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Municipal Entity Underwriting Application - page 27 / 34

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Municipal Entity Underwriting Application

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Totals

Provide details of all claims that are over $50,000.  Include the date of event and the amount paid or reserved.  

Including ALAE Excluding ALAE

Provide claim detail for claims over $50,000 (attach separate sheet if necessary):

Date of Claim

Description of Claim

Amount of Claim

(Total of Paid and Reserves)

Is claim still open?

 Yes   No

 Yes   No

 Yes   No

 Yes   No

 Yes   No

 Yes   No

 Yes   No

 Yes   No

 Yes   No

 Yes   No

Have any new loss control measures been taken to prevent a recurrence of large losses?    Yes   No

If yes, please explain.  

Crime

Loss Data Valued as of:

n/a

Year

Claims Processor (In-house, Insurance Co. Name, TPA Name)

# Of Claims

Amounts Paid

Reserved

Total incurred

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27 of 3410/23/2007

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