Page 1 of 17
denotes a required field.
How did you hear about the Brokers' Risk Trustees' E&O Coverage?
Invalid Input

1)
Legal Name of School District/Educational Entity
Required

2)
School District/Educational Entity Mailing Address
Invalid Input

City
Invalid Input

State
Invalid Input

Zip
Invalid Input

Phone
Invalid Input

Fax
Invalid Input

email
Required

3)
School District/Educational Entity Type
Invalid Input

Invalid Input

If a cooperative, please specify the number of students
you provide services for.
Invalid Input

If a cooperative, please specify the number of students
you provide services for.
Invalid Input

If a cooperative, provide total payroll for the current school year
Invalid Input

If a cooperative, provide an estimated total payroll for the upcoming school year
Invalid Input

4)
Names of Current Board Members
Invalid Input

5)
Name of School Treasurer
Invalid Input

6)
Name of Superintendent
Invalid Input

7)
If the Superintendent has served the School District for less than two (2) years, please identify prior experience
Invalid Input

8)
Number of Schools in the District
Preschool or K through 5
Invalid Input

Preschool or K through 8
Invalid Input

Preschool or K through 12
Invalid Input

Grades 6 through 8
Invalid Input

Grades 9 through 12
Invalid Input

Other (specify grades)
Invalid Input

Total Number of School Districts
Invalid Input

8)
Enrollment by grades
Enrollment Preschool or K through 5
Invalid Input

Enrollment Preschool or K through 8
Invalid Input

Enrollment Preschool or K through 12
Invalid Input

Enrollment Grades 6 through 8
Invalid Input

Enrollment Grades 9 through 12
Invalid Input

Enrollment Other (specify grades)
Invalid Input

Total Enrollment
Invalid Input

9)
Number of Staff
Number of Technical Staff
Invalid Input

Total number of Employees
Invalid Input

Special Education Programs

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

10)
Do schools provide for their own Special Education Services?
Invalid Input

If Yes, how many Special Education Students are enrolled?
Invalid Input

11)
Does the School District participate in a Special Education Cooperative?
Invalid Input

If Yes, how many Special Education Students are enrolled there from the School District?
Invalid Input

If Yes, name of Special Education Cooperative?
Invalid Input

12)
Does the School District act as the Administrative Unit for the Special Education Cooperative?
Invalid Input

If Yes, does the District have a written Administrative Contract with the Special Education Cooperative?
Invalid Input

13)
If the School District is participating in a Special Education Cooperative, does the District provide any of the Special Education Programs?
Invalid Input

14)
Does the Special Education Cooperative have Professional Liability Coverage?
Invalid Input

15)
Does the Special Education Cooperative have Malpractice Insurance for their non-teaching professionals
(i.e., Physical Therapists, Speech Therapists, Counselors, Psychologists, etc.)?
Invalid Input

16)
Does the Special Education Cooperative have Workers’ Compensation, Property and General Liability Insurance?
Invalid Input

17)
Do you have written procedures for the development of an Individualized Education Program (IEP) for each Student?
Invalid Input

Vocational Education Programs

18)
Does the School District provide Vocational Programs?
Invalid Input

If Yes, does the School District provide for its own Vocational Program?
Invalid Input

If Yes, how many students are enrolled?
Invalid Input

19)
Does the School District participate in a Vocational Cooperative?
Invalid Input

If Yes, how many are enrolled from the School District?
Invalid Input

20)
Does the School District act as the Administrative Unit for the Vocational Cooperative?
Invalid Input

21)
If the School District participates in a Vocational Cooperative, does the School District provide any of the Vocational Programs?
Invalid Input

22)
Does the Vocational Cooperative have Professional Liability Coverage?
Invalid Input

23)
Does the Vocational Cooperative have Workers’ Compensation, Property and General Liability Insurance?
Invalid Input

Employment Practices

24)
Does the District have a written policy for suspension, dismissal and/or non-renewal of staff (professional and non-professional)?
Invalid Input

Year policy first adopted
Invalid Input

25)
Have any of the Districts' employees been suspended, demoted or transferred within the last 12 months?
Invalid Input

If Yes, describe action taken and dates
Invalid Input

26)
Have there been any employee dismissals, terminations, reduction in staff, or non renewal of employment contracts within the last 12 months?
Invalid Input

If Yes, describe action(s) taken and dates
Invalid Input

27)
Does the District plan any redistricting or other activity (including reduction in staff, employee terminations, dismissals, or non-renewal
of employment contracts) which would have a significant effect on the number of employees?
Invalid Input

If Yes, please explain
Invalid Input

28)
Does every teacher have an employment contract?
Invalid Input

29)
Are all employment contracts worded the same (other than tenured or non-tenured contracts)?
Invalid Input

30)
Has the School Board adopted a pay scale or hiring practice for personnel providing for remuneration without regard to age, sex, race or creed?
Invalid Input

Year first adopted
Invalid Input

31)
Has the School District adopted an affirmative action program for employment?
Invalid Input

Year first adopted
Invalid Input

32)
Are background checks conducted on all employees prior to hiring?
Invalid Input

33)
Is an offer of employment contingent upon such checks?
Invalid Input

34)
Are background checks conducted on current employees?
Invalid Input

35)
Are background checks conducted by the State Police?
Invalid Input

Sexual Harassment Guidelines

36)
Has the District established a policy and guidelines related to reporting and investigating allegations of sexual harassment?
Invalid Input

If Yes, are the guidelines in writing?
Invalid Input

37)
Does the District conduct seminars on preventing, identifying and reporting incidents of sexual harassment?
Invalid Input

If Yes, How often are the seminars conducted?
Invalid Input

If Yes, Is attendance mandatory for all employees?
Invalid Input

38)
What steps, if any, are taken by the School District to educate students concerning sexual harassment?
Invalid Input

Additional Questions

39)
What steps if any, are taken by the school dictrict to educate parents, students and all employees on the prevention,
identifying and reporting of bullying?
Invalid Input

40)
Is the School District a candidate for consolidation, annexation or dissolution next year?
Invalid Input

If Yes, please explain
Invalid Input

41)
Has the District informed all the proper personnel of the State’s Requirement on reporting any instance of suspected
child abuse to proper authorities?
Invalid Input

42)
Has the District adopted a written policy on suspected child abuse?
Invalid Input

43)
Has the District experienced any instance whereby this requirement was violated?
Invalid Input

If Yes, please explain
Invalid Input

44)
Does the District carry General Liability Insurance?
Invalid Input

If Yes, Does the insurance specifically cover claims arising out of Sexual Abuse or Child Molestation?
Invalid Input

45)
Has the District ever been required by any governmental authority to institute any integration or busing plan?
Invalid Input

If Yes, please list instances
Invalid Input

46)
Has any school within the School District ever been involved in or been closed by any dispute regarding integration,
segregation, school busing or equal rights or strikes by students or teachers?
Invalid Input

If Yes, please list instances
Invalid Input

47)
Has the District informed all the proper personnel of the state law banning corporal punishment?
Invalid Input

48)
Has the District adopted a written policy on corporal punishment that complies with State Law?
Invalid Input

49)
Has the District borrowed any money (or issued any tax anticipation warrants) against any tax levy pursuant to the
School Code or §9-107 of the Local Government Tort Immunity Act during the past 12 months?
Invalid Input

50)
Are there plans to do so during the next 12 months?
Invalid Input

Previous Insurance and Loss Information

51)
Has any policy or application for school board Errors & Omissions liability insurance or coverage on behalf of the
District Board of Education or any of its employees been declined, canceled, or renewal refused within the last 5 years?
Invalid Input

If Yes, please list details
Invalid Input

52)
Have there been, within the last 5 years, or are there now pending any Errors & Omissions claims, suits, legal actions or Proceedings against
the District or the Board of Education or against any other person proposed for this coverage in their Covered capacity?
Invalid Input

If Yes, please list details
Invalid Input

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.

53)
Does any person proposed for this coverage have knowledge or information of any facts, circumstances or situations which might
give rise to a claim under the proposed Coverage Agreement?
Invalid Input

If Yes, please list details
Invalid Input

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.

54)
Has the School District ever been required to conduct a Special Education Hearing under the Handicapped Children’s Protection Act?
Invalid Input

If Yes, please list details (including plaintiff attorney fees awarded)
Invalid Input

55)
Relative to the "No Child Left Behind Act" of 2001 and any amendments thereof, please advise all instances of academic early warning,
academic watch, adequate yearly progress and any federal restructuring.
Invalid Input

56)
Have there been any instances whereby the Fair Labor Standards Act requirements for exempt and non-exempt employees
has been violated or alleged to have been violated?
Invalid Input

If Yes, please describe instances
Invalid Input

57)
List Errors & Omissions carriers for the past five years (if none, state "None" in Name of Carrier field)
Name of Carrier
Required

Policy # (if available)
Required

Policy Term
Required

Limit
Required

Deductible
Required

Premium
Required

Name of Carrier
Required

Policy # (if available)
Required

Policy Term
Required

Limit
Required

Deductible
Required

Premium
Required

58)
Current Retroactive Date
Required

59)
Limit of Liability Desired
Invalid Input

Other limit
Invalid Input

60)
Deductible Desired
Invalid Input

Other Deductible
Invalid Input

Person designated to receive all notices from the Company or its authorized representative concerning the coverage

Name
Required

Title
Required

Email
Required

Address
Required

City
Required

State
Invalid Input

Zip
Required

Please include copies of following documents:

Sexual Harassment Guidelines
Invalid Input

Anti-Bullying Policy
Invalid Input

Claims/Loss Data from current carrier
Invalid Input

If a cooperative, please include copies of following documents:

Total Payroll
Invalid Input

Cooperative’s Bylaws
Invalid Input

Articles of Joint Agreement
Invalid Input

Agreement between Cooperative and its Members
Invalid Input

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.

Read the Warranty Above
Required

Digital Signature of BOARD PRESIDENT
Required

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

Digital Signature of BOARD SECRETARY
Required

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

Applicant's Email
Required

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.
Security Code
Invalid Input

© 1978 - 2018 Brokers' Risk Placement Service, Inc. - All rights reserved.