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denotes a required field.
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8)
Number of Schools in the District
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8)
Enrollment by grades
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9)
Number of Staff
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Special Education Programs

Please provide information on how the School District provides Special Education Programs and/or Facilities for students.

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Vocational Education Programs

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Employment Practices

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Sexual Harassment Guidelines

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Additional Questions

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Previous Insurance and Loss Information

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Please provide current detailed loss data, supplied by each of the Errors and Omissions liability insurers for the past five years. For your use, please see attached sample claims authorization letter. WITH RESPECT TO QUESTION 52, IT IS AGREED THAT ANY CLAIM ARISING FROM THE FACTS, CIRCUMSTANCES OR SITUATIONS WHICH FORM THE BASIS FOR SUCH CLAIMS, SUITS, LEGAL ACTIONS OR PROCEEDINGS IS EXCLUDED FROM THE PROPOSED COVERAGE.

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WITHOUT LIMITATION OF ANY OTHER REMEDY AVAILABLE TO THE COMPANY, IT IS AGREED THAT IF THERE IS KNOWLEDGE OR INFORMATION OF SUCH FACTS, CIRCUMSTANCES, OR SITUATIONS, THEN ANY CLAIM SUBSEQUENTLY ARISING THEREFROM IS EXCLUDED FROM THE PROPOSED COVERAGE.

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57)
List Errors & Omissions carriers for the past five years (if none, state "None" in Name of Carrier field)
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Person designated to receive all notices from the Company or its authorized representative concerning the coverage

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Please include copies of following documents:

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If a cooperative, please include copies of following documents:

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Warranty

The Undersigned declare that to the best of their knowledge the statements set forth herein and any documents and information submitted in connection herewith are true, accurate and complete and that every effort has been made to obtain sufficient information from each and every person proposed for this coverage to facilitate the proper and accurate completion of this Application Form. The undersigned further declare that they have not suppressed, omitted, or misstated any material facts. The undersigned agree that if the information supplied on or in connection with this Application Form changes between the date of this Application Form and the effective date of the coverage, the undersigned will immediately notify Brokers’ Risk Placement Service, Inc. and Brokers’ Risk Placement Service, Inc., in its sole discretion, may withdraw or modify any outstanding quotations or authorization or agreement to bind coverage. The signing of this Application Form does not bind the applicant to purchase the coverage. However, it is agreed that this Application Form and any documents or information submitted herewith shall be the basis of the contract should a Coverage Agreement be issue and are to be considered as incorporated in and constituting part of the Coverage Agreement.

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By typing your name in this box and clicking submit you are accepting the terms of this Application Form.

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By typing your name in this box and clicking submit you are accepting the terms of this Application Form.

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All data on this application is considered highly confidential and is only for Company's use. Signing this Application Form does not bind the Company to provide this Insurance, but it is agreed that this Application Form shall be made a part of this certificate and shall be the basis of the contract should the certificate be issued.
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