Municipal Entity Underwriting Application
Annual Aggregate Limit
Unique Extensions or Exclusions
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.
SUMMARY OF GENERAL LIABILITY RATABLE EXPOSURES
Total Operating Expenditures.
Capital Improvements (bondable items including interest thereon, new construction, major improvements & purchases of major items.
Expenditures for independent contractor operations:
Welfare benefits ( not administrative costs)
Classifications that are separately rated:
Arenas, Stadiums or Convention Centers
Dams, Dikes, Lakes and Reservoirs – existent hazards only.
Medical Care Facilities ( separately budgeted)
Schools & Colleges
Streets, roads, highways or bridges – existent hazard only
Transportation Systems & facilities, including airports, bus systems or other mass transit facilities
Utilities – electric and gas
Other ( Ski Facilities, Wharves, Piers, Docks, Marinas & Watercraft or Zoos
xiii) Deduction for Law Enforcement – if insured elsewhere
e. Total Deductions
Total Ratable Expenditures
Is a sewage disposal plan maintained?
If yes, please give payroll.
Number of miles of sewer lines maintained.
7 of 3410/23/2007