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Municipal Entity Underwriting Application

Year:

Processor:

Year:

Processor:

Year:

Processor:

Totals

Provide details of all claims that are $50,000 or greater of Retained Limit.  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.  

Wrongful Acts/Public Officials Liability

Loss Data Valued as of:

n/a

Year

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

Exposure

(See Note Below)

Retained Limit

# Of Claims

Amount Paid

Reserved

Total Incurred

Year:

Processor:

 Gross   Net

Year:

Processor:

 Gross   Net

Year:

Processor:

 Gross   Net

Year:

Processor:

 Gross   Net

Year:

Processor:

 Gross   Net

Year:

Processor:

 Gross   Net

Year:

Processor:

 Gross   Net

32 of 3410/23/2007

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