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Page 1 of 12
MANAGEMENT LIABILITY
EDUCATIONAL INSTITUTION LIABILITY APPLICATION
1. Legal name of the entity which is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other business/dba names, including subsidiaries, commissions or boards created by the Applicant for
which you are seeking coverage under this policy:
3. Type of educational entity: Public Private Educational Service District Charter School Community
College
Four Year College/University Other (describe): _________________________
4. If an Educational Service District, how many schools comprise this district? _________
5. Please list any names of other entities that you own or manage or that you do business under (such entities are not
requesting coverage under this policy):
6. Primary location address:
7. County of primary location: Date entity established:
8. Total number of branches: List all addresses for additional branches:
9. Entity location is: Rural Urban Suburban
10. Current population of district: ____________________________
11. What is your web-site address? www.
12. Has the name or ownership of the entity changed or has any other business been purchased, Yes No
merged or consolidated with the entity within the last 5 years?
13. Does any entity own or control your business or does your business own or control any entity? Yes No
14. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
15. During the past three years, have you been involved in any school mergers/closings, or plan to do so Yes No
In the next 12 months?
16. Do you plan to have any school openings in the next 24 months? Yes No
17. Is the Applicant managed or administered by any third party under contract or agreement? Yes No
For questions 12-17, please fully explain any “yes” response, including the names, dates, impact involved on revenue &
headcount:
18. Does the Applicant now have tax exempt status under the United States Internal Revenue Service? Yes No
19. Is there now, or has there been, any dispute as to the Applicant’s tax exempt status? Yes No
If Yes, please attach an explanation.
GENERAL INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 12
1. Student Enrollment (if a college/university, the number of students should include the full-time equivalent of part-
time):
Current School Year
Last School Year
Projected Next School
Year
Total number of students
Teacher/Student Ratio
Number of Students With
Disabilities
Teacher/Student with
Disabilities Ratio
Number of Special
Education Students
Teacher/Special Education
Ratio
Average Class Size
2. List the number and type of staff:
Type of Employee
This Year
Administration
Counselors/Psychologists
Law Enforcement/Security
Non-Professional
Teaching Faculty
Other: (describe function):
______________________________
Total Number
3. Number of Board Members: __________
a. Term of office: __________
b. Terms staggered: Yes No If “yes” what is the schedule: __________________________
c. Board Members/Trustees are: Appointed Elected
d. If elected, they are elected by: At Large Single Member Districts
e. Are all Board seats currently filled? Yes No Please explain any “no” response.
_______________________________________________________________________________
4. Does the Applicant perform any of the following services:
If Yes to any question, please explain (attach an additional explanation if needed).
a. Operation of any daycare facilities or services? Yes No
b. Organize or sponsor any type of contest, lottery, tournament, prize, give-away, Yes No
raffle or other game of chance?
c. Operate or sponsor a political action committee? Yes No
d. Organize domestic or international field trips for students? Yes No
e. Manage/administer any entity (other than the Applicant Entity) under contract or agreement? Yes No
For questions 4 A-E, please fully explain any “yes” response, including details of number of participants, type of events,
frequency, etc.:
ORGANIZATION INFORMATION
Page 3 of 12
1. Has the Applicant established written policies/procedures governing students regarding:
All Students Special-Needs Students
Acceptance Yes No Yes No
Corporal Punishment Yes No Yes No
Dismissal Yes No Yes No
Dress Code Yes No Yes No
Drug Testing Yes No Yes No
Extracurricular Activities Yes No Yes No
Parking Yes No Yes No
Promotion Yes No Yes No
Sexual Harassment Yes No Yes No
Suspension Yes No Yes No
Transfer Yes No Yes No
Use of lockers Yes No Yes No
2. Have the above policies and procedures been reviewed by an attorney? Yes No
3. Is the student handbook, including the above policies and procedures, distributed to all students at the time of
enrollment? Yes
No At the start of each new school year? Yes No
Please explain any “no” response to question # 2 and #3 _________________________________________________
_______________________________________________________________________________________________
1. Complete the following chart providing the requested financial information:
Indicate the following as it relates to
the Applicant’s fiscal year end (FYE):
(Please indicate negative figures with “( )” or “-“ as appropriate)
Most Recent FYE
(Month/Year)
(_____/_____)
Prior FYE
(Month/Year)
(_____/_____)
Actual Revenues
$
$
Actual Expenditures
$
$
Surplus or Deficit Amount
$
$
Accumulated Surplus or Deficit
$
$
2. If a deficit exists, please explain how and when it will be eliminated: _________________________________________
_________________________________________________________________________________________________
3. How much of the operating revenue/budget is: State Aid? $________________ Federal Aid? $________________
4. Does the Entity have the authority to issue bonds? Yes No
a. What was the date and size of the most recent bond issuance? ___________________________________
b. What is the Entity’s Bond Rating? __________
c. Is a bond vote or issuance planned for the next 12 months? Yes No If Yes, what is the dollar
amount of the bond? $___________________________
d. Has the Entity been in default of principal or interest on any bond during the past 5 years, or will you be in
the next 12 months? Yes
No
If Yes, explain: _____________________________________________________________________________________
5. Does the Entity have the authority to raise taxes? Yes No
6. Has any bond or tax increase been defeated in the past three years? Yes No
If Yes, explain:_____________________________________________________________________________________
7. Do you expect a budget reduction in the next year? Yes No
OPERATIONAL INFORMATION
FISCAL INFORMATION
Page 4 of 12
If Yes, please provide the estimated amount of the reduction and the impact it will have: _______________________
________________________________________________________________________________________________
1. Number of Employees: Full Time: Part Time:
2. Number of Volunteers: How many hours per week do volunteers work on average?
3. Please describe the services performed by Volunteers for or on behalf of your Entity.
4. Salary Ranges Number of full Number of part
(including bonuses, dividends and commissions) time employees time employees
$50,000 or less:
$50,001 to $100,000:
$100,001 and over:
TOTAL:
If you have multiple locations, please list employees by state:
State:
State:
State:
State:
State:
Full-Time
Part-Time
Volunteers
5. Did any of the following take place in the past 3 years?
a. Strike, slowdown, or other staffing disruption? Yes No
b. Disputes involving integration, segregation, discrimination, or violations of civil rights (with staff or
students)? Yes
No
c. Has any employee been suspended, dismissed, demoted, transferred, or had a tenure contract non-
renewed? Yes
No
Please explain all “yes” answers to 5 A-C: _______________________________________________________________
6. Does the Applicant use seasonal or temporary employees? Yes No
If so, when and how many?
Are these employees included in #4 above? Yes No
7. Does the Applicant use leased workers? Yes No
If Yes, how many have been retained by the Applicant in the past 12 months?
Are these employees included in #4 above? Yes No
8. Does the Applicant use independent contractors? Yes No
If Yes, how many work solely for the Applicant?
9. For which of the following services does the Entity or District use subcontractors (check all that apply):
Administrative/Secretarial Accounting/Financial Custodial Food Medical Specialized Education
Transportation Other Please explain in detail: ______________________________________________________
________________________________________________________________________________________________
EMPLOYEES
Page 5 of 12
10. Do you require all subcontractors or independent contractors to provide evidence of carrying liability insurance?
Yes
No Are you added as an additional insured to these policies? Yes No
11. How many employees are covered by collective bargaining or other union agreements?
12. In the past 12 months, how many employees have left your employ?
Of the above, how many were terminated involuntarily?
1. Has the Applicant established written policies/procedures governing teachers & other personnel regarding:
Background checks Yes No
Demotion Yes No
Dismissal Yes No
Drug Testing Yes No
Hiring Yes No
Promotion Yes No
Sexual Harassment Yes No
Suspension Yes No
Transfer Yes No
2. Do you conduct background checks on all:
Applicants? Yes No
New Hires? Yes No
Volunteers? Yes No
3. Please check the appropriate areas for the type of checks performed:
Type
Teachers
Other Employees
Volunteers
Academic Credentials
Credit
Criminal Checks-All States
Criminal Checks-Federal
Criminal Checks-Home State
Driving Record
Licenses
Personal References
Prior Employers
Random Drug Tests (post
hire)
Other: (Describe): ________
_______________________
4. Have the Applicant’s supervising personnel or other employees attended training and education programs/seminars on
sexual harassment and other types of discrimination within the last 12 months? Yes
No
If Yes, who has attended?
If Yes, who conducts the sessions?
EMPLOYMENT PRACTICES & HUMAN RESOURCES
Page 6 of 12
5. Does the Applicant have its employment policies/procedures reviewed by labor or employment Yes No
counsel?
If Yes, identify the firm and date of last review:
6. Does the Applicant have a Human Resources or Personnel Department? Yes No
If No, who handles this function?
7. Does the Applicant have an employee handbook? Yes No
If Yes, does the Applicant distribute it to all employees? Yes No
If Yes, do all employees sign for its receipt? Yes No
If Yes, does it expressly state that it is not a contract and that employment is “at will”? Yes No
8. Does the Applicant have written procedures for handling employee complaints of discrimination Yes No
and/or sexual harassment?
9. Does the Applicant require all terminations to be reviewed by:
The person in charge of human resources? Yes No
Outside counsel? Yes No
10. Does the Applicant maintain a personnel file for each employee? Yes No
1. After inquiry with each person as appropriate does anyone have any other Material Facts to Yes No
disclose? (If Yes, please provide such Material Facts on a separate sheet.)
A Material Fact is one likely to influence assessment of this risk, the premium charged or the terms and conditions
imposed by Underwriters. If you are in any doubt as to whether a fact would be considered material, you should
disclose it. All of the information requested in this proposal is material.
1. Provide the Applicant’s School Board Liability Insurance history below.
Policy Period
(Month/Day/Year)
Insurance
Company
Limits Per Claim/
Aggregate
Deductible
Retro Date
Annual
Premium
2. Has the Applicant ever purchased an Extended Reporting Period for a School Board Liability Yes No
Insurance Policy? If Yes, what date was it purchased and for what duration? _________________________________
3. Does your current School Board Liability policy include Employment Practices Liability (EPL) coverage? Yes No
If “No”, do you have a separate Employment Practices Liability (EPL) policy in place? Yes No
If “Yes”, please proceed to question #3. If “No”, please proceed to question #4.
4. Provide your firm’s recent Employment Practices Liability insurance history below:
OTHER MATERIAL INFORMATION
INSURANCE AND LOSS HISTORY
Page 7 of 12
Policy Period
(Month/Day/Year)
Insurance Company
Limits Per Claim/
Aggregate
Deductible
Retro Date
Annual
Premium
If requesting prior acts coverage you will be asked upon binding coverage to provide a copy of your current insurance
declaration page documenting the expiring retroactive date and limits. Prior acts coverage may not be available if the
date of your current retroactive coverage is different from what we have quoted or if there is any gap between
effective dates.
5. Does the Applicant currently carry General Liability Insurance? Yes No
6. During the past 5 years, has your School Board Liability or Employment Practices policy been canceled Yes No
or non-renewed?
If Yes, please provide the date & explanation:
7. Requested School Board Liability Limits for Each Claim & Aggregate: $500,000 $1,000,000 $2,000,000
$3,000,000 Other $
Requested Deductible (Per Claim): $10,000 $15,000 $25,000 Other
8. Other than routine visits, has the entity had any on-site monitoring visits by a State or Federal Regulatory Agency
within the last 3 years?
Yes
No
If yes, provide the name of the agency, purpose of the visit and results: _____________________________________
___________________________________________________________________________________________________
9. Is the Applicant operating under any court orders? Yes No
If Yes, please explain: _______________________________________________________________________________
10. Has the entity been criticized by the state board of education?
Yes
No
If yes, please attach details including the Applicant’s response.
11. After inquiry with each person as appropriate, in the last five (5) years, have any School Board Yes No
Liability claims, or any wrongful termination discrimination, sexual harassment claims or any other
wrongful employment practices liability claim or suit (including third party claims), ever been made
against the Entity or any predecessor Entity or any current or former member of the Entity or predecessor
Entity (whether insured or uninsured)?
If “Yes,” how many? Please complete a separate Supplemental Claim Form
for each claim or suit and include a currently valued loss run for each claim.
Page 8 of 12
12. After inquiry with each person as appropriate, do you, or any of your board members, trustees, Yes No
regents, or employees know of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident that could result in a School Board Liability claim, or any employment
related claim, including third party claims (whether insured or uninsured)?
If “Yes,” how many? If “Yes,” please complete a separate Supplemental
Claim Form for each potential claim and provide as much details as possible.
13. Of the total number of EEOC/state agency charges filed against any Applicant over the last five years, indicate the
number of primary allegations as follows:
1) Location
No.
2) Racial
Discrimination
3) Age
Discrimination
4) Religious
Discrimination
5) Other Ethic
Discrimination
6) Equal Pay
Act Violation
7) Other
Gender
Discrimination
8) Violation of
Am. With
Disabl. Act
14. With respect to litigated cases (including wrongful termination suits under state law other than antidiscrimination law)
and EEOC/state agency charges over the last five years for which any settlement was or may be paid, please provide
the following information, which must be currently valued:
Date
Occurrence
Claimant
Allegation
Damages Paid
Damages
Reserved
Legal Expenses
Paid
Legal Expenses
Reserved
As part of this Application, please submit the following documents (these documents, and the representations and facts
they contain, are made a part of this Application, whether such documents are physically delivered to the Company by the
Applicant or are obtained by the Company from any public source, including the Internet):
• Currently valued School Board Liability Insurance loss runs for the past 5 years.
• Copy of the Declarations page from your current School Board Liability Insurance Policy
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE 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.
REQUIRED ATTACHMENTS
Page 9 of 12
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE 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.
NOTICE 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.
NOTICE 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 denial of insurance benefits.
NOTICE 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.
NOTICE 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.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
NOTICE 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 a 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 the person to criminal and civil penalties.
NOTICE 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.
NOTICE 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or
omit any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
Applicant: Title:
(Authorized signatory for Applicant Entity)
Applicant’s Signature: Date:
Agent/Broker Name:
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signature
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Page 10 of 12
MANAGEMENT
LIABILITY
SCHOOL
BOARD LIABILITY SUPPLEMENTAL CLAIM APPLICATION
This form is to be completed when the Applicant has been involved in any claim or is aware of an incident which
may give rise to a claim. COMPLETE ONE FORM FOR EACH CLAIM OR INCIDENT.
If space is insufficient to answer any questions fully, attach a separate sheet.
In lieu of attaching suit papers, please provide a complete narrative description of the allegations involved
1. Full Name of Applicant:
2. Full Name of Individual(s) or entity involved in the claim:
3. Additional defendants
4. Full Name of Claimant:
5. Is the Claimant still your student/employee/customer after bringing the claim? Yes No
6. Indicate whether: CLAIM SUIT Incident/Circumstance Only (no claim or suit)
7. Date and location of alleged act, error or omission:
8. Date of claim: Date reported to Insurance Company:
9. What is the status of the claim? Closed/Settled Open/Pending Incident/Circumstance
10. IF CLOSED:
Total paid including deductible(s)? Responses such as “unknown” or “unavailable” are insufficient.
Defense costs
Loss/compensatory damages
Paid by you-out of pocket
$
$
Insurance Company
$
$
Date Resolved: _____/_____/_____ Trial Out of Court
11. IF PENDING:
(a) Claimant’s settlement demand? $ _____ Defendant’s settlement offer (if any): $
(b) Insurer’s reserve amounts? Loss $ Defense $
(c) Amounts already spent defending the claim? By you? $ By the insurer? $
(d) What is your best estimate of the likely settlement amount for this matter? $
(e) What is your best estimate of the date when you expect this claim to be resolved?
Note: Answering “unknown” or “unavailable” to the above questions is an insufficient response.
12. Name(s) of Insurer(s) responding to this claim or incident
Policy Number:
Limits of Liability: Deductible:
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 11 of 12
13. Provide narrative description of suit, claim or incident, including the allegations involved, the potential size of injury
and your response (do not provide suit papers):
_______________________________________________________________________________
14. Explain what action(s) have been taken to prevent reoccurrence of a similar claim and/or steps to better defend/avoid
such allegations in the future: ______
_____________________________________________________________________________________________
_________________________________________________________________________________________________
FRAUD WARNING
NOTICE TO ALABAMA, ALASKA, ARIZONA, ARKANSAS, CALIFORNIA, CONNECTICUT, DELAWARE, GEORGIA, IDAHO, ILLINOIS, INDIANA, IOWA, KANSAS,
MARYLAND, MASSACHUSETTS, MICHIGAN, MINNESOTA, MISSISSIPPI, MISSOURI, MONTANA, NEBRASKA, NEVADA, NEW HAMPSHIRE, NORTH CAROLINA,
NORTH DAKOTA, OREGON, RHODE ISLAND, SOUTH CAROLINA, SOUTH DAKOTA, TEXAS, UTAH, VERMONT, WASHINGTON, WEST VIRGINIA, WISCONSIN,
AND WYOMING APPLICANTS: In some 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, for the purpose of misleading, conceals information
concerning any fact material thereto, may commit a fraudulent insurance act which is a crime in many states.
NOTICE 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 policy holder or
claimant for the purpose of defrauding or attempting to defraud the policyholder or claiming with regard to a settlement or award payable for insurance
proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
NOTICE 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.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of
claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
NOTICE TO HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or
benefit is a crime punishable by fines or imprisonment, or both.
NOTICE 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.
NOTICE 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.
NOTICE 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 denial of insurance benefits.
NOTICE 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.
NOTICE 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.
NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud an 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 $5,000 and the stated value
of the claim for each such violation.
NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she 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.
NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes a any claim
for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Page 12 of 12
NOTICE 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 a 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 the person to criminal and civil penalties.
NOTICE 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.
NOTICE 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.
The Applicant acknowledges that the answers provided herein are based on a reasonable inquiry and/or investigation. The Applicant warrants that the
above statements and particulars together with any attached or appended documents are true and complete and do not misrepresent, misstate or omit
any material facts.
The Applicant agrees to notify us of any material changes in the answers to the questions on this questionnaire which may arise prior to the effective
date of any policy issued pursuant to this questionnaire and the Applicant understands that any outstanding quotations may be modified or withdrawn
based upon such changes at our sole discretion.
Completion of this form does not bind coverage. Applicant’s acceptance of the company’s quotation is required prior to binding coverage and policy
issuance.
All written statements and materials furnished to the company in conjunction with this application are hereby incorporated by reference into this
application and made a part of this application.
I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my
Professional Liability Application. I understand that an incorrect or incomplete statement could void my
protection.
Applicant Name (Print) ______________________________ Title:
Applicant’s Signature: _______________________________ Date:
(Authorized signatory for Applicant Entity)
Agent/Broker Name:
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Completed 2 July 2020

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