Fillable Schools Supplemental Application

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Schools Supplemental Application

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The Schools Supplemental Application form is 4 pages long and contains:

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  • 50 check-boxes
  • 29 other fields

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Page 1 of 4
NON-PROFIT
ORGANIZATION DIRECTORS AND OFFICERS LIABILITY
SCHOOL
SUPPLEMENTAL APPLICATION
1. Name of Applicant:
1. Type of school:
Independent School Private college or university Other (describe)
2. IRS tax status: 501(c)(3) Public entity Other (describe)
3. Complete the table below providing the number of Full Time and Part Time Students currently enrolled:
Full Time Students
Part Time Students
4. Complete the table below providing the number of Full Time, Part Time, Tenured, and Tenure-Track Faculty currently
employed:
Full Time Faculty Part Time Faculty Tenured Faculty Tenure-Track Faculty
5. Complete the table below providing the Unionized Faculty and Non-Faculty currently employed:
Unionized Faculty
Unionized Non-Faculty
6. Are all degree programs accredited or certified? Yes No
If Yes, who provides accreditation or certification?
If No, please attach an explanation.
7. Within the last 24 months and with respect to the Insured Organization:
a. Has an accrediting organization threatened or taken disciplinary action? Yes No
b. Has an athletic organization threatened or taken disciplinary action? Yes No
If either of these questions above were answered Yes, please attach an explanation.
8. Within the last 24 months has any degree program:
a. Sought accreditation? Yes No
b. Lost accreditation? Yes No
GENERAL INFORMATION
ORGANIZATION INFORMATION
Kinsale Insurance Company
P. O. Box 17008
Richmond, VA 23226
(804) 289-1300
www.kinsaleins.com
Page 2 of 4
c. Been unable to attain accreditation? Yes No
d. Become provisionally accredited? Yes No
e. Been placed on probationary status by an accreditation body? Yes No
If any of the questions above were answered Yes, please attach an explanation.
9. Have any degree or certification programs been created or eliminated in the past 2 years, Yes No
or are any such changes under consideration or planned within the next 12 months?
If Yes, please complete the table below:
Degree or Certification Program
Created or Eliminated
Number of Students Enrolled
Created Eliminated
Created Eliminated
Created Eliminated
Created Eliminated
Created Eliminated
Created Eliminated
10. Does the Applicant:
a. Have a written policy for employee/faculty fraternization with students? Yes No
b. Is this policy circulated periodically as a reminder? Yes No
c. Have a written procedure for handling student harassment complaints? Yes No
d. Have an appeal procedure for admissions? Yes No
e. Who is responsible for overseeing this appeal procedure? Yes No
f. Have a written procedure for student disciplinary issues? Yes No
g. Have a criminal background check completed on all new employees? Yes No
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):
• Most recent annual financial statement
• List of Directors and Officers and outside affiliations
• Publications if unavailable on website
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.
Signature of Applicant/Title/Date (Must be signed by a Principal, Partner or Officer of the Firm)
REQUIRED ATTACHMENTS
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signature
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Page 3 of 4
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.
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.
Page 4 of 4
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.
Applicant: ______________________________________ Title:
(Must be signed by a Principal, Partner, or Officer of the Firm)
Applicant’s Signature: _____________________________ Date:
Agent/Broker Name:
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Schools Supplemental Application

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Completed 2 July 2020

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