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Applicant Information

Association Information

Chemical Educators Application

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:

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.

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