NAVREF Insurance Programs - Application for Professional Liability Insurance

about navref

NATIONAL UNION FIRE INSURANCE COMPANY OF PITTSBURGH, PA

A CAPITAL STOCK COMPANY (Herein called the Company)

ADMINISTRATIVE OFFICES

70 PINE STREET, NEW YORK, N.Y. 10270

Association Professional Liability Application

NOTICE: THE POLICY PROVIDES THAT THE LIMIT OF LIABILITY AVAILABLE TO PAY JUDGMENTS OR SETTLEMENTS SHALL BE REDUCED BY AMOUNTS INCURRED FOR LEGAL DEFENSE. FURTHER NOTE THAT AMOUNTS INCURRED FOR LEGAL DEFENSE SHALL BE APPLIED AGAINST THE DEDUCTIBLE AMOUNT.

1 Name of Applicant:__________________________________________________________________________

Address:_____________________________________________________________________________________

_____________________________________________________________________________________________

2 Limit of Liability Desired:

$250,000	$500,000	$1,000,000
$2000,000	$3,000,000	$5,000,000

3 Deductible:

$500 $1000 $2500

$5000 Other:_______________

4 Briefly describe the functions, purpose and general operations of the association:__________________

________________________________________________________________________

5 a) Number of members ____________________

b) Number of directors and officers ____________________

c) Number of staff members ____________________

6 a) Year organized ____________________

b) Geographical scope (state, national, etc.) ____________________

7 Briefly describe minimum membership qualifications:

________________________________________________________________________

8 Indicate gross revenues

a) Last year ____________________

b) This year ____________________

9 a) Does the association publish any magazines, periodicals or newsletters? Yes No
If so, attach a sample of each.

b) Does the association publish a technical manual? Yes No
If so, describe:

_____________________________________________________________________________________________

10 Please answer each of the following and attach details of any "yes" answer.

a) Does applicant provide a referral service, legal aid service, or computer service to its members or the public?	Yes	No
b) Does applicant promote or sponsor any type of group travel, conventions, parades or other similar events, or assume any liability in connection therewith?	Yes	No
c) Does applicant promote, sponsor or provide any form of insurance to its members or non-members?	Yes	No
d) Does applicant act as a fiduciary or administrator under the Employee Retirement Income Security Act of 1974?	Yes	No
e) Is applicant engaged in any form of research, development, experimentation or testing?	Yes	No
f) Does the applicant act as or participate in a peer review group or committee for assessing the qualifications and performance of others or the quality of products manufactured, sold, handled or distributed by others?	Yes	No
g) Does the applicant take any disciplinary action or recommend disciplinary action as a result of peer review group activities?	Yes	No
h) Does applicant develop standards used to evaluate the quality of goods, manufactured products or services rendered?	Yes	No

11 Does the applicant maintain primary personal injury coverage (libel, slander, etc.)?	Yes	No
12 Does the applicant maintain directors and officers liability coverage?	Yes	No
13 Has any similar association professional liability coverage ever been declined or cancelled?	Yes	No
14 Is similar insurance currently in force	Yes	No
If so, indicate: Carrier____________________________________ Expiration Date_____________________________ How long in force____________________________
15 Does any person proposed to be insured have knowledge or information of any act, error or omission which might reasonably be expected to give rise to a claim against him. (if so attach full particulars)	Yes	No

16 Attach a list and status of all association professional liability claims made against any proposed insured during the past five years.
If none, please check here:	Yes	No
17 Please attach one copy of each of the following: Membership Brochure Association's Constitution and By-Laws Current Annual Report

This application does not bind the applicant or the Company to complete the insurance, but it is agreed that this form shall be the basis of the contract should a policy be issued, and it will be attached to and made a part of the policy.

The undersigned authorized officer of the association hereby represents that to the best of his knowledge the statements set forth in this application are true. If the information supplied on this application changes between the date of the application and the time when the policy is issued the applicant will immediately notify the Company.

Notice to New York and Ohio Applicants:

"ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY

OR OTHER PERSON FILES AND APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM

CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF

MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, COMMITS A

FRAUDULENT INSURANCE ACT, WHICH IS A CRIME."

PRODUCER: The P. Allen Haney Company SIGNATURE:______________________________________

ADDRESS: 5272 River Rd., Suite 700
Bethesda, MD 20816-1405
TITLE:___________________________________________

DATE:___________________________________________

Check here if you are interested in securing information regarding Pension trust Insurance for your

liability under the Employee Retirement Income Security Act of 1974 (ERISA)

29299 (7/80)

last updated: 01/31/08