Fillable Educational Services & School SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Educational Services & School SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Educational Services & School
SUPPLEMENTAL APPLICATION
Please complete and attach to Acord applications
Please review the policy carefully and discuss the coverage with your insurance advisor.
Please answer all questions completely. If there is insufficient space to complete an answer, please continue on a separate sheet
indicating the question number. This Application must be completed, signed, and dated by an authorized person for the
district. Please include all attachments referenced throughout the Application. Please type or print.
The information requested in this Application is for underwriting purposes only and does not constitute notice to the Insurer
under any Policy of a Claim or potential Claim. All such notices must be submitted to the Insurer pursuant to the terms of the
Policy, if and when issued.
GENERAL INFORMATION SECTION
1) Name of Educational Organization:_____________________________________________________________
2) Telephone number: (___)_________________ Fax number: (___)_______________________
3) E-mail address: ________________________ Web site address: _______________________
4) Contact name: _________________________ Title:___________________________________
5) Type of Educational Organization: __________________________
6) Please indicate how your organization is chartered or incorporated and the original date filed:
________________________________________________________________ _____ /_____/_____
.
7) Do you have a Risk Manager or Safety Officer?
□ Yes□ No
8) Name________________________________ Title:________________________________
9) Do you have a formal safety and loss control program?
□ Yes□ No
10) Do you have program for facility and equipment inspection?
□ Yes□ No
Documented?
□ Yes□ No Frequency________________
11) Are there any vacant or unoccupied school buildings?
□ Yes□ No If “ yes” please provide location,
description, and inspection procedures_______________________________________________
12) Do you have any renovation and/or new building construction planned for the next 12 months?
□ Yes□ No
If yes, please describe type of project and estimated projected cost__________________________________
____________________________________________________________________________________________
13) Does the school require certificates for any contractor?
□ Yes□ No
Amount of Insurance Required?_______________________________________
Do contracts require school to be named as additional insured?
□ Yes□ No
MP 3006 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc., with
its permission.
Page 2 of 7
GENERAL LIABILITY SE
CTION
14) Is there regular outside use of school property? □ Yes □ No, If yes,
Do you have a formal Building Use Form?
□ Yes □ No
15) Do you have Daycare or Latch Key Facilities
□ Yes □ No If “yes”, is it operated by the
school?
□ Yes □ No Number of children daily__________ Age of children______________
16) Bleachers-Please complete the following:
Number with seating capacity of Less than 250 __________________
Number with seating capacity of 251 - 500 ______________________
Number with seating capacity of 501 - 1,000 _____________________
Number with seating capacity of More than 1,000 _________________
17) Does the school have swimming pools?
□ Yes □ No If yes, please complete the following
No Indoor_______ No Outdoor_______ Open to public?
□ Yes □ No
No of diving boards________ Maximum Height__________ Depth __________
18) Please list the school sponsored events or classes relating to any of the following
C
arpentry Program
□ Forestry Program□ Vocational Agriculture □ Aircraft □
Watercraft □ Rifle Range □ Skateboard Parks □ Trampoline □
Rock Climbing Walls□ Rodeo Events □ Wilderness Adventure □ Survival □
19) Does the school have a Student Accident Policy? □ Yes □ No
Is it voluntary or are all students covered? _______________ Are all students athletes required to
Have medical coverage?
□ Yes □ No
20) Does the school have a comprehensive written policy for handling violence?
□ Yes □ No
21) Does the school have a written disaster plan?
□ Yes □ No
22) Does your organization;
Publish written or recorded materials?
Yes No
Have a website, host an internet chat room or message board?
Yes No
Produce commercials, television show or radio show?
Yes No
Please provide details:_________________________________________________________
ADDITIONAL LIABILITY COVERAGES
MP 3006 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc., with
its permission.
Page 3 of 7
23) Plea
se indicate the number of full time equivalent ( FTE ) in each position
Position No. Position No.
Athletic Trainers _____ Nurses _____
Occupational Therapists _____ Psychologist _____
Speech Therapist _____ Speech Pathologist ______
Social Workers _____ Counselor _____
Emergency Medical Technicians _____ Nursing Instructor _____
Nursing Students _____ Veterinary Instructors _____
Veterinary Assistant Students _____ Dental hygienists/assistant Teachers _____
Dental hygienist/assistant Students_____ Other (please describe) _____
____________________________________________________________________________________
____________________________________________________________________________________
24) Total # of Teachers (FTE) ________ Total Employees___________ Volunteers________
___
25
) Total # of students( ADA) Preschool_______ K-8_____ 9-12______
_
26) Does the school have a police department?
□ Yes □ No If yes, # of officers_________
Other police department staff #_______
27) Does the school have Security staff?
□ Yes □ No Total# _________
Are any Security Officers armed? If so #_______________
AUTOMOBILE
28) If the school has a contract for transportation, what limit of liability coverage is required to be carried by
contra
ctor?__________________
__
29) Does the school require and retain a certificate from the transportation contractor?
□ Yes □ No
30) What is the minimum and maximum age permitted for drivers? MIN____ Max____
31) Do you have a formal training, vehicle maintenance and safety program?
□ Yes □ No
32) Are all drivers transporting students required to have CTL’s?
□ Yes □ No
33) Are the CTL random drug and alcohol testing followed?
□ Yes □ No
34) Are regular medical checkups required for drivers?
□ Yes □ No
35) Do you order Motor Vehicles Reports on all drivers at time of hiring?
□ Yes □ No
How often are MVR ordered once employed?__________
MP 3006 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc., with
its permission.
Page 4 of 7
36) Do you have written drivers procedures manual □ Yes □ No
37) What combination of accidents and traffic violations in a three year period is permissible before driver is
Reprimanded?________ Removed from duty?_________
38) If transportation of handicapped or special needs students is needed, are the drivers required to receive
spec
ial training?
□ Yes □ No
37) If employee uses their own personal vehicle on school business, what limits of liability do you require on
the personal automobile policy? $ ________ Copy of policy or certificate retained in file?
□ Yes □ No
ADDITIONAL INFORMATION SECTION:
Provide any additional information that you feel is relevant to our review of your application on a separate page.
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.
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.
MP 3006 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc., with
its permission.
Page 5 of 7
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.
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.
MP 3006 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc., with
its permission.
Page 6 of 7
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.
APPLICANT AUTHORIZATION AND CERTIFICATION:
The undersigned being authorized by, and acting on behalf of, the applicant and all persons or concerns seeking
insurance, has read and understands this Application including the appendixes and any supplements, and declares
all statements set forth herein are true, complete and accurate. The undersigned acknowledges and agrees that the
submission and the Insurer's receipt of such written report, prior to the inception of the policy applied for, is a
condition precedent to coverage.
The undersigned understands the information submitted herein becomes a part of my Educator's Management
Liability Insurance Application.
The signing of this Application does not bind the undersigned to purchase the insurance, nor does review of the
Application bind the insurance company to issue a policy. This Application including any appendixes and
supplemental applications shall be the basis of the contract should a policy be issued
This application must be signed by the ranking elected or appointed official of the Entity making the Application
(e.g. School Board President or Superintendent or equivalent officer) or the Risk Manager (or the Ranking Official
assigned this function).
Date Signed Signature of Applicant
Print Name and Title
SIGNATURE AND AGREEMENTS
THE APPLICANT ACCEPTS NOTICE THAT HE/SHE IS REQUIRED TO PROVIDE WRITTEN
NOTIFICATIONS TO THE COMPANY OF ANY CHANGES IN THE RESPONSES GIVEN TO THIS
APPLICATION THAT MAY HAPPEN BETWEEN THE SIGNATURE DATE BELOW AND ANY PROPOSED
EFFECTIVE DATE.
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MP 3006 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc., with
its permission.
Page 7 of 7
The undersigned is an authorized representative of the applicant and certifies that reasonable enquiry has been
made to obtain the answers to questions on this application. He/She certifies that the answers are true, correct and
complete to the best of his/her knowledge.
Signature of Applicant
____
__________________________
Print Name and Title ______________________________
Date:____________________________________
This application form duly completed, together with any supplementary information must be signed in ink by the
applicant
____________________________________________________________
Please Print Name of Producer
__________________________________________________________________________________
Signature of submitting Producer Date Signed
Retailer Wholesaler
Producing Agency:
Address:
______ _______
Telephone: ( ) ______
General Reminders; Did you remember to:
Complete Acord applications for all applicable coverages requested?
Did you complete each question in all applicable sections as we cannot offer a quote based on
incomplete information?
Did you sign and date all applications?
Did you attach current loss runs?
Did you attach a Statement of Values (if applicable)?
Did you attach an Educators Management Liability Application (if applicable)?
Did you provide a copy of the following?
Employee & Student Handbook
Most Recent Financials
Sexual Abuse & Harassment Policy
Building Use Form
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Educational Services & School SUPPLEMENTAL APPLICATION (Risk Placement Services, Inc.)

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Completed 30 July 2020

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