RENEWAL APPLICATION
PROPERTY/CASUALTY COVERAGE
SCHOOLS AND COLLEGES
Section I - Entity Information
Name of Entity:
Agent Use Only
Agent:
Agency:
Need By Date:
Effective Date:
Expiration Date:
Section II - Coverage
Auto Liability/Physical Damage
General Liability/Cyber Liability
Property (Inland Marine/Boiler & Machinery)
School Board Legal Liability
Law Enforcement Liability
Crime
Section III - General Information
1.
Have there been any changes in the past year that would have a significant impact on this renewal?
Yes
 If yes, explain:
Total number of employees:
Total number of students:
Total Revenue:
Section IV- Auto Liability/Physical Damage
Automobile Liability/Physical Damage
Updated TPS Vehicle Schedule is Required
Section V - General Liability
General Liability
Please Provide Updated Exposure Basis
School Districts
Elementary, Kindergarten or Junior High
High School
Corporal Punishment
Colleges
Colleges
Dormitory Facilities
School Districts/Colleges
Employee Benefits Liability
Grandstands or Bleachers
Stadium
Nurses
Swimming Pools
Day Care Facility
Dwelling – Teacherages
Other:
Class Code
47471
47473
47469
Class Code
67509
67511
Class Code
44444
44194
48638
44444
48925
41716
63010
Exposure Basis
#
#
#
Exposure Basis
#
#
Exposure Basis
#
#
$
#
#
#
#
Explanation
Total number of students
Total number of students
Each faculty member
Explanation
Area (total square footage)
Area (total square footage)
Explanation
Total number of employees
Total # of grandstands/bleachers
Annual gross sales
Total number of nurses
Total number of pools
Average daily attendance
Area (total square footage)
Section VI - Property
Property
Updated TPS Property Schedule is Required
Buildings
BPP: Contents
EDP
CME
Band Equipment:
IM:
IM:
Property Values
$
$
$
$
$
$
$
Revised 02/2017 – web version
AOP
W&H
EDP
CME
Band Equipment:
IM:
IM:
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Deductibles
$
$
$
$
$
$
$
No
RENEWAL APPLICATION
PROPERTY/CASUALTY COVERAGE
SCHOOLS AND COLLEGES
Section VII - School Board Legal Liability
1.
School Board Legal Liability
Student Enrollment (if a college, the number of students should include the full-time equivalent of part-time students)
Current Year
Number of Students:
2.
#
List the number for each of the following:
a) Teachers:
b) Total Number of Employees:
Full Time
#
#
Part Time
#
#
Fiscal Information
1.
Budget (last two years): Provide an explanation for any deficit or large surplus
Year
Revenues
Expenditures
$
$
$
$
$
$
2. Does entity expect a budget deficit this year or next?
If yes, is there a fund balance to cover the deficit?
3. Does entity expect a budget reduction in the next year?
Surplus/Deficit
Accumulated Surplus
$
$
Yes
No
Yes
No
Yes
No
Operational Administrative Information
1.
2.
Any school closings or mergers expected in the next 12 months?
a) Any new school campuses opening in the next 24 months?
b) Does entity expect a reduction in staff in the next 18 months?
If yes, has entity’s attorney reviewed the staff reduction plan?
Yes
Yes
Yes
Yes
No
No
No
No
Yes
No
Yes
No
Yes
No
Claim History:
1. Is entity aware of any claims, acts, omissions, incidents or circumstances which might
reasonably be expected to be the basis of a claim or suit?
 If yes, explain:
Section VIII - Law Enforcement Liability
Law Enforcement Liability
Provide the number of employees for each type listed below:
1. Chief (Department Head): #
2. Other ranking officers: #
3. All other Officers with arresting authority: #
4. Police Dogs (please attach certificate of training for both dog and dog-handler): #
5. School Crossing Guards: #
Claim History:
1.
Is the entity aware of any fact, situation, incident or circumstance which they have reason to
believe might result in a claim under this coverage?
If yes, a) Please provide by attachment a detailed description of each matter.
b) Have these matters been reported to TPS or any previous carrier?
Section IX - Crime
Crime
Employee count should include full & part time, leased, temporary & seasonal workers from all locations
No. of employees: #
volunteers: #
who handle money: #
Locations: #
Must provide currently valued loss runs for the 4 prior years if coverage was not with TPS.
Return the completed application via email to [email protected]
The undersigned authorized representative declares that, to the best of your knowledge, the information set forth in this application is true and complete.
APPLICANT’S SIGNATURE
Revised 02/2017 – web version
TITLE
PHONE NUMBER
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DATE