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RELIGIOUS INSTITUTION PACKAGE (Risk Placement Services, Inc.)

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RELIGIOUS INSTITUTION
PACKAGE
New Business Application
All Questions Must Be Answered In Full
To:
From: (Producer)
AJG Branch:
General Comments About The Risk:
Named Applicant (Insured):
Address:
City:
County:
State:
Zip:
mm/dd/yy
mm/dd/yy
mm/dd/yy
Maximum $1,000,000
Index for sections referred to in this application
Section I - Property
Section II - Comprehensive General Liability
Section III - Automotive Liability
Section IV - Miscellaneous Liability - Errors & Omissions/Employee Practices/Sexual Abuse
Section V - Excess Workers' Compensation/Employers' Liability
Section VI - Employee Benefit Liability
Section VII - Crime
A.
PROPOSED PLAN LIMITS
XS SIR
XS SIR
$
$
Minimum $100,000
$
Expiration Date:
Target Loss Fund:
Anticipated Inception Date:
Target Price:
Quote Required By:
Excess Loss Fund Protection Limit:
Please note: Section II, III, IV and VI all constitute part of the same combined single limit when two or more sections are
involved in the same occurrence.
SECTION I - PROPERTY
Maintenance Deductible
All Risks of Physical Loss or
Damage: maximum limit $975,000 x/s
$25,000, SIR $100 minimum
Please note: Higher limits and Lower SIR's may be available on request.
Earthquake: maximum $975,000 annual
aggregate x/s $25,000 SIR $100
minimum maintenance deductible
GENERAL INFORMATION
XS SIR
Flood: maximum $975,000 annual
aggregate x/s $25,000 SIR $100
minimum maintenance deductible
B.
COVERAGE TO INCLUDE
(Please check Yes or No and detail both Projected and Expiring Values)
Yes No
X
X
X
X
X
X
X
X
X
X
X
X
X
X
AUTOMATIC SUB-LIMITS
C.
PROPERTY INFORMATION REQUIRED
(All Values to be expressed 100%)
1. Please forward a complete Electronic Property Schedule.
(Excel Spreadsheet Format preferred)
2. Largest Valued Location:
(Policy Provides First Party Cover Only)
Extra Expense
$0
Loss Of Rents
Accounts Receivable
Valuable Papers and Records
EDP Equipment
Fine Arts
Automatic $250,000
$0
$0
$0
Expiring
$0
$0
Total Number of Locations
Please Note: $ values must be given for all items
where coverage is required.
Miscellaneous (Specify)
Course Of Construction
Coverage
Total Buildings
Total Contents
Business Interruption
Business Interruption
(other than Rental Income)
Tuition Fees
EDP Media
$0
Coverage
Property In Transit
X
Ground-Up Sub Limit If Not Full Limit Projected Values
$0
$0
$0
$0
$0
$0
$0
Mobile Equipment
$0
$0
$0
$0
$0
$0X No Specific Sublimit Required
$0
X
ACV Basis
Auto Physical Damage
Underground Property
(Provide Details Separately)
EDP Extra Expense
Automatic Sub-Limit
Please provide description if greater than $250k
Values If Greater than
Automatic Sub-Limits
$0
Total Insurable Values
Please provide description if greater than $250k
Garage Keepers' Legal Liability
Automatic $250,000
Please provide description if greater than $250k
Automatic $250,000
Proposed
Expiring
Description of Location:
a. Real and Personal Property
b. Business Interruption/Extra Expense
c. All Other Values
d. Total Values
3. Total ACV at highest value garage location
Yes No
4. Is Flood coverage required?
*Subject to minimum $500,000 deductibles per Building, Contents per Building and Business Interruption (Flat)
Yes No
5. Is Earthquake coverage required?
California New Madrid
Zone A IV
Zone B V
Zone C VI
Zone D VII
Zone E VIII
Totals
Yes No
6. Is Coastal Wind coverage required?
Please include all Wind Values within five miles of the Coast
7. Construction / Protection Details:
a. Approximate percentage of Total Values (Buildings and Contents) and actual number of Locations for the following classifications:
Location (s)
Location (s)
Location (s)
Location (s)
Location (s)
Location (s)
b. Give percentage of Total Values (Building and Contents) and actual number of Locations with the following protections:
Location (s)
Location (s)
Location (s)
$
$
Totals
0
$
$
$
$
Flood Zone V*
Total Insured Values
Flood Zone A*
$
No. Of Locations
$0
$
$
0
0
$0
$0
$
$
$0
No. Of Locations
Total Insured Values
$
%
$
$
No. Of Locations
Total Insured Values
$
$
$
%
%
%
%
Other - Please Describe
Wind Resistive
Sprinklered
Frame
Brick
Non-Combustible
%
%
Fire Resistive
Burglar Alarms
%
Central Station Alarms
%
Location (s)
Location (s)
Location (s)
D.
CURRENT PROPERTY PROGRAM DETAILS
A.
PROPOSED PLAN LIMITS
XS SIR
B.
GENERAL UNDERWRITING INFORMATION
1. Description of Applicant and Operations
5. Does the Assured have Social Service Agencies?
6 .
7. Schools
Limit
Other - Please Describe
%
SIR/Deductible
Carrier
SECTION II - COMPREHENSIVE GENERAL LIABILITY
Swimming Pools
Nurses
Religious/Clergy
Trustees/Board Members
Counsellors (Other than Clergy)
(Complete supplemental application if coverage is required)
(Complete supplemental application if coverage is required)
Day Care Facilities
Nursing Homes
Projected
Maximum limits $975,000 XS Minimum $25,000 SIR
Please note: Higher limits and Lower SIR's may be available on request.
Please Note: This section is a key part of the underwriting review process and therefore please give as much general information about the applicant as
possible.
Projected
Expiring
2. Parishes/Churches
3. Parishioners/Members
Yes
No
4. Total Payroll
Any unusual or significant exposures
(Complete supplemental application (Homes for Aged, Retirement Communities,
Shelters for Women/Children/Homeless/Unwed Mothers/Drug
Rehabilitation/Adoption Facilities or other Habitational exposures.)
Number Of Schools
Full Time Students
Part Time Students
Teachers
%
Smoke Detectors
Security Guards
%
Current Premium
Projected Projected Projected Projected
0 0 0 0 0 0 0 0
8. Independent Contractors
Does the applicant use/require: Independent contractors?
If Yes, Please check type
Construction
Bus Transportation
Does the Applicant require the following:
Certificates of Insurance
Applicant is named as an Additional Insured on Contractor's Policy
Hold Harmless Agreements on all contracts
C.
COVERAGE TO INCLUDE
Please check Yes or No, and detail ground-up limit if required:
Yes No
Current Comprehensive General Liability Program Details:
(Please check Claims Made or Occurrence - If Claims Made, please provide Retro Date mm/dd/yy)
A.
PROPOSED PLAN LIMITS
XS SIR
B.
COVERAGE TO INCLUDE
Please check Yes or No, and detail ground-up limit if required:
Yes No
Expiring
Total
(Complete supplemental application if coverage is required for athletics and dormitories, if school has organised athletic competition
and/or if school has boarding students)
Elementary
High School
College
Totals
Expiring
Total
Expiring
Total
Expiring
Total
Host Liquor/Liquor Law Liability
Medical Payments - Premises (Maximum $10,000 per person)
Coverage
Limits are equal to or greater than those carried by the applicant
SECTION III - AUTOMOTIVE LIABILITY
Is current coverage
Comprehensive General Liability
Ground-Up Sub Limit if not Full Limit
Claims Made
Occurrence
Retro Date
Current Premium
Limits
SIR/Deductible
Carrier
Coverage
Cemetery Malpractice
Ground-Up Sub Limit if not Full Limit
Maximum limits $975,000 XS Minimum $25,000 SIR
Please note: Higher limits and Lower SIR's may be available on request.
No
Yes
Yes
No
7. Schools
Number Of Schools Full Time Students Part Time Students Teachers
C.
VEHICLE SUMMARY
D.
CURRENT AUTO LIABILITY PROGRAM DETAILS
A.
PROPOSED PLAN LIMITS
(CLAIMS MADE)
XS SIR
XS SIR
B.
EMPLOYMENT PRACTICE / CIVIL RIGHTS / DISCRIMINATION
3. Brief description of how these complaints are dealt with.
Errors & Omissions maximum limit $1,975,000/$1,975,000 Annual
Aggregate XS minimum $25,000 SIR.
Employment practices maximum limit $1,975,000/$1,975,000 annual
aggregate XS minimum $25,000 SIR.
Please note: Higher limits and Lower SIR's may be available on request.
Please complete separate Supplemental Application form if coverage required.
1. Has any person, former employee or job applicant made a claim alleging unfair or improper treatment regarding employee hiring, remuneration,
advancement or termination of employment?
2. Brief description of how the insured evaluates their employee complaint procedure.
Limit
Expiring:
0
Current Premium
Motor Bikes
Total:
0
Buses and Vans with seating capacity greater than 11 (other than 15 seater Passenger Vans)
15 Seater Passenger Vans
Medium Trucks (over 10,001 to 20,000Ibs. GVW)
Heavy Trucks (over 20,000Ibs. GVW)
Vans (other than noted below), Pickups and All Other Light Trucks (up to 10,000Ibs. GVW)
Please detail the number of vehicles:
All Other Private Passenger Cars
No Fault
Medical Payments Auto (Maximum $10,000 per person)
Underinsured Motorists
Uninsured Motorists
SECTION IV - MISCELLANEOUS ERRORS & OMISSIONS / EMPLOYEE PRACTICES
SIR/Deductible
Carrier
4. How frequently are supervisors required to be trained/retrained?
5. Advise how these procedures are reviewed and updated.
6. Any known incidents/claims/pending litigation?
If Yes, Please describe. Include uncured amounts.
Note: Policies are different than procedures, but sometimes contained within one document.
Retro Date:
A.
PROPOSED PLAN LIMITS
XS SIR
B.
WORKERS' COMPENSATION INFORMATION
1. Number of Employees
2. Total Payroll Last Three Years
3. Manual Premium (unmodified) Last Three Years *
* Please provide supporting documentation of how
manual premium is calculated, i.e. Exhibit showing
payroll class codes and rates
Prior Year
$0
Prior Year
$0
$0
Expiring Year
$0
Projected Year
Projected Year
$0
Prior Year
Projected
(Please check Claims Made or Occurrence - If Claims Made, please provide Retro Date mm/dd/yy)
Claims Made
Prior Year
$0
$0
Expiring
SECTION V - EXCESS WORKERS' COMPENSATION / EMPLOYERS' LIABILITY / STOP GAP
Expiring Year
$0
Is current coverage:
Maximum limits $475,000 XS Minimum $50,000 SIR
Please note: Higher limits and Lower SIR's may be available on request.
7. Does current Employment Practices Liability Coverage include
Sexual Harassment?
Yes
No
Occurrence
If Yes, and Sexual Harassment Coverage is requested, a fully completed sexual harassment supplemental application and a copy of the Assureds
Sexual Harassment policies and procedures must be included with the application.
Current Premium:
Limits:
SIR/Deductible:
Carrier:
Yes
No
Date of Loss (mm/dd/yy) Ground-Up Incurred Cause / Description
4. Experience Mod Last Three Years
C.
Give details of any pending legislation in the application state involving any change in benefits.
D.
Current Excess Workers' Compensation / Employers' Liability / Stop Gap Program Details.
A.
PROPOSED PLAN LIMITS
(CLAIMS MADE)
XS SIR
Retro Date:
A.
PROPOSED PLAN LIMITS
XS SIR
XS SIR
XS SIR
SIR/Deductible:
Carrier:
Current Premium:
Limits:
SECTION VII - CRIME
Money & Securities
Employee Dishonesty
Forgery & Alteration
Maximum Limit $490,000 XS Minimum
$10,000 SIR
Maximum Limit $490,000 XS Minimum
$10,000 SIR
Limits:
Maximum Limit $490,000 XS Minimum
$10,000 SIR
Maximum limits $9,975,000 / $9,975,000 XS Minimum $25,000 SIR
Is current coverage:
Claims Made
Occurrence
(Please check Claims Made or Occurrence - If Claims Made, please provide Retro Date mm/dd/yy)
Maintenance Deductible
SIR/Deductible:
Carrier:
Please note: Higher limits and Lower SIR's may be available on request.
Prior Year
Limits:
Current Premium:
Expiring Year
SECTION VI - EMPLOYEE BENEFIT LIABILITY
SIR/Deductible:
Current Premium:
Projected Year
Carrier:
Prior Year
Last Five Years:
Note: Underwriter approval of a T.P.A. other than Gallagher Bassett Services Inc., is required prior to quoting.
(See unbundling Procedures in the Online Gallagher Portal - or ask you Arthur J Gallagher (UK) Ltd broker for details)
A.
Does the Applicant have a dedicated Risk Manager?
B.
Please provide a description of the applicant's risk control and risk management procedures.
Including information pertaining to:
1. Self-inspection Requirements and Procedures:
2. Organsiational Structure for Safety and Loss Prevention:
3. Training of Employees:
4. Scheduled Maintenance Procedures:
5. Accident and Claims Review Procedures:
6. Contracts with separate Loss Prevention Organisations:
Xs
1/
ALTERNATIVE LIMITS / COVERAGES REQUIRED (If Applicable)
Coverage
Limit
SIR
Target Price
LOSS PREVENTION AND RISK MANAGEMENT
Yes
No
5/
1/
2/
3/
4/
CLAIMS ADMINISTRATOR BY LINE OF BUSINESS
To
From
Line Of Business
Claims Administrator
Xs
Xs
2/
3/
Please Check
Required Information
Expiring exposures
E-mail electronic property schedule
Loss information for the last 5 full years plus current year
to be valued at no earlier than 90 days prior to inception
List of all losses excess of 50% of proposed SIR's
Confirmation GB are used
- Else TPA unbundling procedures must be adhered to and approval sought in advance
Copies of Loss runs mailed to Munich American Risk Partners
Broker Surplus Line License details
- (Name, Office, License Number)
Is it a bid?
Who is the competition?
Executive Summary
- Including any key issues not already mentioned in the General Comments about the Risk Section
Optional Information - If Coverage required
Terrorism Questionnaire
Flood Zone A and V Exposure Information
Policies & Procedures Manual for Sexual Harassment
- Plus any Ground Up losses - last 5 years
POOLS
- Only
Underwriters require a 30 day lead time.
Time spent by AJG UK completing submissions to underwriters' standards does not count against the 30 days.
By-Laws and Interlocal agreement
Enabling Legislation
- Start up Pools only
Details of Loss Fund Funding
- Is it fully funded, how are assessments handled?
Management of the pool
- Staff Details
Details of the Allocation formula
Number of Members
- Last 6 Years
Financial Report for the Pool (Must be current)
Feasibility or the Actuarial study (Must be current)
SUBMISSION INFORMATION CHECKLIST
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Completed 30 July 2020

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