Public Entity Errors and Omission Application
THIS IS AN APPLICATION FOR A CLAIMS MADE POLICY
Name of Public Entity:Mailing Address:
Effective Date:
Date of first continuous Public Officials coverage: Insurance Company:
Limit Requested: / $1,000,000/$1,000,000 / $1,000,000/$3,000,000
Deductible Requested
$2,500 $5,000 $7,500 $10,000 $15,000 $25,000 $50,000 $100,000 Other
Is Employment Practices Liability Insurance desired? YES NO
If so, complete the EPLI section of this application starting on Page 3.
Population, according to latest census:Census Year:
If Sewer or Water District, Number of users:
Latest Bond Rating (Moody’s or Standard & Poor’s):Current Previous
Actual year-end financials for past three years:
Year / Total Revenue / Total Expenditures / Accumulated Surplus/Deficit
$ / $ / $
$ / $ / $
$ / $ / $
Number of employees (excluding independent contractors). Do not include employees from the following units as they are excluded from coverage: Schools; airports; transit authorities; hospitals; nursing homes; municipally owned gas or electric companies; housing authorities; or port authorities.
Full-Time: Part-Time:Volunteers:
Describe any current Public Officials insurance Policy
Company: / Effective Date:
Limits: $/ $Deductible/Retention: $ / Premium: $
Has any similar insurance been declined, cancelled or not renewed? / YES NO
If “YES”, Give reason:
Have you ever been self-insured? / YES NO
If “YES”, list dates:
CLAIM HISTORY
For the purpose of this application, “claim” shall mean a “lawsuit” or other written demand seeking “damages” as a result of a wrongful act. Answer the following questions based on this definition.
With respect to claims over the last five years, please provide the following information:
Date Claim Received by Insured / Description of Claim / Claimant / Damages Paid / Damages Reserved / Legal Expense Reserved
$ / $ / $
$ / $ / $
$ / $ / $
Have any of the following situations occurred within the last five years?
Has any claim been made or is now pending against the Entity or any person in his/her capacity as an official or employee of the Entity that is not listed in the claims history above? / YES
NO
Does any official or employee have knowledge of any fact, circumstance or situation, which might reasonably be expected to give, rise to a claim against them or against the Entity? / YES
NO
If YES to any of the above, explain under Supplement Section.
ADDITIONAL INFORMATION / CERTIFICATION
Provide any additional information that you feel is relevant to our review of your application:
/ If EPLI is not being requested proceed to Page #6.
Date of first continuous EPLI coverage:Insurance Company:
Deductible Requested (If different from the Errors and Omissions Policy)
$2,500 $5,000 $7,500 $10,000 $15,000 $25,000 $50,000 $100,000 Other:Year / Total Revenue / Total Expenditures / Accumulated Surplus/Deficit
$ / $ / $
$ / $ / $
$ / $ / $
PREVIOUS AND OTHER INSURANCE
Have you previously purchased employment practices liability insurance?
If "Yes," please state for each prior policy: / YESNO
Insurer
/Policy Period
/Policy Limits/Deductible or Self Insured Retention
$$
$
Has any previous employment practices liability insurer ever cancelled or non-renewed your coverage?
If "Yes," please state the reasons given by such insurer for the cancellation or non-renewal.
(Use supplemental section, Page 6, if necessary.) / YESNO
Has any insurer ever declined or rejected your application for employment practices liability insurance?
If "Yes," please state the reasons, if any, given by such insurer for the declination.
(Use supplemental section, Page 6, if necessary.) / YESNO
LOSS HISTORY
You must advise us of all Claims that have been made against the public entity or its employees to be insured during the past 5 years (irrespective of whether or not covered by insurance) and all incidents, facts or circumstances known to any of your Officials Managers, Or Supervisory Employeeswhere an applicant for employment, Employeeor third party has either written about or verbally mentioned making a Claimfor Inappropriate Employment Conduct, Harassment or Discrimination.
Have any Claims (including lawsuits or threatened lawsuits) been made against the public entity or its employees to be insured, by any Employee (including Officers) or applicant for employment, during the past 5 years, for alleged Inappropriate Employment Conduct, Harassment or Discrimination?
If "Yes," how many such Claims have been made? /
YES NO
For each Claim, please describe in detail such Claim, including whether such Claim is still pending, the total incurred for defense of such Claim, and the total paid for settlement of judgment rendered.
(Use supplemental section, Page 6, if necessary.)
Have any Claims (including lawsuits or threatened lawsuits) been made against the public entity or its employees to be insured, by any third party, during the past 5 years, for alleged Harassment or Discrimination?If "Yes," how many such Claims have been made? /
YES NO
Have any complaints or charges been filed against the public entity or its employees to be insured, with any regulatory agency (including but not limited to the National Labor Relations Board, the Equal Employment Opportunity Commission or any similar Federal or State agency) during the past 5 years?If "Yes," please describe in detail each such complaint or charge, the findings made by the regulatory agency and the total incurred for defense of the complaint or charge.
(Use supplemental section, Page 6, if necessary.) / YESNO
Trident Insurance Services of New England, Inc. T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302Page 1 of 7
Is any Official, Manager or Supervisory Employee employed by the public entity or its employees to be insured aware of any facts, circumstances, disagreements or incidents which might result in a Claim against you or any such subsidiary, by any Employee (including Officers) or applicant for employment, for Inappropriate Employment Conduct, Harassment or Discrimination?If "Yes," please describe all such facts, circumstances, disagreements or incidents.
(Use supplemental section, Page 6, if necessary.) / YESNO
Is any Official, Manager or Supervisory Employee employed by the public entity or its employees you or any subsidiary to be insured aware of any facts, circumstances, disagreements or incidents which might result in a Claim against you or any such subsidiary, by any third party for Harassment or Discrimination?
If "Yes," please describe all such facts, circumstances, disagreements or incidents.
(Use supplemental section, Page 6, if necessary.) / YESNO
Has any employee of the Entity been suspended, demoted, dismissed, transferred or had their contract of employment non-renewed within the last twelve months
(Use supplemental section, Page 6, if necessary.) / YESNO
Please provide your loss runs for the last 5 years. Attach the details behind this application, including a description of any single loss over $10,000 and a description of the measures taken to prevent reoccurrence of these large losses.
EMPLOYEES AND SPECIAL GROUPS
Number of Employees, not including employees from the following units as they are excluded from coverage: Schools; airports; transit authorities; hospitals; nursing homes; municipally owned gas or electric companies; housing authorities; or port authorities.
Full Time / Part Time / Seasonal / Temporary / Leased
If you have any "Seasonal” or "Temporary" Employees, please provide an explanation of the work duties and average length of employment for each group. (Use supplemental section, Page 6, if necessary.) / YESNO
Do any of your Employees belong to a union or do you have collective bargaining agreements impacting any of your Employees? / YESNO
Union / Number of Employees / Collective Bargaining Agreement
YESNO
YESNO
YESNO
Are there any groups of persons who are not directly employed by you or any subsidiary to be insured (such as Employees of subsidiaries not to be insured, suppliers, consultants, wholly-controlled entities, etc.) for which you may legally be deemed an "employer" or for which you may have liability, either by operation of law or by contract or other means.
If "Yes," please explain. (Use supplemental section, Page 6, if necessary.)
NOTE: Claims made by any such persons who are not identified in this application will not be subject to coverage under the policy, if any. / YESNO
In the past year, have you or any of your staff attended an educational program that addresses EPL issues? / YESNO
Metrogard Program EPLI Seminar Date: How many attended?
Other Seminar Name/Sponsor: Date: How many attended?
Trident Insurance Services of New England, Inc.T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302Page 1 of 7
For full-time Employees who have left during the 2 years preceding this application, please state:Past Year / Employees / Officers
Terminated
Left Voluntarily
TOTAL
Prior Year / Employees / Officers
Terminated
Left Voluntarily
TOTAL
Are you anticipating any reductions / lay-offs in staff? / YESNO
HUMAN RESOURCES
Please indicate whether the following are true for you the public entity or its employees to be insured. For any "No" response, please provide full details. (Use supplemental section, Page 6, if necessary.)
Written employment agreements are made with all Employees and officials / YESNO
All new job applicants complete a written employment application form / YESNO
All new Employees are given an induction or appropriate training upon joining / YESNO
There is an Employee Handbook which is provided to all non-union Employees / YESNO
All Employees are required to acknowledge in writing receipt of the Employee Handbook / YESNO
The Employee Handbook has been reviewed by your attorney or Human Resources Department
If “Yes” when was it last reviewed? / YESNO
Personnel files, with attendance records for vacation, sick leave and personal days recorded, are maintained for each Employee / YESNO
All Employees, whether full time or part time, receive at least annual written performance evaluations, and those evaluations are kept in each Employee's personnel file / YESNO
All Officer or Employee disciplinary actions or terminations are reviewed and approved, before implementation, by either your labor attorney or your Human Resources Department / YESNO
Do you have a full-time Human Resources Department or a retained attorney who has labor law expertise? If so, what is their name? / YESNO
SUPPLEMENTAL SECTION
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. This Application shall be the basis of the contract should a policy be issued and will be referenced in the policy.
If this is a Renewal Application, it shall be a supplement to the Application(s) attached to the current policy and said Applications together with this Renewal Application constitute the complete Application which shall be the basis of the contract should a policy be issued.
DECLARATION
I declare that to the best of my knowledge and belief, and after surveying all Officials, and Department Heads, the statements set forth herein are true and include all material information. I further declare that if the information supplied herein changes between the date of this application and the commencement date of the policy issued in connection with the application, I will immediately notify Insurers of such change, and accept that in such circumstances, the quotation may be modified or withdrawn.
Date: / Applicant's authorized Signature. Must be signed by the Mayor, Manager equivalent office, the Risk Manager or official assigned to this function / Title:
APPLICATION SUPPLEMENT
APPLICABLE IN ALL NEW ENGLAND STATES OTHER THAN MAINE AND VERMONT
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 the person to criminal and civil penalties.
Date: / Applicant’s Signature: / Title:
Trident Insurance Services of New England, Inc.T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302Page 1 of 7