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

Fill Online, Printable, Fillable, Blank MANAGEMENT LIABILITY APPLICATION (Risk Placement Services, Inc.) Form

Use Fill to complete blank online RISK PLACEMENT SERVICES, INC. pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

MANAGEMENT LIABILITY APPLICATION (Risk Placement Services, Inc.)

On average this form takes 50 minutes to complete

The MANAGEMENT LIABILITY APPLICATION (Risk Placement Services, Inc.) form is 9 pages long and contains:

  • 1 signature
  • 15 check-boxes
  • 187 other fields

Country of origin: US
File type: PDF

Use our library of forms to quickly fill and sign your Risk Placement Services, Inc. forms online.

BROWSE RISK PLACEMENT SERVICES, INC. FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
MP 2004 06 14
Copyright, American Alternative Insurance Corporation, 2013
Includes copyrighted material of the Insurance Services Office, Inc., with
its permission.
Page 1 of 9
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.
A. GENERAL INFORMATION SECTION
1) Named Organization (Applicant):
___________________________________________________________________________
2) Mailing address: _____________________________________________________________________________
(street) (city) (county) (state) (zip code)
3) Telephone number: (___)_________________ Fax number: (___)___________________
4) E-mail address: ________________________ Web site address: _______________________
5) Contact name: _____________________________________
6) Is your organization organized under the not-for-profit status of the Internal Revenue Code?
□ Yes □ No
7) Type of Entity: (Individual, Partnership, Joint Venture, Corporation, Other) __________________________
State of Incorporation (if applicable)_____________________________
8) Date Applicant was organized: _____ /_____/_____. Has the organization operated continuously from
this date?
□ Yes □ No. If no, please explain:______________________________________________________
_____________________________________________________________________________________________
9) Description of operations:______________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
10) Number of years under current management?___________
11) Number of years of management experience?___________
B. POLICY INFORMATION
1) Limit of Liability Desired:
□ $1,000,000 □ $2,000,000 □ $3,000,000 □ Other $ _______________
COV B
& C:
$ 2,500 $5,000 $10,000
$15,000 $20,000 Other
$______
2) Total budget for last fiscal year: $_______________
MP 2004 06 14
Copyright, American Alternative Insurance Corporation, 20013Includes
copyrighted material of the Insurance Services Office, Inc., with its
permission.
Page 2 of 9
3) Did your organization purchase Directors & Officers Liability Coverage in the past? □ Yes □ No (If “yes,”
please provide the following.):
a) Name of D&O insurer: ________________________________________________
b) Policy expiration date: ___________________________________
c) Retroactive date: ________________________________________
d) Limits of liability: $_______________wrongful act; $________________aggregate
e) Self-insured retention or deductible: $___________________
f) Loss history including incurred and paid loss amounts
4) Does the organization carry General Liability insurance?
□ Yes □ No
5) Has any insurer ever refused to renew or cancel your Directors & Officers Liability coverage?
□ Yes □ No(If “yes,” please provide reason.) Missouri Applicants are not required to reply.
____________________________________________________________________________________
C. OPERATIONS & FUNDING SECTION
1) Provide the total number of Employees: full time ______ part time______ temporary ______
2) Provide the total number of Volunteers: __________________
3) Total Number of Locations:___________ Are all locations in the same state?
□ Yes □ No
If No, please list locations by State including Employees per location:
Location# _____ Address: ____________________________________ _____
# of Employees: full time ______ part time______ volunteers_________
Location# _____ Address: ____________________________________
# of Employees: full time ______ part time______ volunteers_________
Location# _____ Address: ____________________________________
# of Employees: full time ______ part time______ volunteers_________
4) Does the board of directors have at least 51% participation by directors not employed by your
organization?
□ Yes □ No
5) Has your organization merged with any other facilities or business enterprises within the past ten years?
□ Yes □ No (If “yes,” list the names and dates of the organization with which your operations have merged).
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
6) Does the organization expect to acquire or be acquired by any other entity within the next year?
□ Yes □ No (If “yes,” please explain on a separate sheet of paper and attach to this application.)
7) Have there been any changes in senior management during the past three years?
□ Yes □ No. (If “yes,”
please explain on a separate sheet of paper and attach to this application.)
8) Does Applicant have financial statements prepared or reviewed by an independent auditing/CPA firm?
□
Yes □ No
9) Provide applicants Gross Annual Revenues for most recent fiscal year: $__________________________
10) Has any accreditation, affiliation or governmental license been suspended, revoked, lapsed or resulted in
a fine or penalty?
□ Yes □ No. (If “yes,” please explain on a separate sheet of paper and attach to this
application.)
11) Provide the following information on all subsidiaries: If none, please check here:
□
Name ________________________________ Name of parent organization__________________
Date of acquisition _____________________ Net worth $_______________________
Percentage of ownership _______________% Total assets $______________________
Nature of operation_____________________ Net income $______________________
MP 2004 06 14
Copyright, American Alternative Insurance Corporation, 20013Includes
copyrighted material of the Insurance Services Office, Inc., with its
permission.
Page 3 of 9
Operated for-profit or non-profit_______________________________________
12) Does the applicant receive donations or contributions from the general public?
□ Yes □ No
13) Please list all other sources which provide 10% or more of the applicant's operating funds:____________
____________________________________________________________________________________________
____________________________________________________________________________________________
14) Does the applicant have an audit committee?
□ Yes □ No.
15) Is the applicant involved in any of the following areas of activity:
Providing administrative or management services to any other entity
□ Yes □ No.
If yes, please provide details: ______________________________________________________________
________________________________________________________________________________________
Engaging in or sponsoring any research, development, experimentation or testing
□ Yes □ No.
If yes, please provide details: ______________________________________________________________
________________________________________________________________________________________
Promoting, sponsoring or providing insurance to members
□ Yes □ No
If yes, please provide details: ______________________________________________________________
________________________________________________________________________________________
Publishing any magazines, periodicals, newsletters or technical manuals
□ Yes □ No.
If yes, please provide details and samples:___________________________________________________
________________________________________________________________________________________
16) Does the organization have involvement in accreditation or standard setting activities?
□ Yes □ No
If yes, please provide details: ______________________________________________________________
________________________________________________________________________________________
17) Does the organization anticipate closing any facilities, reducing staff, or laying off any employees during
the next 2 years?
□ Yes □ No. If yes, please state the reason for the action and identify the number of
employees affected by the action:_______________________________________________________________
____________________________________________________________________________________________
18) Has the named organization or any of its officers, directors or other proposed “insureds” been advised
that he, she, or it is the subject of a complaint, suit, inquiry, investigation or other regulatory or judicial
proceeding by any governmental or self-regulatory entity?
□ Yes □ No (If “yes,” please provide complete
details on a separate sheet of paper and attach to this application.)
D. EMPLOYMENT PRACTICES
1) Annual employee turnover for each of the last three years: _____ Latest Yr. _____ Second Yr. _____Third Yr.
2) How many employees have been terminated or laid off in the past three years? ______
3) Do you have an Employment Application for hiring?
□ Yes □ No
4) Do you publish an employee handbook?
□ Yes □ No If “yes,” is it distributed to all employees? □ Yes □ No
5) Do you provide written performance evaluations for all employees?
□ Yes □ No.
If “yes,” how frequently?
□ biannually □ annually □ every second year
6) Do you have a written, progressive disciplinary program?
□ Yes □ No
7) Do you have a written grievance program?
□ Yes □ No (If “yes,” please attach a copy.)
MP 2004 06 14
Copyright, American Alternative Insurance Corporation, 20013Includes
copyrighted material of the Insurance Services Office, Inc., with its
permission.
Page 4 of 9
8) Do you uniformly perform comprehensive background checks for screening all employment applicants?
□ Yes □ No . Are volunteers subject to the same background checks? □ Yes □ No
9) Does the employment background check include drug or alcohol screening?
□ Yes □ No
10) Has the organization established an affirmative action program?
□ Yes □ No
11) Do you have a written anti-sexual harassment policy?
□ Yes □ No If “yes,” is it distributed annually to
all employees?
□ Yes □ No
12) Do you have a separate human resources or personnel department?
□ Yes □ No (If “no,” how is this
function handled?)
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
13) Do you have a formal orientation program for new employees?
□ Yes □ No
14) Are all managers and employees in supervisory positions provided Human Resource training with
regard to promulgated policies and procedures?
□ Yes □ No
15) Has a specific individual within your organization been assigned the responsibility of receiving and
reporting “incident” reports and loss information?
□ Yes □ No
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
16) Do you have an Employee Assistance Program (EAP)?
□ Yes □ No (If “yes,” please describe.)
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
17) Do you seek counsel from a human resource person or attorney prior to terminating an employee?
□ Yes □ No
18) Do you have outside counsel review your employment handbook?
□ Yes □ No
19) Describe your policy for handling requests for references on past employees.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
20) Has your organization been involved in any grievance or other administrative hearing before a National
Labor Relations Board, Equal Employment Opportunity Commission, Federal Labor Standards, Fair
Labor Standards, Civil Rights Commission, Department of Labor or any governmental agency within the
last five years?
□ Yes □ No (If “yes,” please provide specific details including dates, damages incurred, legal
expenses, current status and description of the circumstances on a separate sheet of paper and attach to this
application.)
E. PAST ACTIVITIES
MP 2004 06 14
Copyright, American Alternative Insurance Corporation, 20013Includes
copyrighted material of the Insurance Services Office, Inc., with its
permission.
Page 5 of 9
1) Are there any pending claims or demands against the Named Organization or anyone for whom this
insurance is intended that may be covered by any similar insurance presently or previously in effect or
currently proposed?
□ Yes □ No
If Yes, please provide complete details:
It is understood and agreed that, if any such claim exists, or any such facts or circumstances exist which
could give rise to a claim, then those claims and any other claims arising from such facts or circumstances
are excluded from the proposed coverage.
2) Has the named organization or any of its directors, officers, or other proposed “insureds” been a part of
any civil or criminal litigation or arbitration proceeding related to the applicant’s activities?
□ Yes □ No.
(If “yes,” please provide complete details on a separate sheet of paper and attach to this application.)
F. PRIOR KNOWLEDGE SECTION
Does anyone for whom insurance is intended have any knowledge or information of any act, error, omission,
fact or circumstance which may give rise to a claim within the scope of the proposed insurance?
□ Yes □ No
If Yes, please provide complete details:
It is understood and agreed that, if such knowledge of or information concerning such act, error,
omission, fact or circumstance exists, any claim arising therefrom is excluded from this proposed
coverage.
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
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 POLICY 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:
A. THIS POLICY APPLIES ONLY TO "CLAIMS" FIRST MADE OR DEEMED MADE AGAINST THE
"INSUREDS" DURING THE "POLICY PERIOD" OR BASIC EXTENDED REPORTING PERIOD.
B. 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.
)
MP 2004 06 14
Copyright, American Alternative Insurance Corporation, 20013Includes
copyrighted material of the Insurance Services Office, Inc., with its
permission.
Page 6 of 9
G. ADDITIONAL REQUIRED MATERIALS SECTION
Please include the followin
g
(
where a
pp
licable
)
:
Complete list of all Directors or Trustees including their name, position, term of office,
and affiliation with an
other outside or
anizations
Complete list of all Officers including their name, position, and affiliation with any other
outside or
g
anizations
Most recent Annual Re
p
ort, includin
g
CPA o
p
inion letters
Latest available interim financial statements
Co
py
of the Charter and B
y
laws of the A
pp
lican
t
Co
p
ies of brochures or other
p
ublications
p
ublished b
y
the A
pp
licant
Or
g
anizational Chart includin
g
an
y
cross holdin
g
s
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 2004 06 14
Copyright, American Alternative Insurance Corporation, 20013Includes
copyrighted material of the Insurance Services Office, Inc., with its
permission.
Page 7 of 9
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.
MP 2004 06 14
Copyright, American Alternative Insurance Corporation, 20013Includes
copyrighted material of the Insurance Services Office, Inc., with its
permission.
Page 8 of 9
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 2004 06 14
Copyright, American Alternative Insurance Corporation, 20013Includes
copyrighted material of the Insurance Services Office, Inc., with its
permission.
Page 9 of 9
NOTE:
This Application must be signed by the Chairman and/or Chief Executive Officer of the Named Organization
acting as the authorized Agent of the Applicant applying for this insurance.
___________________________________________________
Printed Name of Chairman of the Board or Chief Executive Officer
___________________________________________________
Signature of Chairman of the Board or Chief Executive Officer
___________________________________________________
Title
___________________________________________________
Date
INSURANCE AGENT INFORMATION:
Agency name: __________________________________________________________________________________
Contact person: __________________________________________________________________________________
Agency address: __________________________________________________________________________________
____________________________________________________________________________________________________
Telephone number: _____________________________ Fax number: ____________________________
E-mail address: __________________________________________________________________________________
click to sign
signature
click to edit
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

MANAGEMENT LIABILITY APPLICATION (Risk Placement Services, Inc.)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 23 November 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document