Fill - Free fillable SOLIDARITY PROTECTION GROUP LABOR LIABILITY NEW BUSINESS APPLICATION (Access E&S Insurance Services) PDF form

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SOLIDARITY PROTECTION GROUP

a voluntary membership organization operating pursuant to the Liability Risk Retention Act of 1986 and whose principal office is:

4323 Warren Street, NW, Washington, DC 20016-2437

LABOR LIABILITY NEW BUSINESS APPLICATION

The policy, for which this application is made, is written on a claims-made and reported basis. The coverage afforded by

this policy is limited to liability for only those claims first made during the policy period, the automatic reporting period or

the extended reporting period (whichever is applicable) resulting from wrongful acts, wrongful offenses or wrongful

employment practices and which are subsequently reported to Hudson Insurance Company within the earlier of: A) Ninety

(90) days or B) by the end of the policy period, the automatic reporting period (whichever is applicable). This is a policy

with claims expenses included in the Limit of Liability. Please read the policy carefully.

I. GENERAL INFORMATION

Name of the Union: ________________________________________________________________________

Address: ____________________________________________ _ Telephone Number: ______________

Website Address (URL) of Union: ____________________ Date the Union was established: ______________

Insurance Representative: ________________________ _______________________________________

Address: ____________________________________________ _ Telephone Number: ______________

Prior Insurance Carrier(s): Policy Period: Limit of Liability: Retention: Premium:

____________________ __________ _______________ __________ __________

If no prior coverage, check here: _____

Requested Effective Date: __________

Requested Limit of Liability: ____________________ Requested Retention: ____________

Provide the number of Directors and Officers, Employees, and Members:

Current Year Prior Year

Directors/Officers (D&O’s): __________ _________

Employees (other than D&O’s): __________ _________

Volunteers: __________ _________

Members: __________ _________

Provide the following financial information:

Total Revenue: __________ _________

Net Assets: __________ _________

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II. UNDERWRITING QUESTIONS

A. Union Information and Management

1. During the most recent OLMS audit, did the Union receive any negative comments or has the Union been given the

opportunity of voluntary compliance? ____Yes ____No

2. Does the Union (If yes, please explain and attach additional pages as needed):

a. Publish any magazines, periodicals or newsletters? ____Yes ____No

b. Publish a technical manual? ____Yes ____No

c. Provide a hiring hall or job referral system? ____Yes ____No

d. Provide legal aid services to its members? ____Yes ____No

e. Promote, sponsor and/or provide any form of insurance to its members (other than negotiated benefits)

____Yes ____No

f. Other miscellaneous professional services to members or others? ____Yes ____No

3. Does the Union have a human resources or personnel department? ____Yes ____No

a. If no, does the Union have a designated or qualified staff member serving as the equivalent function?

____Yes ____No

4. Does the Union have a written employee handbook? ____Yes ____No

(If Yes, does the employee handbook contain the policies and procedures addressing;

a. Compliance with the American’s with Disabilities Act ____Yes ____No

b. Compliance with the Employment Standards Act and/or U.S. FMLA

____Yes ____No

c. Prohibited discriminatory practices in hiring, promotion and compensation

____Yes ____No

d. Employee Performance Evaluations ____Yes ____No

e. Employee disciplinary actions and discharge ____Yes ____No

f. Employee grievance reporting and resolution process ____Yes ____No

g. Outline anti-sexual harassment policy ____Yes ____No

h. Outline anti-discrimination policy with respect to evaluating applicants for membership

____Yes ____No

5. Do employees acknowledge receipt of the employee handbook in writing?

____Yes ____No

6. Do managerial/supervisory personnel receiving training in the implementation of these policies and procedures?

____Yes ____No

NOTE: If you answer Yes to questions 7-11 below, you must provide a detailed, written narrative and pertinent

documentation.

7. Does the Union anticipate filing a Terminal Report in the next twelve (12) months? ____Yes ____No

8. Have any of the following reports been submitted within the past twelve (12) months: LM-1 (amended), LM-15

(initial), LM-15 (semiannual), LM-15A, LM-16 or LM-30? ____Yes ____No

9. Has any Union officer, director or executive board member missed more than three (3) meetings within the past

twelve (12) months? ____Yes ____No

10. Has any Director, Officer or other employee been terminated (with or without cause) within the past twenty-four (24)

months? ____Yes ____No

If yes, how many? ______________

11. Has any application for union liability or similar insurance ever been declined or has any such insurance ever been

cancelled or non-renewed? ____Yes ____No

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12. Does the Union obtain a second signature on all checks drawn on the Union’s bank account(s)? If no, please explain

(attach additional pages as needed): ____Yes ____No

13. Does the Union maintain minutes of all membership and executive board meetings for at least five (5) years? If no,

please explain (attach additional pages as needed): ____Yes ____No

14. Does the Union have its own in-house counsel? ____Yes ____No

15. Does the Union have a law firm/attorney on a formal retainer? ____Yes ____No

16. Does the Union have an attorney review all Union publications prior to release? If no, please explain (attach

additional pages as needed): ____Yes ____No

17. Does the Union have a formal internal audit committee that regularly reviews the Union’s internal control

procedures? If no, please explain (attach additional pages as needed)____Yes ____No

18. Does the Union employ one or more full-time business agents? ____Yes ____No

B. Loss History: If you answer Yes to questions 12-15 below, you must provide a detailed, written narrative and submit

pertinent documentation. It is also agreed if such fact, circumstance or situation exists, whether or not disclosed, any claim

is excluded from this proposed coverage.

19. Has the Union or any proposed Insured Person been involved in any civil or criminal action or litigation?

____Yes ____No

20. Has the Union or any proposed Insured Person been involved in or have knowledge of any inquiry, investigation,

complain or notice from any State or Federal Authority or Congressional or Legislative Committee regarding

activities, procedures or practices of the Union, its members, officers, or employees?

____Yes ____No

21. Has the Union or any proposed Insured Person reported any claims, or given written notice of any facts,

circumstances or situations which may be reasonably be expected to result in claim, under the provisions of any prior

or current union liability policy or similar insurance? ____Yes ____No

22. In any proposed Insured aware of any facts, circumstances or situations which may reasonably be expected to result in

a claim under the proposed policy? ____Yes ____No

III. REQUIRED ATTACHMENTS

Provide the following material with respect to the Union:

 A copy of the latest CPA audited annual financial statement (including all notes)

 A copy of the last LM-2, LM-3, LM-4, or IRS Form 990 and all completed schedules.

 Most recent copies of all materials published by the Union.

 The complete by-laws, if the by-laws deviate from the National or International constitution and by-laws.

 Additional information may be requested based on specific applicant characteristics.

Please submit application and all required attachments to your insurance representative/broker.

Insurance representative/broker, please submit application and all required attachments to:

Euclid Specialty Managers

2701 Prosperity Avenue, Suite 220

Fairfax, VA 22031

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IV. SIGNATURE

The undersigned represents, after inquiry, that to the best of his or her knowledge and belief the statements set forth herein are true,

and he or she has not withheld any information which is reasonably likely to influence the judgment of Hudson Insurance Company in

considering this application for Labor Liability Insurance. The undersigned further represents that if the information supplied by him

or her on this application changes between the date of this application and the effective date of the insurance or the when the policy is

bound (whichever is later), the undersigned will immediately notify Hudson Insurance Company in writing of such changes and the

insurer may withdraw or modify any outstanding quotations based upon such changes. The signing of this application does not does

not bind the insurer to complete insurance, but it is agreed that this application and any attachments form the basis of the contract

should a policy be issued and shall be deemed attached to and form a part of the policy. Hudson Insurance Company is hereby

authorized to make any investigation and inquiry in connection with this application it deems necessary.

This application must be signed by the President or Secretary-Treasurer of the Union.

Authorized Signature:______________________________ Title:_____________________

Print Name:_______________________________________ Date:_____________________

V. FRAUD WARNINGS

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 policyholder or claimant for the

purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable

from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

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 OREGON APPLICANTS: Any person who knowingly and with intent to injure, deceive, defraud any

insurer or other person files an application or a claim containing any false, incomplete or misleading information or conceals

information concerning any material fact may be guilty of insurance fraud, which is a crime and may subject such person to

criminal and civil penalties.

NOTICE TO APPLICANTS IN AR, FL, KY, MN, NJ, OK, AND PA: 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.

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 ALL OTHER APPLICANTS: Any person who knowingly and with intent to injure, deceive, defraud any

insurer or other person files an application or a claim containing any false, incomplete or misleading information or conceals

information concerning any material fact commits insurance fraud, which is a crime and subjects such person to criminal and

civil penalties.

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CLAIMS INFORMATION

A. Provide:

1. Name of Claimant:_________________________________________________________________________

2. Date of Alleged Wrongful Act:________________________________________________________________

Date claim was made:_______________________________________________________________________

3. Date reported to Professional Liability Insurer:____________________________________________________

4. Name of Professional Liability Insurer:__________________________________________________________

5. Allegation:________________________________________________________________________________

B. Describe the claim, including the alleged wrongful act, the event that led to the claim, and the current status

of the claim:

___________________________________________________________________________________________

Claim Fee Information:

Total Loss: $____________ Claimant Demand: $_________________

Legal Fees Charged to Date: $____________

C. What loss prevention measures, if applicable, have been taken to prevent a similar claim from recurring?

___________________________________________________________________________________________

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