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    Public Officials and Employment Liability Application

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    GENERAL INFORMATION

    Physical address*
    Is your Mailing address the same as your Physical address?
    Mailing address (if different)*
    Contact Person
    If so, please provide name:
    You operate as a:*

    MM slash DD slash YYYY
    If district or authority, show service population
    If district or authority, show service population
    Total number of employees:
    How are they added?
    If appointed, by whom?
    How many employees hold professional designations?
    Do you have your own Law Enforcement department?
    If not, do you have a contract for these services?
    Total number of Law Enforcement employees:

    INSURANCE INFORMATION

    Please complete the following chart based on coverage currently in force. Please indicate where coverage is not in force.
    Click + Button to Add Rows.
    Policy Type
    Policy Number
    Company Name
    Expiration
    Limits
    Deductible
    Premium
     
    Does your current Educators Legal Liability coverage have a Retroactive Date?*
    Does your current Educators Legal Liability policy provide coverage for employment related practices?
    Has your Educators Legal Liability coverage ever been denied, canceled or non-renewed?
    Please tell us what terms you are interested in this year.
    Click + Button to Add Rows.
    Limits of Liability
    Deductible
    Effective Date
    Bid Date
     

    UTILITIES / AUTHORITIES

    Which of the following operations do you own, operate, or administer?

    Water Utility
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Sewer Utility
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Gas Utility
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Do you produce Gas?
    Do you own or operate any gas wellheads or pipelines?
    Electric Utility
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Do you generate power?
    What is your source?
    Airport Authority
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Do you operate the airport?
    Do you lease to a third party?
    Do you have Aviation Liability Coverage?
    Are expansions or changes of operations or runways expected?
    Housing Authority
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Transit Authority
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Type of vehicles?
    Port Authority
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Please check:
    Schools
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Medical/Health Care Facility
    Nuclear Facility
    NUMBER OF EMPLOYEES
    NUMBER OF USERS
    Other
    List any other subsidiary boards, commissions, or authorities.

    LAND USE AND PLANNING

    Do you have a zoning commission?
    Does your legal counsel attend all meetings of the planning and zoning board?
    Do you have a written master plan for economic development?
    MM slash DD slash YYYY
    Do you have formally approved land use ordinances that have been reviewed by legal counsel?
    Do you have a formal procedure to file for a variance to land use statutes?
    Do you have a formal written policy prohibiting officers and/or board members from sitting on decisions in which they may have a conflict of interest?
    Have you had any disputes or claims involving a wrongful “taking”, zoning variance or land use right?
    Have you had any disputes or claims involving the approval of building permits, design, or code enforcement?
    Have you had any disputes, claims or complaints involving open or closed landfills in the last 5 years?

    EMPLOYMENT PRACTICES AND PROCEDURES

    Do these supervisors receive training in the proper implementation of your policies and procedures?
    Do you have a written employment manual including all personnel policies and procedures?
    MM slash DD slash YYYY
    Is this manual reviewed by counsel experienced and qualified in employment law?
    Is this manual distributed to all employees upon hiring?
    Do you follow a formal written procedure for employee disputes/complaints?
    Do you have a written policy with respect to both sexual and non-sexual harassment?
    Are all actions to dismiss or demote employees reviewed in advance by legal counsel?
    Do you require that due process be served and documented for all proceedings involving dismissal demotion or suspension?
    Are all probationary or disciplinary actions recorded in writing and signed by the employee?
    Are you an Equal Opportunity Employer?
    Has there been a layoff of employees or reductions in service in the last three years?
    Have you had a strike, slowdown, or other employee disruption in the last three years?
    Has any person, former employee or job applicant filed a complaint or claim alleging unfair or improper treatment regarding employee hiring, remuneration, advancement, or termination of employment?
    Have you had any disputes involving integration, segregation, discrimination or violation of civil rights?
    Have any complaints been filed with the EEOC within the last three years?
    Have all disputes, complaints, and claims been reported to your current or prior Public Officials carriers?
    Max. file size: 50 MB.
    Max. file size: 50 MB.

    FINANCIAL / BOND INFORMATION

    Please complete the following chart using budget figures for the past three years (must be completed)
    Year
    Revenues
    Expenditures
    Surplus(+)/Deficit(-)
    Accumulated (+)/(-)
     
    Do you know your latest bond rating? (Moody or Standard Poor)
    Has any bond issue been defeated within the past three years?
    If yes, has the proposal been resubmitted, or is it expected to be resubmitted?
    Has your institution been in default on the principal or interest on any bond?
    Max. file size: 50 MB.

    LOSS HISTORY

    Has any claim been made against the entity, or any person in their capacity as an official or employee of the entity, in the last five years?*
    Does any official or employee have any knowledge of any fact, circumstance or situation which might reasonably be expected to give rise to a claim? If yes, please attach a narrative summary with details.*
    With respect to your Public Officials and Employment Practices Liability coverage, please complete the following table using the total dollars expended for both the settlements of claims and the expenses associated with defending those claims. “Reserves” refers to the estimated future expenses to resolve or dispose of the claims and includes both settlement and defense expenses.
    Click + Button to Add Rows.
    Year
    Premium
    Number of Claims
    Total Loss Paid Including Deductible
    Total Expenses Paid Including Deductible
    Total Amount Reserved
    Total Incurred Losses + Expenses
     
    Max. file size: 50 MB.

    WARRANTY AND ATTESTATION

    Consent

    Alabama: 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.

    Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.

    Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

    Arkansas: 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.

    California: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in prison.

    Colorado: 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 for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

    Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.

    District of Columbia: 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.

    Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

    Idaho: Any person who knowingly and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.

    Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.

    Kansas: Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A “fraudulent insurance act” means an act committed by any person who, knowingly and with intent to defraud, presents, causes to be presented 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 statement 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 conceals, for the purpose of misleading, information concerning any fact material thereto.

    Kentucky: 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.

    Louisiana: 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.

    Maine: 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.

    Maryland: 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.

    Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

    New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

    New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

    New Mexico: 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.

    New York: 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.

    Ohio: 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.

    Oklahoma: WARNING: 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 information is guilty of a felony.

    Pennsylvania: 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.

    Rhode Island: 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.

    Tennessee: 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.

    Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.

    Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.

    Virginia: 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.

    Washington: 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.

    West Virginia: 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 maybe subject to fines and confinement in prison.

    NOTICE TO ALL OTHER STATE APPLICANTS: Any person who knowingly includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

    The undersigned being authorized by, and acting on behalf of, the applicant and all persons or concerns seeking insurance, has read and understands this application, and declares that all statements set forth herein are true, complete and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for, which may render inaccurate, untrue or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the applicant’s submission and Insurer’s receipt of such written report, prior to the inception of the policy applied for, is a condition precedent to coverage. The signing of this application does not bind the undersigned to purchase the insurance, nor does review of the application bind the insurance company to issue a policy. The applicant does hereby agree that this policy, if issued, is issued in reliance upon the truth of this application, including all requested attachments, which will be incorporated into and made a part of this policy.
    Consent
    Alabama: 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.
    Alaska: A person who knowingly and with intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information may be prosecuted under state law.
    Arizona: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.
    Arkansas: 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.
    California: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in prison.
    Colorado: 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 for insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
    Delaware: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.
    District of Columbia: 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.
    Florida: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.
    Idaho: Any person who knowingly and with intent to defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is guilty of a felony.
    Indiana: A person who knowingly and with intent to defraud an insurer files a statement of claim containing any false, incomplete, or misleading information commits a felony.
    Kansas: Any person who commits a fraudulent insurance act is guilty of a crime and may be subject to restitution, fines and confinement in prison. A “fraudulent insurance act” means an act committed by any person who, knowingly and with intent to
    defraud, presents, causes to be presented 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 statement 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
    conceals, for the purpose of misleading, information concerning any fact material thereto.
    Kentucky: 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.
    Louisiana: 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.
    Maine: 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.
    Maryland: 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.
    Minnesota: A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.
    New Hampshire: Any person who, with a purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.
    New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.
    New Mexico: 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.
    New York: 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.
    Ohio: 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.
    Oklahoma: WARNING: 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 information is guilty of a felony.
    Pennsylvania: 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.
    Rhode Island: 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.
    Tennessee: 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.
    Texas: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
    Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law.
    Virginia: 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.
    Washington: 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.
    West Virginia: 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 maybe subject to fines and confinement in prison.

    NOTICE TO ALL OTHER STATE APPLICANTS: Any person who knowingly includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. The undersigned being authorized by, and acting on behalf of, the applicant and all persons or concerns seeking insurance, has read and understands this application, and declares that all statements set forth herein are true, complete and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for, which may render inaccurate, untrue or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the applicant’s submission and Insurer’s receipt of such written report, prior to the inception of the policy applied for, is a condition precedent to coverage. The signing of this application does not bind the undersigned to purchase the insurance, nor does review of the application bind the insurance company to issue a policy. The applicant does hereby agree that this policy, if issued, is issued in reliance upon the truth of this application, including all requested attachments, which will be incorporated into and made a part of this policy.
    Clear Signature

    Public Risk Underwriters Insurance Services Of Texas, LLC

    101 W. Renner Rd.
    Suite 300
    Richardson, TX 75082
    Office: (469) 449-1516

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