Type of Educational Institution*
Please check the box below that adequately reflects your activities as an educator:*
Premium Determination |
Base Rate |
$0.00 |
Additional Contingent Liability |
$0.00 |
Additional Pollution Limit |
$0.00 |
Processing Fee |
$10.00 |
Subtotal |
$0.00 |
Surplus Lines Tax |
$0.00 |
State Fee |
$0.00 |
Stamping Fee |
$0.00 |
Fire Tax |
$0.00 |
Municipality Fee |
$0.00 |
Policy Total |
$0.00 |
Prior Coverage History
Do you currently have
Educator's Professional Liability
Other Professional Liability
Please attach a listing of all employment lawsuits, administrative proceeding (e.g. EEOC), as well as any professional liability lawsuits (for which this coverage is construed against any entity) which was commenced during the past 3 years. Describe the type of allegation, the court or agency involved and any determination, judgment, defense cost or settlement for each. If there have been no losses, please indicate here:
Prior Knowledge/Warranty
Note: If there has been no previous professional liability coverage or in the
event continuity is not granted it will be necessary to answer the following:
It is important that you fill in the blank in this paragraph.
No person proposed for coverage is aware of any facts or
circumstances which he or she has reason to suppose might give rise
to a future claim that would fall within the scope of the proposed
coverage, except: