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Municipal Entity Underwriting Application

GENERAL INFORMATION

Name of Insured

Phone

Address (Street, City, State, Zip Code)

County

Website

Risk Manager

Phone

Name of Agent/Broker Contact

Agency/Brokerage

Phone

Address (Street, City, State, Zip Code)

Type of Entity (check all that apply) State  County City/Village Pool/Trust Other (specify)

Effective Date of Coverage

Quote Due Date

New Renewal

Has any insurance carrier cancelled coverage in the past three years?

If yes, provide the date of cancellation and the reason.  

 Yes

 No

Financial/bond information

1.

What is your bond rating?

Current Year

Moody’s

Standards & Poors

2.       If a Pool or Trust, attach copy of latest audited financial statements.        

Loss CONTROL InFORMATION

n/a

1.

Is a full-time safety/loss control person employed?

If yes, describe responsibilities.  

 Yes

 No

2.

Do you have any formal written program in place regarding third party exposures listed below:

Public Officials Liability

 Yes

 No

Contractual Liability

 Yes

 No

Peer Harassment

 Yes

 No

Employment Related Practices

 Yes

 No

Vehicle/Fleet

 Yes

 No

3.

Do you incorporate the effectiveness of your loss control efforts into the performance evaluation for administrators, department heads, supervisors, and managers?  

 Yes

 No

4.

Do you have an internal claim and loss costs analysis system that prompts necessary program changes on a timely basis?  

 Yes

 No

5.

Municipal Security.

 Employees

 Independent Contractors

 Armed

 Unarmed

If armed, and employees, are they POST certified?  

 Yes  

 No

6.

Does your entity conduct regular scheduled safety meeting for all employees?

 Yes

 No

7.

Does your entity provide any incentives for following safety precautions?

 Yes

 No

1 of 3410/23/2007

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