Metrogard New/Renewal Submission Checklist

All items must be submitted when coverage is applicable.

The following checklist is provided as a tool to help you put together a complete submission. The will aid in a faster and more complete quotation.

PROPERTY
Updated and signed original Statement of Values
Lease Agreements
INLAND MARINE
Updated Inland Marine Schedules
Due to ISO changes, any Contractors Equipment which is licensed for use on public roads must now be covered under the Auto policy for both liability and physical damage. Please identify any registered equipment currently covered under Inland Marine and provide us with a cost new. These items will need to be moved to the Auto policy upon renewal.
CRIME COVERAGE
Metrogard Crime Supplement is required for limits of $50,000 or more
GENERAL LIABILITY
Provide exposures
Supplemental applications as indicated on application or requested by underwriter
Governmental Expenditure Worksheet
Additional Insured Contracts
PROFESSIONAL LIABILITY
Law Enforcement Liability Application
Public Officials E&O and Employment Practices Liability Application
School Board E&O and Employment Practices Liability Application
AUTO
New Applications must include complete vehicle list with: Year, Make, Model, VIN, Cost New, Class Code, Gross Vehicle Weight (all trucks / trailers), # of passengers for any bus, physical damage deductibles, if applicable.
Renewal applications must include a list of all vehicle additions, deletions, and revisions
Drivers list – include all departments, license #s, DOB and state in which they are licensed
WORKERS’ COMPENSATION
Up-to-date Payrolls
Experience MOD Worksheet (New Application Only)
OCEAN MARINECompleted applications from our *website are required each year
UMBRELLA
Completed WH Greene umbrella application from our *website are required each year
Original W.H. Greene application signed by insured are required within 10 days of binding

MUNICIPAL INSURANCE PROGRAM

IMPORTANT

It is your responsibility to update the limits of existing coverages and identify any coverage or exposures that are not included.

The undersigned hereby acknowledges that a quotation provided by this office for this application, is based on the information contained herein. Any inaccuracies are the responsibility of the broker.

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any facts material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR; in ME and VA, insurance benefits may also be denied.)

Applicant’s Signature: (Date)

Broker’s Signature: (Date)

Coverage cannot be considered until a signed copy of this summary is received at our office

Please complete as indicated.

Broker / Insured
Contact: / Contact Name:
Insurance Agency: / Entity Name:
Address: / Address:
Address 2: / Address 2:
Town: / Town:
State: / Zip: / State: / Zip:
Phone: / Phone:
Fax: / Fax:
Email: / Email:
Federal Employer Identification #:
Risk Manager or Equivalent:
Town Attorney:
School Attorney:
Contact us:
Trident Insurance Services of New England, Inc.T. 800.444.3916
PO Box 1170 F. 413.774.3916
Greenfield, MA 01302
COVERAGE REQUESTED / Renewal Business / New
Business /

If new business, Expiring

Premium

If new coverage, provide

Expiring Carrier

Effective

Date

Property

/ $

Inland Marine

/ $

Crime

/ $

General Liability

/ $

General Liability – Additional Insureds

/ $

Law Enforcement Liability

$

Public Entity Errors & Omissions

/ $

Public Entity Employment Practices Liability

/ $

Educational Entity Errors & Omissions

/ $

Educational Entity Employment Practices Liability

/ $

Commercial Auto

/ $

Garage keepers

/ $

Workers Compensation

/ $

Equipment Breakdown

/ $

Hull, Protection & Indemnity

/ $

Marina Operations Legal Liability

/ $

Umbrella/ Excess Liability

/ $
Other: / $
Other: / $
Other: / $
Other: / $
Other: / $
IMPORTANT: We cannot quote New Business unless a minimum 5 years loss experience (current year plus 4) and expiring premiums are included.

PROPERTY

Renewal applicants: complete only if new Limits or Deductibles are desired - or check if NO CHANGE:

Blanket Limit: (Submit 100% Valuation Only.)
The SOV must include all the information requested on the SOV form on our web page
Note: $75,000,000 per occurrence loss limit is applicable to any blanket limit over this amount.
POLICY DEDUCTIBLE($1000 Minimum):

$1000 $2500 $5000 $10,000 $25,000 Other $

Other Property Coverages

Basic Limits included in Plus

Limit Desired

Deductible Desired

Business Income w/o Extra Expense - CP0032

N/A

$

Policy Deductible

Extra Expense only – CP0050

$25,000

$

Policy Deductible

Business Income including Extra Expense – CP0030

/ $25,000

Extra Expense only

Policy Deductible

Increased Cost of Construction (Coverage C)

N/A

(Max $1,000,000)

Policy Deductible

Flood (excluding zones listed below*)

N/A

(Max $10,000,000)

/ $

($50,000 min)

Earthquake

N/A

(Max $5,000,000)

/ $

($25,000 min)

Fire Legal Liability - Include schedule of locations

$100,000 Included in GL

Indicate amount in excess of GL: $

Policy Deductible

Debris Removal

$25,000

/ $

(Max $250,000)

Policy Deductible

Property in Transit

$15,000

$250

Fire Protection Device Recharge

$5,000

/ $

(Max $25,000)

None

Lock Replacement

$1,000

/ $

(Max $10,000)

$100

Personal Effects

$10,000

None

Personal Property of Others

$10,000

Policy Deductible

Food Spoilage

$10,000

$250

Utility Services-excluding overhead transmission lines

$25,000

Policy Deductible

Other:

Coverage does not apply to any locations situated in FEMA Zones A, AO, AH, A1-A30, A99, AR, AR/A1-30, AR/AE, AR/AH, AR/AO, AR/A, V, VE and V1-V30

Statement of Values must be updated annually and must include the following:

Number of stories
Year of Construction

Occupancy type
Square footage

ISOConstruction Class
Sprinkler Status

PROPERTY - This section must be completed annually.

Please list any locations in which the insured is Lessor or Lessee and provide a copy of the lease agreement.

Lessor

Lessee

1.Address:

2.Address:

3.Address:

4.Address:

Yes / No

Are there any vacant / unoccupied / tax-takeover locations owned by the insured?

If so, coverage cannot be provided on the Statement of Values. Please complete our vacant building supplemental application for consideration of coverage.
Do you have a Recycling and/or Transfer Station?

If yes, please complete “Recycling and/or Transfer Stations” supplemental applications from

Are ALL owned buildings on the Statement of Values (SOV).Yes No

Please indicate the date of the most recent property valuations done on insured owned building:

Method of valuation?

Please list Loss Payees with complete address; specific items and lease #.

Item Description

Location

Lease#

INLAND MARINE - This section must be completed annually.

COVERAGE

Basic Limit included in PLUS

Limit

Desired

Deductible

Desired

Accounts Receivable / $25,000 / $ /

Electronic Data Processing Equipment / $25,000 / $ / $
Electronic Data Processing Media / $10,000 / $ / $
Electronic Data Processing Extra Expense / $5,000 / $ / $
Valuable Papers / $25,000 / $ / $
*Contractors Equipment$500 Min Deductible / N/A / $ / $
** Fine Arts / $15,000 / $ / $
*Commercial Articles – (Cameras, AV Equipment) / N/A / $ / $
*Musical Instruments / $10,000 / $ / $
** Fire Trucks(s) Replacement Cost
(Provide Replacement cost, not cost new.)
$1000 Min Deductible / N/A / $ / $
*Fire Department Equipment (not Trucks) / $10,000 / $ / $
*Police Equipment / Included above / $ / $
** Miscellaneous Special Floater Items (specify) / N/A / $ / $
Other: / $ / $
*Important:if you have not submitted a schedule for these coverages, a per-item limitation will apply.
** Schedule required for these coverages.

CRIME COVERAGE

Renewal applicants: complete only if new Limits or Deductibles are desired - or check if NO CHANGE:

Total number of employees:

/ Total number of employees handling money:

COVERAGE

Basic Limit included in PLUS

Limit

Desired

/ Deductible

$500 minimum*

Employee Dishonesty

$10,000

Depositors Forgery

N/A

Money and Securities: Inside and Outside

$10,000

Computer Fraud

N/A

Peak Season Coverage: to

N/A

Other:

N/A

Indicate Name of Employee Benefit Plans Included as Insured for ERISA Compliance (if applicable):

Metrogard Crime Supplemental Application is required for all crime coverages with limits of $50,000 or more.

*For Limits of $100,000 or more, the minimum deductible is $1,000.
GENERAL LIABILITY EXPOSURES - This section must be completed annually.
Basis / Exposure / Subcontracted? / Comments
Yes / No
Airport / N/A / N/A / N/A / Excluded
Beach / Each / Supplemental Application required.
Cable TV-Internet Provider / N/A / Provide Description of Operations
Camp Programs / # Camper Days / Supplemental Application required
Climbing Wall / Each / Supplemental Application required
Dams-Levees-Dikes / Each / Existence Hazard Only
Day Care -Children & Adult -NFP Only / Per Person (avg. daily attendance) / Supplemental Application required
Golf Course / Gross Sales / Supplemental Application required
Government Subdivision / Net Expenditures / Governmental Expenditure Worksheet Required
Herbicide-Pesticide Spraying / Each / Copy of license(s) required.
Hospital / N/A / N/A / N/A / Excluded
Ice or Roller Rink / Gross Sales / Supplemental Application required
Lakes-Reservoir / Each / Existence Hazard Only
Landfill / Each / Limited to Transfer Station
Lessor's Risk / Area / Attach a description for each location
Marinas / Gross Sales / Complete MOLL application
Nursing Home / N/A / N/A / N/A / Excluded
Ropes Course / Each / Supplemental Application required
Skateboard Park / Each / Supplemental Application required
Ski Facility / N/A / N/A / N/A / Excluded
Special Events / # Per Year / Supplemental Application required
Stadium-Bleachers-Grandstands
(Excluding. Schools) / Each / Excluded over seating capacity of 5000.
Streets/Roads / Each Mile
Swimming Pool / Each / Supplemental Application required
Trampoline-Similar Rebounding Device / N/A / N/A / N/A / Excluded.
Watercraft / Each / Supplemental Application required
Wharves-Piers-Docks / Area / Supplemental Application required
Zoo / Each / Supplemental Application required
Automotive Repair Facility / Gross sales
Faculty Liability for Corporal Punishment / Each Faculty Member
Public Elementary, Kindergarten or Jr. High / Per Student
Public High School / Per Student
Public Trade or Vocational School / Per Student
Grandstand/Bleacher / Each
Utilities
Electric Light or Power / Payroll / Pass thru operation only.
Supplemental Application required
Gas Utility / N/A / N/A / N/A / Excluded.
Water Utility / Payroll
Sewer Utility / Payroll
Miles of Sewer
GENERAL LIABILITY
Please Indicate desired Limits: / General Aggregate$ Maximum: / $ 3,000,000
Products Aggregate:$ Limits: / $ 3,000,000
Each Occurrence: $ / $ 1,000,000
Medical Expense: $ / $ 10,000
Check additional exposures:
Employee Benefits ($1 Million Occurrence and Aggregate Limit, $1000 deductible)(Claims Made)
Is this new coverage? Yes No
If yes, Date of first continuous Claims Made Coverage? Retroactive Date will apply.
Total # of employees including all departments:
Sexual Abuse / Molestation / Non-Employee Harassment -
New: complete Sexual Abuse Applications from
Renewal: refer to renewal letter from your underwriter.
Emergency Medical Technicians & Paramedics Professional Liability (Employees of Named Insured only)
Number of EMTs
Number of Paramedics
Number of Ambulances
Nurses Professional Liability (Employees of Named Insured only)
Number of Registered Nurses (Nurse Practitioners are not eligible)
Number of Licensed Practical Nurses (LPNs)
Are any of the above indicated nurses operating from a non-school facility? If so, please describe:
FullLiquor Liability – Referral to Underwriting Required $ Gross Sales.
*Other than host and fund raising for the sole benefit of the insured program coverage extension per CG2151
Describe activity:
Yes / No
Are any of your departments separately insured?
If so, please provide name of department:
Policy No.: Carrier:
Effective Dates: to Coverage:
Does insured require parent /student waiver of liability forms for extracurricular activities and/or field trips?
Does insured have security guards employed or contracted?
If so, do they carry a weapon?
GENERAL LIABILITY - Additional Insureds:
Must have underwriting approval prior to issuing a certificate of insurance.
Must be required by contract and a copy of such contract included with this application for type C, D, E and F below
Indicate type of Additional Insured with symbols as follows:
A.Leased Land
B.Leased Equipment / C.Designated Person – Event
D.Designated Person/Organization / E.Manager / Lessor – Leased Premises
F.Limited Designated Person / Organization
NAME / ADDRESS / TOWN / ST / ZIP / TYPE
Description:
Description:
Description:
Description:
Description:
If there are more Additional Insureds, please add a sheet with the information to the back of this application.
LAW ENFORCEMENT LIABILITY
Law Enforcement Application
New: Metrogard Law Enforcement application, available at is required prior to quoting and binding.
Renewal: Refer to renewal letter from your underwriter.
Requested Limit / Requested Deductible
$1 Million Occurrence / $1 Million Aggregate / $ 2,500 / $10,000 / $50,000
$1 Million Occurrence / $3 Million Aggregate / $ 5,000 / $15,000 / $100,000
$ 7,500 / $25,000
Law Enforcement Officials
Number of Full Time Officers
Number of Part Time Officers
Maximum detention capacity of any single holding facility:
Any detention facility with more than a 25 inmate capacity is not eligible for coverage under this program.
PUBLIC ENTITY ERRORS & OMISSIONS (Claims Made)
Retroactive Dates will apply
New: Metrogard Public Entity E&O application, available at is required prior to quoting and binding.
Renewal: Refer to renewal letter from your underwriter.
Effective Date: / Date of 1st Continuous Claims Made Coverage:
Insurance Company:
Requested Limit / Requested Deductible
$1 Million per Wrongful Act / $1 Million Aggregate
$1 Million per Wrongful Act / $3 Million Aggregate / $ 2,500
$ 5,000
$ 7,500 / $10,000
$15,000
$25,000 / $50,000
$100,000
Provide Population of City, Town, Village or County:
Provide Number of Users if coverage is for Water, Sewer or Fire District:
Employment Practices Liability Extension
Full Time:
Part Time: / Indicate the number of employees (excluding independent contractors.) Do not include employees from the following units as they are excluded from coverage: schools, airports, transit authorities, hospitals, nursing homes, municipally owned electric companies, housing authorities or port authorities.
EDUCATIONAL ENTITY ERRORS & OMISSIONS (Claims Made)
Retroactive Dates will apply
New: Metrogard Public Entity E&O application, available at is required prior to quoting and binding.
Renewal: Refer to renewal letter from your underwriter.
Effective Date: / Date of 1st Continuous Claims Made Coverage:
Insurance Company:
Requested Limits / Requested Deductible
$1 Million per Wrongful Act / $1 Million Aggregate
$1 Million per Wrongful Act / $3 Million Aggregate / $ 2,500
$ 5,000
$ 7,500 / $10,000
$15,000
$25,000 / $50,000
$100,000
Student Enrollment
Total Student Enrollment
Employment Practices Liability Extension
Indicate total number of school department employees only.
Full Time:
Part Time:
COMMERCIAL AUTOMOBILE
YES / NO
Are all owned vehicles included on vehicle list?
Are there any non-owned vehicles on the list?
Are there are any services contracted (i.e. buses)?
If so, include copies of contracts.
Total number of Vehicles
Total number of Vehicles carrying Collision
Total number of Vehicles carrying Comprehension
Total number of Employees
REQUESTED LIMITS
$Limit of Liability
$Uninsured / Underinsured Limits
$Medical Payment Limit - ($5000 Maximum available)
# of Registration Plates not issued for a specific vehicle.
REQUESTED DEDUCTIBLES
Deductible options vary by state. Please specify.
$Comprehensive - Symbol 7 Only
$Collision - Symbol 7 Only
YES / NO
Massachusetts – Waiver of Deductible
Connecticut – Full Glass Coverage
Connecticut – Uninsured Motorists Conversion Coverage
LOCATION AGGREGATE LIMIT
Any single location of garaged/stored vehicles in excess of $2 Million in value is excluded from coverage.
Drivers List (required to bind) – include all departments, license #s, DOB and state in which they are licensed.
YES / NO
Does the insured employ a Safety Manager?
Does the insured conduct auto safety or safe driver training?
Does the insured adhere to a preventative maintenance schedule?
Are driver’s records reviewed prior to hire?
Are driver’s records reviewed periodically, at least once a year?
Is primary garaging Indoors? or Outdoors?
If indoors, is primary garaging kept locked when not being accessed?
If outdoors, is primary garaging enclosed and locked when not being accessed?
GARAGEKEEPERS
This coverage can be written only in conjunction with any owned autos.
Garage Liability exposures are rated as part of General Liability, (see page 5, Automobile Repair Facility)
Renewal Applicants, please indicate changes only – or check if NO CHANGE
Optional Garagekeepers Endorsement:Direct PrimaryLegal Liability
$Comprehensive Limit per Location (Maximum limit available for all locations is $250,000)
Comprehensive Deductible: per car/per occurrence:$100/500$250/1,000$500/2,500
$Collision Limit per Location (Maximum limit available for all locations is $250,000)
Collision Deductible:$100$250$500
Please include a list of locations, including addresses where this coverage applies.
List Garage Location, including address and department:
WORKERS’ COMPENSATION
Renewal Applicants: please update Payrolls and Experience Modification Factor
Please indicate any other changes.
LIMITS:$ BI by Accident, each AccidentMinimum Limits: $500,000
$ BI by Disease, policy limit $500,000
$ BI by Disease, each employee $500,000
Estimated PayrollClassClassification
0106Tree Removal
5506Street & Road Maintenance
5509*Street & Road Maintenance (*Connecticut Only)
7380Drivers
7382Bus: All other
7520Water Operators & Drivers
7580Sewage operators & Drivers
7590Garbage Works
8810Clerical Office
8820Attorney
8835Nursing – All Employees
8868Schools - Professional
9015Building Operations by Owner
9060Country Clubs
9079Restaurant NOC
9101School – All other
9102Park NOC – All Employees
9220Cemetery Operations & Drivers
9402Street Cleaning / Driver
9403Garbage Collectors & Drivers
9410Municipal
The following information is required in order to release a quote:
Number of Employees
Experience Modification Factor (Attach MOD worksheet) For new business.
Audit Contact: Phone
Federal Employer ID:
Maine risks, Insured’s Unemployment Number::
Rhode Island: Unemployment ID Number (UAIN): #
Note: If coverage is currently written in a pool, Form ERM6 must be completed for reporting to NCCI.
EQUIPMENT BREAKDOWN COVERAGE(BOILER & MACHINERY)
Renewal Applicants: Please indicate changes only – or check if NO CHANGE
$Program Limit (Standard Program Limit is $75,000,000)
$Deductible ($500 Minimum)
Insured Inspection Contact:
Phone:
Please answer this question every year. Does the insured co-generate or distribute electricity? Yes No
Hull, Protection & Indemnity
SEPARATE applications are required Annually
Hull - Protection & Indemnity Application is required, available at
Crew and students are excluded from Coverage
Marina Operator’s Legal Liability - Application is required, available at
UMBRELLA
WH Greene Umbrella Application is Required annually
Underlying Carriers must be:

Approved Metrogard / Diplomax Program carrier
Or carriers with an A. M. Best’ A-VI, B+VII rating or better.
Or an approved Self Insurance Group (SIG).

P&I cannot be included without prior approval.
Limit Desired $ If over $10,000,000, contact your underwriter.
Minimum Underlying Limits: $1,000,000 / $1,000,000 aggregate (where applicable) and $500/$500/$500,000 Workers Compensation Employers Liability. Refer to your underwriter for requirements of our other carriers.
Original W.H. Greene application signed by insured is required within 10 days of binding.

Trident Insurance Services of New England, Inc.T. 800.444.3916

PO Box 1170 F. 413.774.3916

Greenfield, MA 01302Page 1 of 13