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Page 1 of 11
PUBLIC ENTITY AND EMPLOYMENT PRACTICES LIABILITY APPLICATION
1. Legal name of the Public Entity who is the primary applicant and will be the first named insured listed on the policy:
2. Please list all other entities / organizations that you are requesting to be a named insured on the policy (a request does
not guarantee that all such entities will be quoted / covered):
3. Principal Address:
City: State: Zip:
Public Entity’s Website: www.
4. Do you have a Full Time Risk Manager? Yes No
If “yes” – how many years has the Risk Manager been in this position? years
Name of Risk Manager: Phone Number: ( ) -
5. Type of Public Entity: Town City County State
Special District or Commission (Please Indicate):
Airport
Parks Department
Transit Authority
Development/Finance Authority
Port Authority
Utility (Gas/Electric/Cable)
Housing Authority
Sports/Convention Center
Water/Sewer
Other:
6. Populations Trends: Please provide Population information:
CURRENT YEAR
PRIOR YEAR
2
nd
PRIOR YEAR
Seasonal increase in population? Yes % No
7. Are the Public Entity’s board, council or commission members appointed or elected? Appointed Elected
a. If APPOINTED, by whom?
b. If ELECTED, are they elected via: Single Member District At Large Combination of Both
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 11
+
-
+
+
-
-
Please provide the following information. If “Yes” to any question below, or if the applicant has budget deficits in the past
three years, please explain on a separate attachment.
1. a) Indicate fiscal year end date:
b) Please provide a budget figure for the current and prior two fiscal years:
CURRENT YEAR
PRIOR YEAR
2
nd
PRIOR YEAR
Revenues
$
$
$
Expenditures
$
$
$
Surplus/Deficit
$
$
$
Outstanding Bond Issues
$
$
$
Budget Surplus (Deficit)
$
$
$
c) Has any State or Federal funding (aid) been eliminated in the past year?
Yes No
d) Does the Public Entity anticipate any special project which will result in a
substantial budget increase or decrease in the next 3 years?
Yes No
e) Has the Public Entity been in default on principal or interest on any bond?
Yes No
If you selected “yes” to either C, D, or E, please provide a narrative explanation including dates and amounts involved.
2. Latest bond rating (Standard & Poor’s or Moody’s): Previous Rating:
3. Please attach a copy of your most recent comprehensive annual financial report.
Please respond to the following inquiries and use a separate attachment for details requiring further explanation.
1. Does the public entity administer any of the following operations?
For “yes” responses, please complete the applicable questions.
A. Authorities
a) Airport Authority
Yes No
1. Is the airport Owned Operated Leased
2. Is management of the airport contracted to a third-party?
Yes No
3. Have flight patterns changed in the last 180 days?
Yes No
b) Housing Authority
Yes No
1. Provide # of housing units operated
2. Are buildings tested for lead paint?
Yes No
3. If lead paint is present, do you have a remediation plan to correct the situation?
Yes No
4. Is there a policy to house senior citizens and disabled persons on lower floors?
Yes No
5. Is there a policy regarding fair housing opportunities?
Yes No
6. Are monthly inspections of all locations performed?
Yes No
c) Port Authority
Yes No
1. # of employees Lake Ocean River
GENERAL INFORMATION
OPERATIONS
Page 3 of 11
d) Transit Authority
Yes No
1. # of vehicles operated:
2. Types of vehicles operated:
B. Utilities
a) Electric Utility
Yes No
Provide # of users: Annual Revenues: $
Residential Commercial Industrial
1. Does utility own or maintain distribution lines?
Yes No
2. Are distribution lines buried?
Yes No
3. Does the utility monitor electromagnetic fields?
Yes No
4. Does the utility generate electricity?
Yes No
b) Gas Utility
Yes No
Provide # of users: Annual Revenues: $
Residential Commercial Industrial
c) Water / Sewer Utility
Yes No
Provide # of users: Annual Revenues: $
Residential Commercial Industrial
C. Zoning / Safety
a) Building Inspection
Yes No
1. Do you have a formal process for application and approval of permits?
Yes No
2. Estimate number of denials during past year:
b) License Issuance
Yes No
1. Do you have a formal process for application and approval of licenses?
Yes No
2. Estimate number of denials during past year:
c) Permit Issuance
Yes No
1. Do you have a formal process for application and approval of permits?
Yes No
2. Estimate number of building permits granted in the past year :
3. Estimate number of building permits denied in the past year :
d) Police Department
Yes No
1. If no, who provides service?
e) Tax Assessment / Collection
Yes No
1. Do you reassess real property on a regular basis?
Yes No
2. If so, how often?
If not, when was the last reassessment of all real property in the entity’s jurisdiction?
f) Zoning
Yes No
1. Approximate # of zoning variations granted during the preceding 12 months:
2. Is there a formal procedure in place for granting of variances?
Yes No
3. Is there a policy prohibiting zoning board members from voting on zoning action
which might affect a business they own, invest in, or are employed / retained by?
Yes No
Page 4 of 11
4. Is there a policy requiring persons disclose such relationships?
Yes No
5. Does the public entity’s attorney attend all zoning board meetings?
Yes No
6. Do you have a master plan for economic development?
Yes No
7. What is the date of the most recently issued Master Plan? / /
D. Other
a) Daycare
Yes No
1. Are services for: Children Adults
2. # of beds:
b) Hospital / Nursing Home
Yes No
1. Is hospital: Owned Operated Leased
2. # of beds:
c) Landfill
Yes No
1. Is landfill: Open Closed Hazardous Waste
2. Are any sites designated as Superfund Sites?
Yes No
3. Is any new landfill being considered or opened during the next 24 months?
Yes No
d) Other Not Listed
Yes No
1. Please Describe:
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 Time Employees
Number of Part Time Employees
(including bonuses, dividends, and commissions)
$50,000 or less:
$50,001 to $100,000:
$100,001 and over:
TOTAL:
Number of employees in each category:
Accountants
Engineers
Police
Architects
Fire/Rescue
Road / Utilities
Attorneys
General Office
Other:
EMPLOYEES
Page 5 of 11
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 with 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 “yes” - when and how many?
7. Does the Applicant use leased workers?
Yes No
If “yes” – how many have been retained by the Applicant in the past 12 months?
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 Public Entity use subcontractors (check all that apply)
Administrative / Secretarial
Custodial
Medical
Transportation
Accounting / Financial
Food
Specialized Education
Other
Please explain in detail:
10. Do you require all subcontractors or independent contractors to provide evidence of
carrying liability insurance?
Yes No
If “yes” - 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 all 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
EMPLOYMENT PRACTICES & HUMAN RESOURCES
Page 6 of 11
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
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:
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?
5. Does the Applicant have its employment policies/procedures reviewed by labor or
employment counsel?
Yes No
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 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 and/or sexual harassment?
Yes No
9. Does the Applicant require all terminations to be reviewed by:
The person in charge of human resources?
Outside Counsel?
Yes No
Yes No
10. Does the Applicant maintain a personnel file for each employee?
Yes No
Page 7 of 11
1. After inquiry with each person as appropriate, does anyone have any other Material
Facts to disclose? (If “yes” – please provide such Material Facts on a separate sheet.)
Yes No
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 Public Entity's 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 Public Entity
Liability Insurance Policy?
Yes No
If “yes” – what date was it purchased and for what duration?
3. Does your current Public Entity's 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 #4. If “no” – please proceed to question #5
4. Provide your firm’s recent Employment Practices Liability insurance history below:
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.
OTHER MATERIAL INFORMATION
INSURANCE AND LOSS HISTORY
Page 8 of 11
5. Does the Applicant currently carry General Liability Insurance?
Yes No
6. During the past 5 years, has your Public Entity's Liability or Employment Practices policy
been canceled or non-renewed?
Yes No
If “yes” – please provide the date & explanation:
7. Requested Public Entity's 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 Agency within the last 3 years?
Yes No
If “yes” – please explain:
9. Is the Applicant operating under any court orders?
Yes No
If “yes” – please explain:
10. After inquiry with each person as appropriate, in the last five (5) years, have any Public
Entity 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)?
Yes No
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.
11. In the last 5 years, have any of the following taken place:
a. Grand Jury investigations into activities of any official or employee?
Yes No
If “yes” – please provide details
b. Indictment of any official or employee?
Yes No
If “yes” – please provide details
12. After inquiry with each person as appropriate, do you, or any of your board members,
trustees, or employees know of any circumstances, acts, errors, omissions, or any
allegations or contentions of any incident that could result in a Public Entity Liability
claim, or any employment related claim, including third party claims (whether insured or
uninsured)?
Yes No
If “yes” – how many?
Please complete a separate Supplemental Claim Form for each potential claim and
provide as much detail as possible.
Page 9 of 11
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:
Location
No.
Racial
Discrimination
Age
Discrimination
Religious
Discrimination
Other Ethnic
Discrimination
Equal Pay Act
Violation
Other Gender
Discrimination
Violation of
Americans w/
Disabilities Act
14. With respect to litigated cases (including wrongful termination suits under state law other than anti-
discrimination law) and EEOC/State agency charges over the last five years for which 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 Public Entity Liability Insurance loss runs for the past 5 years.
Copy of the Declarations page from your current Public Entity 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 10 of 11
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.
Page 11 of 11
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:
Page 1 of 3
PUBLIC ENTITY 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. If an Employment Practices Liability Claim, is the Claimant still your employee 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.
APPLICANT’S INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 3
12. Names of Insurer(s) responding to this claim or incident:
Policy Number:
Limits of Liability: Deductible:
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.
Page 3 of 3
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.
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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