ACS | Apply

1. Account Registration

Please Note: If you already have a user account on acs.haysprograms.com, then please login to your account and then submit the application. You can use password forget link in case you do not have/remember the password.

E-Mail*

Password*

Applicant Information

Prefix*

Applicant First Name*

Applicant Last Name*

Mailing Address*

City*

County*

State*

Zip Code*

Telephone*

Association Information

American Chemical Society

ACS Membership #*

Are you a member of AACT?

AACT Membership#*

Chemical Educators Application

Name of Academic Institution in which you work?*

Type of Educational Institution*

Private College/University

Public College/University

Private or Public Secondary School

Other

Please specify*

Please check the box below that adequately reflects your activities as an educator:*

Faculty and instructional staff with responsibility for conduct or supervision of high school and freshman-level undergraduates instructional labs, but no responsibility for supervision of individuals research activities involving manipulations of chemical substances. No coverage for use of pyrophoric or high energy or high toxicity substances or acutely bio-hazardous materials.
Rate: $250 annually

Faculty and instructional staff with responsibility for conduct or supervision of instructional labs at any undergraduate level, but no responsibility for supervision of individual research activities involving manipulation of chemical substances. No coverage for use of pyrophoric or high energy or high toxicity substance or acutely bio-hazardous materials.
Rate: $350 annually

Faculty and instructional staff with responsibilities that include supervision of individual research activities involving manipulation of chemical substances but not involving pyrophoric or high energy or high toxicity substances or acutely bio-hazardous materials. Such individuals would also be covered for instructional labs at all levels.
Rate: $450 annually

Faculty and instructional staff with responsibilities that include responsibility for supervision of individual research activities involving or potentially involving manipulation or pyrophoric or high energy or high toxicity substances or acutely bio-hazardous materials. Such individuals would also be covered for instructional labs at all levels.
Rate: $550 annually

Would you like to increase your contingent liability (bodily injury/property damage) limit from $500,000 to $1,000,000 for an additional premium of $50?*

YesNo

Would you like to increase the pollution limit from $500,000 to $1,000,000 for an additional premium of $50?*

YesNo

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

Carrier

Limits

Deductible

Exp Date

Other Professional Liability

Carrier

Limits

Deductible

Exp Date

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:

None

Or:*

Submission

THE APPLICANT DECLARES THAT, AFTER INQUIRY, TO THE BEST KNOWLEDGE OF ALL PERSONS TO BE INSURED THE STATEMENTS SET FORTH HEREIN AND IN ANY ATTACHMENTS MADE HERETO ARE TRUE, AND NO MATERIAL FACTS HAVE BEEN SUPRESSED, OMITTED, OR MISSTATED.

UNDERWRITERS RESERVE THE RIGHT TO AMEND THE TERMS, CONDITIONS AND LIMITATIONS OF ANY POLICY ISSUED AS A RESULT OF THIS APPLICATION, IF SUBSEQUENT TO THE DATE OF THIS APPLICATION, BUT PRIOR TO THE INCEPTION OF SUCH POLICY, THERE ARE ANY MATERIAL ALTERATIONS TO THE INFORMATION CONTAINED HEREIN.

COMPLETION OF THIS APPLICATION DOES NOT BIND THE UNDERWRITER TO PROVIDE COVERAGE, BUT IT IS AGREED THAT THE STATEMENTS AND PARTICULARS CONTAINED HEREIN WILL BE RELIED UPON BY UNDERWRITERS IN THE EVENT A POLICY IS ISSUED. THIS APPLICATION IS SIGNED ON BEHALF OF ALL OWNERS, PRINCIPALS, PARTNERS, SHAREHOLDERS, DIRECTORS AND EMPLOYEES.

BY SUBMITTING THIS APPLICATION, THE APPLICANT AGREES THAT IN THE EVENT THE APPLICATION CONTAINS MISREPRESENTATIONS OR FAILS TO STATE FACTS MATERIALLY AFFECTING THE RISK ASSUMED BY THE INSURING COMPANY UNDER A POLICY ISSUED, THE POLICY MAY BE DEEMED NULL AND VOID. APPLICATION WILL ATTACH TO AND FORM PART OF THE POLICY.

Signature

Signature*

Title*