MACo/JPIA

APPLICATION CHECKLIST

NAMED INSURED______________________________________

____ All blanks completed--Please use “N/A” where not applicable.

____ Application signed (signature by Chairman or Clerk) and dated by entity

Original to be sent to MACo/JPIA

____ Supplemental information as requested in Application

Please include an Accord for schedules and claims history, too.

____ Application legible and capable of being photocopied

____ Full details regarding previous carrier (Premiums, Deductibles, and Limits)

____ Fully completed claims information for last five (5) years

____ Property values current at 100% of replacement cost,

signed Statement of Values (SOV)

____ Recent budget ________Adopted _____Tentative

____ Premium level needed to write account (reasonable): ___________________

MACo/JPIA

PUBLIC ENTITY APPLICATION

NAMED INSURED: ___________________________________________________

ADDRESS: ___________________________________________________

___________________________________________________

COUNTY: ___________________________________________________

DESIGNATED

RISK MANAGER: _________________________ PHONE: ( ) ________________

SUBMITTING AGENCY: ____________________ PHONE: ( ) _______________

FAX: ( ) ________________

ADDRESS: __________________________________________________________

__________________________________________________________

PRODUCER’S NAME: _________________________________________________

Effective Date: ________________________________________________________

MAINTENANCE DEDUCTIBLE: OPTION: ________________

The information provided in this application is true and correct

to the best of my knowledge.

Signed Date ______________________

Presiding Official

Signed Date ______________________

Agent or Broker

Please include an Accord for schedules and claims history.

PROPERTY / PHYSICAL DAMAGE

INLAND MARINE / CRIME / BOILER & MACHINERY

QUESTIONNAIRE:

I. PLEASE ATTACH A SIGNED STATEMENT OF VALUES (S.O.V)

TOTAL VALUE SHOWN ON S.O.V. $__________________________

II. COVERAGE

Limits - Blanket Replacement Limit of $100,000,000 for Property Damage

*Earthquake and Flood Coverage is automatically provided by

MACo/JPIA coverage.

III. MAINTENANCE DEDUCTIBLE $__________________________

IV. ADDITIONAL QUESTIONNAIRE:

A. Contractor’s equipment (attach schedule)

B. EDP Equipment ____ Schedule ____ Part of Contents

C. Business Interruption Limit $___________________________

D. Crime

1) Number of employees _________

2) Number of officials required by law to be bonded ________

E. Boiler & Machinery Coverage needed _____Yes _____No

GENERAL LIABILITY QUESTIONNAIRE

I. COVERAGE FORM: Occurrence

II. LIMITS OF LIABILITY

$750,000 / claim; $1,500,000 / occurrence

1) $1,000,000 in the aggregate annually with respect to products and completed operation /member

2) $3,000,000 in the aggregate annually with respect to Section II coverage

Optional Liability limits $5,000,000 Yes _____ No _____

Policy limited for federal and out-of-state claims.

III. MAINTENANCE DEDUCTIBLE $___________________________

IV. RATING WORKSHEET

A. Population ___________________________

B. Miles of Roads ___________________________

C. Number of EMTs, Paramedics, First Responders:

1) Employees _______________________

2) Volunteers _______________________

D. Dams

1) Purpose of Dam: ________________________

2) Date of last inspection ________________________

3) Passed inspection ________________________

E. Nurse Malpractice

Number of Nurses: ____________________________

Full time ____________________________

Part time ____________________________

F. Volunteers

Estimated number of volunteers _________________________

Include volunteers for services such as county fair, senior citizen program, board members, etc

(DO NOT INCLUDE PUBLIC SAFETY VOLUNTEERS SUCH AS SEARCH & RESCUE, SHERIFF’S RESERVES, ETC.)

PUBLIC OFFICIALS ERRORS & OMISSIONS QUESTIONNAIRE

I. COVERAGE FORM: CLAIMS - MADE

II. LIMITS OF LIABILITY $750,000 / claim; $1,500,000 / occurrence

Optional Limits $5,000,000 Yes _____ No _____

Policy limited for federal and out-of-state claims.

III. MAINTENANCE DEDUCTIBLE $_________________________

IV. RATING INFORMATION

A. General Financial Information

FISCAL YEAR TOTAL REVENUE TOTAL EXPENDITURES

Most Recently

Completed __________

B. Please provide a copy of the entity’s most recent budget.

C. 1. Has any person, former employee or job applicant made claim alleging unfair or improper treatment regarding hiring, remuneration, advancement or termination of employment?

____Yes ____No (If yes, please give details on separate page.)

2. Have you had any disputes involving integration, segregation, discrimination, or violations of Civil Rights arisen?

____ Yes ____No (If yes, please provide details on separate page.)

3. Do you follow a formal written grievance procedure for employee disputes/complaints? ____Yes ____No

4. Do you have knowledge or information of any incident or occurrence, which might give rise to any claim being made?

____Yes ____No (If yes, please provide details.)

D. Appointed Board checklist

____Fair ____Cemetery Airport T.V.

____Mosquito ____Refuse ____Planning Nursing Home

____Park ____Health Rodent ____Transit Authority

____Museum ____Weed ____Others: ______________________

g List any joint boards if required to be named as additional insureds on the MACo/JPIA policy.

Prior Acts coverage is subject to confirmation of continuous claims-made coverage in force for the retroactive period @$1,000,000 + limit, with all incidents likely to result in a claim having been reported to the prior carrier.

Retro Date:___________________________

LAW ENFORCEMENT LIABILITY QUESTIONNAIRE

I. COVERAGE FORM: Occurrence

II. LIMITS OF LIABILITY

1. $750,000 / claim, $ 1,500,000 per occurrence

2. $3,000,000 annual aggregate

Optional Liability limits $5,000,000 Yes _____ No _____

Policy limited for federal and out-of-state claims

II. RATING INFORMATION:

1. Number of Officers:

Full time _______________

Part time _______________

2. Jail cell square footage _______________

3. Average daily number of inmates_______________

AUTOMOBILE LIABILITY QUESTIONNAIRE

I. COVERAGE FORM: Occurrence

II. LIMITS OF LIABILITY $750,000 / claim; $1 500,000 / occurrence

Optional Liability limits $5,000,000 Yes _____ No _____

Policy limited for federal and out-of-state claims

III. MAINTENANCE DEDUCTIBLE $_____________

IV. SUMMARY OF VEHICLES (See definitions of each class of vehicle)

VEHICLES NUMBER OF UNITS

1. Private Passenger (PP) _______

2. Light / Medium Trucks (LMT) _______

3. Heavy Trucks (HVY) _______

4. X-Heavy Trucks (XHVY) _______

5. Other Buses _______

6. Police/ Sheriff _______

7. Ambulance _______

8. Jet skis _______

9. Snowmobiles _______

10. Tugboats/Ferries _______

11. ATVs _______

12. Other _______

Total Vehicle Counts ___________

DEFINITIONS

1. All private passenger vehicles excluding police and sheriff vehicles, 4-wheel drive vehicles such as Jeeps, Broncos, Blazers, etc.

2. GVW <20,000 includes vans, pick-ups, and the aforementioned 4-wheel drive vehicles.

3. GVW 20,001 - 45,000 includes dump trucks

4. GVW> 45,000 includes fire trucks, garbage trucks, and tractor-trailers

5. Seating capacity > 8 includes shuttle buses.

6. All off road vehicles either 3 or 4 wheels.

V. Please provide a vehicle schedule including a description of the vehicle as attached and actual cash values.

MONTANA ASSOCIATION OF COUNTIES

MACo/JPIA

MACo/JPIA

PUBLIC OFFICIALS ERRORS & OMISSIONS QUESTIONNAIRE