance or claim, potential or actual claimant, nature of
circumstances or claim, defense costs, indemnity amount, reserve amount and current status for each
claim, notice or circumstance.
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
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 7 of 10
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. THIS APPLICATION WILL BECOME A PART OF SUCH COVERAGE PART IF ISSUED. THE
INSURER WILL HAVE RELIED UPON THIS APPLICATION AND ATTACHMENTS IN ISSUING THIS
COVERAGE PART. IN THE EVENT THAT THE "APPLICATION" CONTAINS ANY MISREPRESENTATION
OR MISSTATEMENT OF A MATERIAL FACT, THIS COVERAGE PART SHALL NOT AFFORD COVERAGE
TO ANY "INSURED" WHO KNEW OF SUCH MISREPRESENTATION OR MISSTATEMENT.
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 DECLARES THAT THE INDIVIDUALS AND “ORGANIZATIONS” PROPOSED FOR
THIS INSURANCE HAVE BEEN NOTIFIED THAT:
THIS COVERAGE PART APPLIES ONLY TO "CLAIMS" FIRST MADE OR DEEMED MADE AGAINST
THE "INSUREDS" DURING THE "POLICY PERIOD" OR BASIC EXTENDED REPORTING PERIOD.
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.
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 8 of 10
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.
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.
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 9 of 10
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.
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.
MP 3005 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office,
Inc., with its permission.
Page 10 of 10
__________________________________________________________________
Printed Name of president, officer, director or equivalent executive
of the applicant educational organization
__________________________________________________________________
Signature of president, officer, director or equivalent executive
of the applicant educational organization.
__________________________________________________
Title
__________________________________________________
Date
INSURANCE AGENT INFORMATION:
Agency name:_______________________________________________________________________
Contact person:______________________________________________________________________
Agencyaddress:______________________________________________________________________
____________________________________________________________________________________
Telephone number:_____________________________
Fax number:__________________________
E-mail address:_______________________________________________________________________
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EDUCATORS MANAGEMENT LIABILITY APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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