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SCHOOLSPRIVATE, TECHNICAL, TRADE AND VOCATIONAL SUPPLEMENTAL APPLICATION (Colonial General Insurance Agency, Inc)

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GL-APP-69s (6-17) Page 1 of 5
SCHOOLS—PRIVATE, TECHNICAL, TRADE AND VOCATIONAL
SUPPLEMENTAL APPLICATION
(Complete in addition to ACORD General Liability Application)
Applicant’s Name:
Mailing Address:
Location Address:
Agency Name:
Agent No.:
Address:
E-mail:
Phone No.:
PROPOSED EFFECTIVE DATE: From To 12:01 A.M., Standard Time at the address of the Applicant
ANSWER ALL QUESTIONS—IF THEY DO NOT APPLY, INDICATE “NOT APPLICABLE” (N/A)
1. Type of School: Alternative/Reform Medical Trade
Charter Military Tutoring
College Preschool Vocational
Co-op/Community Private Elementary School
Correspondence/Internet Private High School
Dental Private Junior High/Middle School
Internet Public
Learning Center Technical
If technical, trade or vocational, what trades are taught?
2. Number of years in business: .................................................................................................................
3. Is school located in a private home?....................................................................................................... Yes No
4. Total number of students enrolled: Students’ ages range from to
Average daily attendance: Percentage of special needs students: %
5. Annual gross receipts from all operations (include tuition fees, food receipts, clothing, equip-
ment sales, etc.): ....................................................................................................................................... $
6. Month(s) and Hour(s) of operation(s):
GL-APP-69s (6-17) Page 2 of 5
7. Teachers Errors and Omissions Coverage limits: (Limits may be provided up to the GL limits)
Each Claim: ................................................................................................................................................ $
Aggregate: .................................................................................................................................................. $
Total number of Teachers: .........................................................................................................................
8. Is student housing available? .................................................................................................................. Yes No
If yes, advise number of beds:
9. Indicate if instruction, training or certification is provided for any of the following:
Aviation (classroom only) Firearm Scuba and Skin Diving
Aviation (other than classroom only) First Aid Skydiving
Cheerleading Gymnastic Sports or Recreation
Cosmetology Hazardous Material Stand-Up Paddle Boarding
Dance Martial Arts Surfing
Driving Safety Swimming and/or Diving
Other:
10.
Describe all operations on premises (wood shop, metalworking, shop, gymnasium, athletic facilities and
grandstands):
11.
Cosmetology schools (identify all operations taught):
12.
Identify protective equipment used for any of the above activities/operations:
13. Any buildings over six stories? ............................................................................................................... Yes No
If yes, advise number of stories for each building:
14. Any prior losses due to mold? ................................................................................................................. Yes No
If yes, has one hundred percent (100%) remediation occurred? ................................................................ Yes No
15. Are all swimming pools, wading pools, hot tubs and spas in compliance with the federal Virgin-
ia Graeme Baker Pool and Spa Safety Act? ........................................................................................... Yes No
16. Does risk engage in the generation of power, other than emergency back-up power, for their
own use or sale to power companies?.................................................................................................... Yes No
If yes, describe:
17. Does applicant have other business ventures for which coverage is not requested? ...................... Yes No
If yes, explain and advise where insured:
SCHOOL SPONSORED ACTIVITIES
18.
Describe any school sponsored exhibitions (an exhibition for this purpose is an event sponsored by you,
open to the public, where the participants are limited to members of the school or club):
GL-APP-69s (6-17) Page 3 of 5
19. Are there any school sponsored sports teams or sporting events? ................................................... Yes No
If yes:
a. Describe:
b. Are students or their parents required to sign liability waivers?............................................................ Yes No
If yes, please attach a copy of the waiver wording that is used.
20.
Describe any off-site activities:
SCHOOL POLICIES/SECURITY
21. Are all teachers properly licensed/registered per state regulations?.................................................. Yes No
If no, please explain:
22. Are background checks completed for all teachers and employees in compliance with state
regulations? ............................................................................................................................................... Yes No
If no, please explain:
23. Does the school allow teachers, aides or administrators to have or carry guns on school
premises? ................................................................................................................................................... Yes No
If yes, please explain:
24. Does the school have a formal discipline program for students? ....................................................... Yes No
If yes, please provide a copy of the program.
25. Does the school have a “zero tolerance” policy regarding violent behavior? ................................... Yes No
If yes, please provide a copy of any written policy.
26. Does the school have a policy regarding visitors to school premises? ............................................. Yes No
If yes, please provide a copy of any written policy.
27. Indicate any of the following included in the school security systems:
Doorbell at main entrance Security cameras
Presence of security guards Self-locking door(s)
Remote release mechanism to open door(s) Video monitors
28. Is there a security guard on premises? .................................................................................................. Yes No
If yes:
a. Number of armed guards employed by school: .......................................... Payroll: $
Number of unarmed guards employed by school: ...................................... Payroll: $
b. Number of armed guards contracted through a security firm?* ......... Contract cost: $
Number of unarmed guards contracted through a security firm?* ..... Contract cost: $
* For contracted security guards, a certificate of insurance and applicant named as an Additional Insured is re-
quired. If these requirements are not met, security guards are rated as employees at the appropriate security
guard rate.
c. Are guards licensed and employee background checks done as required by state or federal
agencies? .............................................................................................................................................. Yes No
GL-APP-69s (6-17) Page 4 of 5
d. Are armed guards certified for use of firearms by the appropriate state agency or firearms certifica-
tion school? ........................................................................................................................................... Yes No
e. Explain the security guard’s legal powers and restrictions as respects arrests, searches and use of weapons:
f. Does the security guard work in conjunction with local police during their shift when apprehending
fugitives? ............................................................................................................................................... Yes No
This application does not bind the applicant nor the Company to complete the insurance, but it is agreed that the infor-
mation contained herein shall be the basis of the contract should a policy be issued.
FRAUD WARNING: 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. (Not applicable in AL, CO, DC, FL, KS, LA, ME, MD, MN, NE, NY,
OH, OK, OR, RI, TN, VA, VT or WA.)
NOTICE 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.
NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or in-
formation 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 policy holder or claimant with regard to a settlement or award pay-
able from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory
Agencies.
WARNING TO DISTRICT OF COLUMBIA APPLICANTS: 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 addi-
tion, an insurer may deny insurance benefits if false information materially related to a claim was provided by the appli-
cant.
NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insur-
er files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a fel-
ony of the third degree.
NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be pre-
sented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any
agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or state-
ment as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or
commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal
insurance which such person knows to contain materially false information concerning any fact material thereto; or con-
ceals, 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.
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 sub-
ject 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 a denial of
insurance benefits.
GL-APP-69s (6-17) Page 5 of 5
NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for
payment of a loss or benefit or who knowingly or willfully 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 MINNESOTA APPLICANTS: A person who files a claim with intent to defraud or helps commit a fraud
against an insurer is guilty of a crime.
NOTICE 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.
NOTICE TO OKLAHOMA APPLICANTS: 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 infor-
mation is guilty of a felony.
NOTICE 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 is guilty of a crime and may be
subject to fines and confinement in prison.
FRAUD WARNING (APPLICABLE IN VERMONT, NEBRASKA AND OREGON): Any person who intentionally presents
a materially false statement in an application for insurance may be guilty of a criminal offense and subject to penalties un-
der state law.
FRAUD WARNING (APPLICABLE IN TENNESSEE, VIRGINIA AND WASHINGTON): It is a crime to knowingly provide
false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penal-
ties include imprisonment, fines, and denial of insurance benefits.
NEW YORK OTHER THAN AUTOMOBILE FRAUD WARNING: 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.
APPLICANT’S STATEMENT:
I have read the above application and I declare that to the best of my knowledge and belief all of the foregoing statements
are true, and that these statements are offered as an inducement to us to issue the policy for which I am applying. (Kan-
sas: This does not constitute a warranty.)
APPLICANT’S SIGNATURE: DATE:
CO-APPLICANT’S SIGNATURE: DATE:
PRODUCER’S SIGNATURE: DATE:
AGENT NAME: AGENT LICENSE NUMBER:
(Applicable to Florida Agents Only)
IOWA LICENSED AGENT:
(Applicable in Iowa Only)
IMPORTANT NOTICE
As part of our underwriting procedure, a routine inquiry may be made to obtain applicable information concerning
character, general reputation, personal characteristics and mode of living. Upon written request, additional information
as to the nature and scope of the report, if one is made, will be provided.
Agent Email:
Preferred Method of Correspondence Email Fax Mail
Applicant Email:
Preferred Method of Correspondence Email Fax Mail
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Completed 22 August 2020

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