X hits on this document

Word document

Municipal Entity Underwriting Application - page 7 / 34

78 views

0 shares

0 downloads

0 comments

7 / 34

Municipal Entity Underwriting Application

Annual Aggregate Limit

Retained Limit

 Deductible   SIR

 Deductible   SIR

Current Carrier

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.

 Yes

 No

SUMMARY OF GENERAL LIABILITY RATABLE EXPOSURES

n/a

1.

Total Operating Expenditures.                                                                                                                                                        

2.

Deductions

a.

Capital Improvements (bondable items including interest thereon, new construction,  major improvements & purchases of major items.                                                               

b.

Expenditures for independent contractor operations:                                                           

c.

Welfare benefits ( not administrative costs)                                                                       

d.

Classifications that are separately rated:

i)

Amusement Parks

ii)

Arenas, Stadiums or Convention Centers

iii)

Dams, Dikes, Lakes and Reservoirs – existent hazards only.

iv)

Fire Department

v)

Housing Projects

vi)

Medical Care Facilities ( separately budgeted)

vii)

Penal Institutions

viii)

Schools & Colleges

ix)

Streets, roads, highways or bridges – existent hazard only

x)

Transportation Systems & facilities, including airports, bus systems or other mass transit facilities

xi)

Utilities – electric and gas

xii)

Other ( Ski Facilities, Wharves, Piers, Docks,  Marinas & Watercraft or Zoos

                xiii)      Deduction for Law Enforcement – if insured elsewhere                           

        e.      Total Deductions

3.

Total Ratable Expenditures     

Sewer Utilities

1.

Is a sewage disposal plan maintained?

If yes, please give payroll.  

 Yes

 No

2.

Number of miles of sewer lines maintained.

7 of 3410/23/2007

Document info
Document views78
Page views78
Page last viewedSat Dec 03 01:08:53 UTC 2016
Pages34
Paragraphs84
Words498

Comments