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Municipal Entity Underwriting Application

Excess Limit

Annual Aggregate Limit

Current Carrier

Unique Extensions or Exclusions

1.

If your entity desires an SIR program, does your entity have a preferred Third Party Administrator (TPA)?

If yes, complete the Third Party Administrator Information section.

 Yes

 No

2.

Do you have a Sexual Abuse Prevention Policy in effect?

 Yes

 No

a.

Does the policy express management’s commitment to sexual abuse prevention?

 Yes

 No

b.

Does the written procedure clearly define the consequences of non-adherence?

 Yes

 No

3.

Are volunteers trained in policies, procedures, and law relating to the Sexual Abuse Prevention Program?  

 Yes

 No

4.

Do policies and procedures include an incident reporting and follow-up mechanism?

 Yes

 No

5.

In the past five years, have any employees or officers been terminated for cause related to sexually abusive behavior?  

 Yes

 No

6.

Are records maintained documenting adherence to all applicable policies and procedures, e.g., hiring and screening, code of conduct, training, incident and follow-up procedures?  

 Yes

 No

7.

Are you aware of any circumstances, which may result in a sexual abuse claim?

If "Yes,” please explain.  

 Yes

 No

Wrongful Acts/PUBLIC officials Liability Information

Claims-Made Coverage:  Retro Date  - Occurrence Coverage

n/a

General Information

Expiring Information

Renewal Information

Premium

Excess Limit

Retained Limit

 Deductible   SIR

 Deductible   SIR

Annual Aggregate Limit

Current Carrier

Unique Extensions or Exclusions

1.

If your entity desires an SIR program, does your entity have a preferred Third Party Administrator (TPA)?

If yes, complete the Third Party Administrator Information section.

 Yes

 No

2.

Do you have a Human Resources or Personnel Department?

If NO please describe handling of this function.  

 Yes

 No

3.

Do you have a Sexual Harassment policy?

If YES, does it contain:

 Yes

 No

a.

Hiring and screening process for new and volunteers?

 Yes

 No

b.

Your position on sexual harassment, discrimination and equal opportunity, etc

 Yes

 No

c.

A clear and open reporting procedure?

 Yes

 No

d.

A  “zero tolerance” policy?

 Yes

 No

19 of 3410/23/2007

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