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Page 1 of 12
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
PRIVATE ORGANIZATION MANAGEMENT LIABILITY APPLICATION INCLUDING
EMPLOYMENT PRACTICES AND FIDUCIARY LIABILITY
REQUESTED COVERAGE
Available Coverage Section
Limit of
Insurance
Each
Claim
Limit of
Insurance
Aggregate
Separate or
Shared
Limits of
Insurance
Deductible
Retroactive
Date
Prior or Pending
Litigation Date
Directors & Officers Liability
Coverage
Employment Practices Liability
Coverage
Fiduciary Liability Coverage
1. Legal name of the business which is the primary applicant and will be the first named insured listed on the policy:
2. Please describe the nature of the Applicant’s business:
3. Please list all other business/dba names, including subsidiaries for which you are seeking coverage under this policy:
Name of Subsidiary
Private Co. or
Nonprofit Org.
4. 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):
5. Primary location address:
6. County of primary location: Date business originally established:
7. Type of Company: (Corp., partnership, LLC, JV, LLP, Other (box format)
8. Total number of branches: List all addresses for additional branches:
9. What is your web-site address? www.
10. 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?
11. Does the Applicant have foreign operations? Yes No
GENERAL INFORMATION
Page 2 of 12
12. Does any entity own or control your business or does your business own or control any entity? Yes No
13. During the past five years, has your name been changed or has any other business purchased, Yes No
merged or consolidated with you?
1. In the next 12 months (or during the past 24 months) is the Applicant contemplating (or has
the Applicant completed or been in the process of completing) the following:
a. Any actual or proposed merger, acquisition, or divestiture? Yes No
b. Any creation of a new organization, subsidiary, or division? Yes No
c. Any reorganization or arrangement with creditors under federal or state law? Yes No
d. Any branch, location, facility, office, or subsidiary closings, consolidations, or layoffs? Yes No
(If any of the questions above were answered Yes, please provide full details, including the timing, the essential terms of
the event, arrangement, impact on employee base and the surrounding circumstances.)
2. Is the Applicant managed or administered by any third party under contract or agreement? Yes No
3. Does the Applicant manage or administer any entity (other than the Applicant Entity) under Yes No
contract or agreement? (If Yes, please provide full details.)
4. Does the Applicant currently carry General Liability Insurance? Yes No
5. Does the applicant participate in any of the following activities:
Franchising? Yes No
Joint Ventures? Yes No
DIRECTORS AND OFFICERS (Complete only if applying for this coverage)
1. Please attach a list of all members of the Board of Director’s including name, affiliation and nomination date.
2. How many board meetings occur on an annual basis: _____________
3. What is the total number of Applicant’s voting shareholders: ___________
4. What is the total number of shares owned by the Directors and Officers: __________
Please list respective percentages of voting shares owned by D’s and O’s on a separate attachment.
5. Are there any shareholders (other than represented in (b) above) who hold more than 5% of the voting shares?
(If Yes, please provide details)
6. Have there been any changes to the applicants Board of Directors or key executives
in the past 12 months? (If Yes, please attach full details.) Yes No
Or contemplating any changes in the next 12 months? (If Yes, please provide full details.) Yes No
7. Does the Applicant’s charter or by-laws contain indemnification provisions? Yes No
8. Does the Applicant or any Subsidiary perform any of the following services:
• Render any professional services or engage in any standard setting, accrediting, credentialing or licensing
activities? (If Yes, please provide full details.) Yes
No
1. Complete the following chart providing the requested financial information:
ORGANIZATION INFORMATION
FINANCIAL INFORMATION
Page 3 of 12
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)
(_____/_____)
Total Assets
$
$
Total Liabilities
$
$
Total Revenues
$
$
Net Income (Net Loss)
$
$
Cash flow from Operations
$
$
2. Is the Applicant currently (or has it been in the past 24 months) in violation of, or has Yes No
it received an amendment to any debt covenant?
(If Yes, please provide full details.)
3. Does the Applicant or any Subsidiary have any plans to raise capital in the next twelve months? Yes No
(If Yes, please provide full details.)
1. Employee Count: Current Year Previous Year
a. Full Time __________ ___________
b. Part Time (include leased and seasonal) __________ ___________
c. Independent Contractors __________ ___________
d. Volunteers __________ ___________
2. 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
3. How many employees are covered by collective bargaining or other union agreements?
4. In the past 12 months, how many officers have left your employ?
Of the above, how many were terminated?
5. In the past 12 months, how many other employees have left your employ?
Of the above, how many were terminated?
1. In the past twelve (12) months, has your total number of employees decreased by more Yes No
than ten percent (10) or five (5) employees, whichever is greater, through any reduction
in force, systematic lay-off, closure of any division, office or facility that you own or operate
Or for any other reason? (If Yes, please provide full details.)
EMPLOYMENT PRACTICES LIABILITY (Complete only if applying for this coverage)
Page 4 of 12
2. In the next twelve (12) months, do you anticipate the total number of employees Yes No
to decrease by more than ten percent (10%) or five (5) employees, whichever is
greater, through any reduction in force, systematic lay-off, closure of any division, office
or facility that you own or operate or for any other reason?
(If Yes, please provide full details.)
3. If during the next 12 months, circumstances of which are you currently unaware make it Yes No
necessary for you to decrease the number of your employees by ten percent (10%) or five (5)
employees, whichever is great, through the implementation of any reduction in force,
systematic layoff, closure of any division, office or facility that you own or operate or for any other reason (with
any such reduction, lay-off or closure not known, anticipated or planned by
you as of the date of this Application), do you agree that you will consult with, and adopt the
advice of, a lawyer who specializes in labor and employment law (may include in-house
counsel, but only if that counsel if qualified and experienced in the practice of labor and
employment law) as respects the implementation of such reduction, lay-off or closure?
(If No, please provide full details.)
4. Does the Applicant anticipate any merger, acquisition, or addition of any operations that Yes No
would comprise a twenty-five percent (25%) or ten (10) employees, whichever is greater,
increase over the current number of employees? (If Yes, please provide full details.)
5. Has any insurer ever cancelled or non-renewed the Applicant or its predecessor for this Yes No
type of coverage? (If Yes, please provide full details.)
1. Does the Applicant have written employment agreements with all officers? Yes No
2. Have the Applicant’s managers and/or supervisors attended training and education programs/ Yes No
seminars on sexual harassment and other types of discrimination within the last 12 months?
If Yes, who has attended?
If Yes, who conducts the sessions?
3. 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:
4. Does the Applicant have a Human Resources or Personnel Department? Yes No
If No, who handles this function?
5. 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 up 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
6. Does the Applicant have written procedures for handling employee complaints of discrimination Yes No
and/or sexual harassment?
7. Does the Applicant require all terminations to be reviewed by:
The person in charge of human resources? Yes No
Outside counsel? Yes No
8. Does the Applicant maintain a personnel file for each employee? Yes No
1. Estimated number of employees with customer/client contact:
HUMAN RESOURCES
THIRD PARTY INFORMATION
Page 5 of 12
2. Please describe the frequency and nature of customer/client interactions.
3. Has the Applicant or its predecessors ever received a complaint, formal or informal, from a Yes No
non-employee, such as a customer, client, or prospective customer or client complaining about
discrimination or harassment by the Applicant or any employee of the Applicant?
(If Yes, please provide details on a separate sheet.)
4. Does the Applicant conduct staff training on client and customer relations issues such as Yes No
avoiding discriminatory behavior?
5. Are there procedures for reporting and dealing with complaints by customers/clients? Yes No
6. Is the Applicant in compliance with Title III of the Americans with Disabilities Act Yes No
(building and premises requirements)?
FIDUCIARY LIABILITY (Complete only if applying for this coverage)
Full Name of Plan
Type of Plan*
Defined Contribution = DC; Defined Benefit = DB; Excess Benefit Plan = EB; Welfare Benefit Plan = WB; Employee Stock
Ownership Plan = ESOP
1. Is any listed Plan a multiemployer or multiple employer plan? Yes No
If yes please provide detail and if merger activity is anticipated.
2. Does the Applicant or any Subsidiary utilize a Plan investment manager? Yes No
If so, what % of Plan assets are managed by the manager as defined by ERISA? _________
3. How often are plan guidelines and goals reviewed and/or amended by the fiduciaries? __________
4. Have any plans been spun-off, merged or terminated in the last two years? Yes No
5. Does the Applicant or any Subsidiary expect any reduction in benefits, cessation of benefits,
or increase in costs to the Plan participants as a result of any plan amendment anticipated
in the next twelve months? Yes No
Was any such amendment adopted within the last two years? 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.
OTHER MATERIAL INFORMATION
Page 6 of 12
1. Provide your firms most recent Directors and Officers insurance history below:
Insurance
Company
Limits Per Claim/
Aggregate
Deductible
Policy Period
(Month/Day/Year)
Retro
Date
Annual
Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
2. Does your expiring D&O policy also include Employment Practices Liability (EPL) insurance and/or Fiduciary Liability
insurance? Yes
No
If “No”, do you have a separate Employment Practices Liability (EPL) or Fiduciary policy in place? Yes No
3. Provide your firms recent Employment Practices Liability insurance history below:
Insurance
Company
Limits Per Claim/
Aggregate
Deductible
Policy Period
(Month/Day/Year)
Retro
Date
Annual
Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
4. Are you being canceled or non-renewed by your current employment practices liability carrier? Yes No
If Yes, please explain why:
5. After inquiry with each person as appropriate, in the last five (5) years, have any Directors and Officers claims,
or any wrongful termination, discrimination, sexual harassment or any other wrongful employment practices liability
claim or suit, including third party claims, ever been made against the Firm or any predecessor firm or any current or
former member of the Firm or predecessor firm? Yes
No
If “Yes,” how many?
6. After inquiry with each person as appropriate, do you, or any of your partners, officers, Yes No
directors, or employees know of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident that could result in a Directors and Officers claim, or any employment related claim,
including third party claims?
If “Yes,” how many?
INSURANCE AND LOSS HISTORY
Page 7 of 12
If Yes to questions 5 or 6, please complete a separate Supplemental Claim Form for (1) each claim or suit and include a
currently valued loss run for each claim, and (2) for each potential claim and provide as much detail as possible.
7. 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
ADA
8. 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
9. Provide your firms most recent Fiduciary Liability Insurance history below:
Insurance
Company
Limits Per Claim/
Aggregate
Deductible
Policy Period
(Month/Day/Year)
Retro
Date
Annual
Premium
Current Year
Previous Year 1
Previous Year 2
Previous Year 3
Previous Year 4
10. a. Does your expiring Fiduciary Liability Insurance policy include Employee Benefits Liability Yes No
(EBL) coverage?
b. Does your expiring Commercial General Liability Insurance policy include Employee Yes No
Benefits Liability (EBL) coverage?
11. Are you being canceled or non-renewed by your current Fiduciary Liability carrier? Yes No
If Yes, please explain why:
12. After inquiry with each person as appropriate, has any Fiduciary or any Directors or Officers Yes No
had a Fiduciary Liability claim or been alleged or found guilty of any Fiduciary breach of duty?
If “Yes”, how many? Please complete a separate Supplemental Claim Form for Yes No
each claim or suit and include a currently valued loss run for each claim.
Page 8 of 12
13. After inquiry with each person as appropriate, do you of any Fiduciary, or any of your partners, Yes No
officers, directors, or employees know of any circumstances, acts, errors, omissions, or any allegations
or contentions of any incident that could result in a Fiduciary Liability claim?
If “Yes,” how many? If “Yes,” please complete a separate Supplemental
Claim Form for each potential claim and provide as much details as possible.
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.
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):
• Most recent annual consolidated audited financial statement
• If requesting EPL, a copy of applicant’s Employee Handbook
• If impact of Applicant layoffs is either 10% of the workforce or more than 100 employees, complete the Downsizing
Supplemental Application.
• If requesting Fiduciary, provide the most recent audited statements for all plans. If exempt from filing audited
statement, provide the most recent Form 5500 for each plan.
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.
REQUIRED ATTACHMENTS
Page 9 of 12
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 applications.
Applicant: Title:
(Must be signed by a Director of Human Resources or other
Principal, Partner, or Officer of the Firm)
Applicant’s Signature: Date:
Agent/Broker Name:
click to sign
signature
click to edit
Page 10 of 12
PRIVATE
MANAGEMENT LIABILITY SUPPLEMENTAL CLAIM APPLICATION INCLUDING
EMPLOYMENT PRACTICES AND FIDUCIARY LIABILITY
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 client after bringing the claim? Yes No
Before or after this claim, did you perform other professional services for this Claimant unrelated Yes No
to this claim?
If Yes to either question, please explain.
6. Before this claim, had you sued or otherwise pursued collection efforts against the Claimant for Yes No
unpaid fees for your professional services?
7. Indicate whether: CLAIM SUIT Incident/Circumstance Only (no claim or suit)
8. Date and location of alleged act, error or omission:
9. Date of claim: Date reported to Insurance Company:
10. What is the status of the claim? Closed/Settled Open/Pending Incident/Circumstance
11. 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
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 11 of 12
12. 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.
13. Name(s) of Insurer(s) responding to this claim or incident
Policy Number:
Limits of Liability: Deductible:
14. Provide narrative description of suit, claim or incident, including the allegations involved, the potential size of injury
and your response:
15. Explain what action(s) have been taken to prevent reoccurrence of a similar claim: ______
_____
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.
Signature of Applicant/Title/Date (Must be signed by a Principal, Partner or Officer of the Firm)
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.
Page 12 of 12
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 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:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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KINSALE PRIVATE ORGANIZATION MANAGEMENT LIABILITY APP PACKAGE 310002-P (497) page 1 of 11

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Completed 2 July 2020

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