Revised 12/05

MACo/JPIA

APPLICATION CHECKLIST

NAMED INSURED______________________________________

____ All blanks completed; (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 - Is it included?

Please include an Accord for schedules and claims history.

____ 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

SPECIAL DISTRICT 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 attach an Accord for schedules and claims history.

PROPERTY / PHYSICAL DAMAGE

INLAND MARINE / CRIME / BOILER & MACHINERY

QUESTIONNAIRE:

I. PLEASE ATTACH A SIGNED STATEMENT OF VALUE (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 are automatically provided by MACo/JPIA coverage.

III. MAINTENANCE DEDUCTIBLE $__________________________

IV. ADDITIONAL PROPERTY / INLAND MARINE- QUESTIONNAIRE:

1. Contractor’s equipment (attach schedule)

2. EDP Equipment ____Schedule ____Part of Content

3. Crime

Number of employees ________________________

Number of elected or appointed officials required by law

to be bonded ________________________

4. Boiler & Machinery Coverage needed ____YES ____NO

5. Business Interruption Limit $ ______________________

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

3) 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. Dams

1) Purpose of Dam: ____________________

2) Date of last inspection ____________________

3) Passed inspection ____________________

C. Budgeted Operating expenditures for the most recent fiscal year

$ ____________________ (Please attach copy of budget)

PUBLIC OFFICIALS ERRORS & OMISSIONS QUESTIONNAIRE

I. COVERAGE FORM: CLAIMS - MADE

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. RATING INFORMATION

A. General Financial Information

YEAR TOTAL REVENUE TOTAL EXPENDITURES

Most Recently

Complete Fiscal

Year _________

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 any disputes involving integration, segregation, discrimination,

or violations of Civil Rights arisen?

___Yes ___No (If yes, please provide details.)

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.)

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: ____________________________________

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 Count _________

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.