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    Law Enforcement 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:*
    please check all applicable operations
    MM slash DD slash YYYY
    If district or authority, show service population):
    If district or authority, show service population):
    Do you have a seasonal population increase of more than 25% during the year?
    Total number of employees:
    Are you a party to any Mutual Aid Agreements?*
    Do you provide contracted services for any other entities?*
    Max. file size: 50 MB.

    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
     
    What type of Law Enforcement Liability coverage do you currently have?*
    MM slash DD slash YYYY
    Does your General Liability policy include coverage for your detention facilities?
    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
     

    HIRING AND TRAINING

    What are the minimum educational requirements for applicants?
    High School Diploma or equivalent?*
    30 or more hours of college?*
    60 or more hours of college?*
    Bachelor’s degree?*
    Which of the following are included in your selection process prior to employment?
    Written Exam?*
    Psychological Exam?*
    Professional psychological evaluation?*
    Background and employment investigation?*
    Do all law enforcement officers meet your state’s minimum standards for training and receive certification prior to assignment to regular street duty?*
    Do you follow written policies regarding in-service training or continuing education for all officers?*
    Is all employee training, both past and present, documented and kept on file?*
    Does your agency have a Field Training Program for new employees?*
    Baton / PR-24 / ASP?*
    Chemical irritants?*
    Stun gun or Taser?*
    Carotid control hold?*
    Department issued handgun.*

    Personal (off-duty) handgun.*

    Shotgun.*

    Are all officers required to complete a defensive driving program?*
    Do all officers receive training in simulated or actual high speed pursuit?*
    First Aid?*
    CPR?*
    Use of defibrillators?*
    What training is required of reserve and auxiliary officers?*

    POLICIES AND PROCEDURES

    Do you maintain a formal Policies and Procedures Manual?*
    Do all employees maintain their own copy?
    Is every employee held accountable for knowing the contents of the manual?
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    Is your manual regularly reviewed by competent legal counsel?
    Do you have formal written policies and procedures pertaining to the following subjects:
    Deadly force?*
    MM slash DD slash YYYY
    Use of non-deadly force?*
    MM slash DD slash YYYY
    Vehicle high-speed pursuit?*
    MM slash DD slash YYYY
    Domestic Violence?*
    MM slash DD slash YYYY
    Search and seizure?*
    MM slash DD slash YYYY
    Intoxicated arrestees?*
    MM slash DD slash YYYY
    Communicable diseases?*
    MM slash DD slash YYYY
    Employee moonlighting?*
    MM slash DD slash YYYY
    Max. file size: 50 MB.

    EMPLOYMENT PRACTICES AND PROCEDURES

    Do you handle your own dispatching?
    Do you dispatch for any other entities?
    Do your Law Enforcement dispatchers also dispatch for emergency medical and fire fighting services?
    Are all incoming calls recorded?
    Are all incoming calls recorded?
    Do you participate in any internship or ride-along programs?
    Do you own, operate or maintain any fixed or rotary wing aircraft?
    Do you own, operate or maintain any watercraft?
    Do you authorize off-duty employment?*
    Is there any moonlighting in bars or taverns?*
    Do you want coverage for moonlighting?*
    Max. file size: 50 MB.

    DETENTION FACILITY

    If you do NOT have a detention facility of any kind, please check this box and skip to the next section.
    Do you have a detention facility of any kind?
    Which of the following best describes your facility?
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    Adult prisoners only?
    Males and females?
    Violent and non-violent prisoners?
    Adults and juveniles?
    Males and females?
    Violent and non-violent inmates?
    Individual detention cells?
    Secured common areas?
    Booking area?
    Sally port?
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    MM slash DD slash YYYY
    Do you have standard fire protection systems including smoke detectors and fire alarms?
    Do dispatchers serve as jailers?
    If so, do they receive the same training?
    Doctor(s)?
    Nurse(s)?
    Dentist?
    Psychologist?
    Do each of the above maintain their own professional errors and omissions liability coverage?
    Has anyone ever successfully committed suicide in your facility?
    Intake screening and classification?
    Medical screening?
    Suicide detection and prevention?
    Periodic walk-through of the facility?
    Administration and control of medication?
    Use of force?
    Emergency evacuation?
    Communicable diseases?
    MM slash DD slash YYYY
    Is your manual reviewed by legal counsel?
    Has your facility ever been subject to a court order or Consent Decree?
    Max. file size: 50 MB.
    Max. file size: 50 MB.

    POSITIONS TO BE INSURED

    Please complete the following by accounting for each employee only once in their primary classification.

    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 Law Enforcement 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

    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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