2014-2015 Application

Please complete the sections which correspond to the coverage you are requesting NJSIG to quote.

INSURED INFORMATION ***EFFECTIVE DATE: ______

1. District Name:
2. District Address:
3. District County:
4. District Contact:
5. Email:
7. Phone:
8. Fax:

QUOTE INFORMATION

9. If a Charter School: / List Year Charter School First Opened: ______
Is the Charter active? Yes No
10.Type of School: / K-8 or K-12 Vo-Tech Other: ______
11. Quote Due Date:
12.Board Meeting Date:

WORKERS’ COMPENSATION & SUPPLEMENTAL INDEMNITY.

13.Professional Employees Payroll (includingClericaland Aides): / $
14.Non-Professional Employees Payroll (includingDrivers): / $
15.Supplemental Indemnity waiting period (0, 7, 14, 21, or 28): / ______ Days

GENERAL LIABILITY, AUTO LIABILITY, ERRORS & OMISSIONS, AND STUDENT ACCIDENT

16. Student Enrollment: / Total Number of Students:______
* If Vo-Tech: Full Time Students: ______Part-Time Students: ______
17. Day Care Services / Doesthe entity provide or sponsor Day Care services? Yes No
If yes, how many children are provided with Day Care services?______
18. Stadiums: / Does the entity own any Stadiums with seating capacity greater than 10,000?: Yes No
If yes, please advise the maximum stadium capacity: ______
19. Swimming Pools: / Does the entity own any swimming pools? Yes No
If yes, do any of these pools have diving boards?Yes No
20. Security: / Does the entity employ security guards? Yes No
If yes, are any of these security guards armed?Yes No
Does the entity use metal detectors? Yes No
21. Auto Liability: / *Please update/complete the attached Vehicle Schedule.
Is BUS Physical Damage Coverage to be quoted on a Replacement Cost Basis? Yes No
(Replacement Cost coverage is only available for Buses 10 years old or newer)
22. Buses: / Doesthe entity contract with Third Party Bus Companies to transport students?:Yes No
If yes, do you have current Certificates of Insuranceon file for these Bus Companies naming your entity as an Additional Insured?Yes No
If yes, what Auto Liability Limits does the Third Party Bus Company carry?:______
23. Errors & Omissions: / Please complete and attach theErrors & Omissions Application.
24. Student Accident:
*No longer available through NJSIG / *If the entity purchases Student Accident coverage from an outside carrier for the 2014-2015 policy year, please include a copy of the 2014-2015 Student Accident Binder to obtain the GL discount.
25. Emergency Shelter / Is any building in your District designated as a community shelter in the event of a natural disaster or any other emergency situation? Yes No

PROPERTY, EQUIPMENT BREAKDOWN AND BUILDER’S RISK

26. Property: / *Please update/complete the attached Schedule of Properties (SOV/locationschedule).
If no change or lower values are indicated, please explain the rationale on a separate sheet.
If District owns/leases locations not on Schedule, please add and note who leased from or to.
27. Equipment Breakdown: / Equipment Breakdown is automaticallyquoted if Property is quoted.
Does the District own or operate Solar Panels, Wind Turbines or any other Alternative Energy Source?: Yes No
28. Extra Expense Limit: / $50,000,000 LIMIT PER NJSIG POOLOCCURRENCE WITH NO EXTRA CHARGE
29. Valuable Papers Limit: / $10,000,000 LIMIT PER NJSIG POOLOCCURRENCE WITH NO EXTRA CHARGE
30. EDP Limit: / $
31. Loss of Business Income/ Tuition Limit: / $
32. Loss of Rents Limit: / $
33.Builder’s Risk: / Are there any planned construction Projects for the 2014-2015 Policy Term? Yes No If yes, pleasecomplete the NJSIG Builders Risk Application.
34.Environmental Coverage: / Environmental Coverage is SITE SPECIFIC. All locations listed on the Schedule of Properties(SOV/location schedule) must reflect the legal address of the property, INCLUDING STREET NUMBER.
35. Flood Zones: / Do you have any buildings located in Flood Zones with a prefix of A or V? Yes No
If yes, do any of these buildings have*basements? Yes No
If yes for basements, please complete and attach the NJSIG Flood Zone Questionnaire * A basement is any area of the building having its floor below ground level (subgrade) on all sides.

CRIME

36. Blanket Faithful Performance Limit: / $
37. Money Orders/Counterfeit CurrencyLimit: / $
38. *Computer Fraud Limit: / $ *PLEASE ANSWER QUESTIONS A) AND B) BELOW:
A) All fund transfer procedures are audited: Yes No
B) The individual who initiates a fund transfer is someone other than one who
verifies/audits the transfer: Yes No
39. Money & Securities Limit: / $
40.Depositors’ Forgery Limit: / $
41.Treasurer Bond Limit: / $
A completed/signed NJSIG Bond Application is needed for: 1)ALL New Bond Holders; 2) if there has been a change in a Bond Holder’s name; 3) if there has beena change in a Bond Holder’s Title; 4) Ifincreasing the bond amount/ limitforan existing Bond Holder.
42. Secretary Bond Limit: / $
A completed/signed NJSIG Bond Application is needed for: 1) ALL New Bond Holders; 2) if there has been a change in a Bond Holder’s name; 3) if there has beena change in a Bond Holder’s Title; 4) If increasing the bond amount/ limit for an existing Bond Holder.

EXCESS LIMITS:Excess coverage will be quoted at current limit if Policy is a renewal to NJSIG. Higher Limits are available.

If New Business, a total limit of $16 million will be quoted.

Effective July 1, 2008, for new business only, NJSIG has standardized commission levels to the following amounts;

15% Package Lines 6% Workers Compensation

15% Errors &Omissions 15% Excess/Higher Limits

10% Supplemental Indemnity

Existing commission levels on renewal accounts will be grandfathered.All new business quotations will include agent/administrative commission.

Agency Name:

Agency Address:

Producer:

New Jersey Property/Casualty License: YES NOIfno what State are you Licensed in?

Phone number:

E-mail address:

In the event membership with NJSIG is new or membership has been less than three full policy years, please provide loss information from prior carrier for General Liability, Automobile Liability, Property and Workers’ Compensation if quotations are desired. The last five years of claim data shouldinclude the current year.

* NJSIG can only process a quote proposal for completed applications. Applications which have a Board Meeting Date and Quote Due Date will be given priority. NJSIG does not guarantee delivery of a quote proposal if an application is not received in a timely fashion or contains insufficient information.

Please return application to the attention of Carla Holloway at:

New Jersey Schools Insurance Group

450 Veterans Drive

Burlington, NJ08016

Email:

Phone: 609-386-6060

Fax: 609-386-8877

Thank you for your continued support!

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