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Municipal Entity Underwriting Application - page 22 / 34

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Municipal Entity Underwriting Application

Current Carrier

Unique Extensions or Exclusions

1.

Do you distribute a written handbook/explanation of all employee benefits?

If yes attach a copy of the handbook.

 Yes

 No

2.

Do you have a full-time trained human resource person?

 Yes

 No

3.

Have you had any claims for administrative E&O or negligent acts?

         If yes include detail in loss run summary

 Yes

 No

4.

Do you have knowledge of any future claims?

If yes provide details.  

 Yes

 No

Automobile Liability Information

n/a

General Information

Expiring Information

Renewal Information

Premium

Excess Limit

Retained Limit

 Deductible   SIR

 Deductible   SIR

22 of 3410/23/2007

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