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Membership Application
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GENERAL INFORMATION |
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Name of Governmental Entity: |
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Population/Area Served: |
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Address: |
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City, State, Zip: |
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Name of Person Completing Application: |
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Title: |
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Telephone: |
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e-mail: |
Fax #: |
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# All Employees: |
Full-time: |
Part-time: |
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# Full-time Police Officers: |
# Auxiliary Police: |
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# Full-time Firefighter/Paramedics: |
# Paid-On-Call: |
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II.
EXPOSURE IDENTIFICATION INFORMATION:
*(0 = Operated by municipality; C = Contracted by municipality)
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ACTIVITY |
YES* |
NO |
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Library (Is it separately insured?) |
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Recreational Facilities (Parks, Lakes, Ponds, etc.) |
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Swimming Pools |
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Docks, Marinas |
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Watercraft (over 25 ft.) |
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Golf Course(s) |
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Paramedic/ EMT Service |
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Health/Outpatient Clinic |
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Water Filtration Plant |
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Sewage Treatment Plant |
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Refuse/Garbage Department |
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Landfill/ Waste Transfer Station |
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Airport |
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Owned Aircraft |
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Museum |
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Underground Storage Tanks (# of ______) |
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Civic Center |
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Buses/Transit System (excludes Senior “Dial-A-Ride” programs) |
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Fireworks Display/ Festivals/ Major Special Events |
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Electric Power Generation and/or Distribution Service |
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Other: Describe any other unusual events or activities (parades, festivals, shooting range, training facility, etc.):
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III.
CURRENT YEAR INSURANCE COVERAGES
The insurance policy summaries and/or actual policies required for submission include:
General Liability
· Employment
Practices Liability
· Medical/Professional
Liability
· Police Professional
Umbrella/Excess Liability
Automobile
Public Officials Liability
Workers’ Compensation
·
Employers’ Liability
Property
· Boiler
& Machinery
·
Crime & Fidelity
IV.
APPLICANT'S CLAIM HISTORY
Ø Provide a five year loss run for policy periods: 2009, 2008, 2007, 2006, and 2005
Ø Indicate claim #, claimant’s name, and show paid and outstanding reserves for each claim in each of the following coverages:
General Liability
· Employment
Practices Liability
·
Medical/Professional
Liability
·
Police Professional
Umbrella/Excess Liability
utomobile
Public Officials Liability
Workers’ Compensation
·
Employers’ Liability
Property
· Boiler
& Machinery
·
Crime & Fidelity
V.
FINANCIAL INFORMATION
Ø Provide comprehensive annual financial reports for 2004, 2005, 2006, 2007 & 2008.
In order to evaluate the applicant's claim history, the above loss report information must be submitted. The data must not be any older than 90 days
VI.
SIGNATURE AND APPLICATION FEE
This application was completed for the purpose of procuring membership in the IRMA organization. I hereby acknowledge that there is no fact, circumstance, or situation, indicating the probability of a claim, nor any incident, claim or threatened litigation of any kind now known to any official or employee to which coverage would be afforded under the proposed insurance that has not been disclosed. I hereby further acknowledge that all the information provided on this application is complete, true and correct to the best of my knowledge. Additionally, I understand that if there is such knowledge that has not been disclosed, any action or claim resulting there from may be excluded from the coverage proposed.
________________________________________
Printed Name
________________________________________
Signature
________________________________________ ______________________
Official title (Mayor, Administrator or Designee)
Date
($1,000 Application fee waived)
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