APPLICATION FOR CLAIMS-MADE COVERAGE - Hagerty

[Pages:3]Collector Car & Boat InsuranceTM

APPLICATION FOR CLAIMS-MADE COVERAGE

THE ASSOCIATION PROFESSIONAL LIABILITY INSURANCE PLAN FOR NON-PROFIT ASSOCIATIONS

[1] Name of Association to be Insured: Principle Address: City/State/Zip: Contact Person: Telephone Number: ( ) Fax Number: ( ) Email:

2. Is the Association incorporated as a Non-Profit Corporation? Note: must be non-profit association to qualify for coverage consideration

Yes No

3. Please describe the purpose, general operation and functions of the Association:

4.a. Is the Association: Local State Regional National or International in scope?

b.Year Association was founded:

c. Number of Chapters, Regions and Affiliated Organizations:

United States

Canada

Other Countries

d. Number of Employees:

e. Is the Association affiliated with a National or International Association?

If "yes", please name Association:

5. What is the Gross Income of your Association during the past fiscal year?

6. Does the Association desire coverage for any For-Profit Subsidiaries of the Association? If "Yes", please attach applicable Audits if separate from Association.

Yes No Yes No

P.O. Box 87, Traverse City, MI 49685-0087 ? P: 800-922-4050 ? F: 231-941-8227 ? WWW.

7. Does the Association offer its members group insurance programs and provide administrative

services, such as application review, premium quotations and premium collection?

Yes No

If "Yes", please attach details.

8.a. Does the Association currently carry this type or similar insurance? If "Yes", please complete:

Insurer Limit Effective/Expiration Dates Deductible Premium

Yes No

b. Has the Association ever been declined, cancelled or refused for this type of insurance? (Notice to Missouri residents: This question does not apply.) If "Yes", please give full details:

Yes No

9. Is the Association or its Directors, Officers or employees involved in any of the following: a. The performance of professional services on behalf of the Association? b. The sponsorship, ownership, marketing or endorsement of any product, technology or service? c. The certification or licensing of any current members? d. The formation, development and/or implementation of any guidelines/standards? e. Arbitration, mediation, or peer review (not including regular employee performance appraisals) activities, procedures or proceedings? f. The publishing of any technical standards or procedural manuals?

Yes No

Yes No Yes No Yes No

Yes No Yes No

If "yes" applies to any of the above, please provide full details and include sample material with the application.

10.a. During the past 5 years have any claims been made, or is any claim now pending against the

Association, its Directors, Officers or employees?

Yes No

b. Is any Association Director, Officer, or employee aware of any situation which may give rise

to a claim being made against them or the Association itself?

Yes No

c. Within the last 5 years has the Association received any inquiry, complaint or Notice of

Hearing from any State or Federal Regulatory Authority or Congressional or Legislative

Committee or EEOC or similar agency?

Yes No

If "Yes", please attach details.

P.O. Box 87, Traverse City, MI 49685-0087 ? P: 800-922-4050 ? F: 231-941-8227 ? WWW.

ADDITIONAL REQUIRED INFORMATION

Please attach copies of the following: 1. Latest Fiscal Year End Audit or Tax Return 2. By-Laws or Constitution 3. Publications and/or Brochures

Mail to: Hagerty Insurance Agency Special Programs Post Office Box 87 Traverse City, MI 49685

THE ASSOCIATION PROFESSIONAL LIABILITY PROGRAM HAS BEEN ORGANIZED AS A PURCHASING GROUP LOCATED AND DOMICILED IN ILLIONIS, PURSUANT TO LEGISLATION ENACTED BY CONGRESS KNOWN AS THE FEDERAL LIABILITY RISK RENTENTION ACT OF 1986. YOU WILL AUTOMATICALLY BECOME A MEMBER OF THE PURCHASING GROUP ONCE YOUR COMPLETED APPLICATION HAS BEEN APPROVED ANY YOUR PREMIUM PAYMENT HAS BEEN RECEIVED.

COMPLETION OF APPLICATION OR TENDERING OF PREMIUM DOES NOT BIND COVERAGE. APPLICATION IS SUBJECT TO COMPANY UNDERWRITING GUIDELINES.

I DECLARE THAT THE INFORMATION SUBMITTED HEREIN IS TRUE TO THE BEST OF MY KNOWLEDGE AND BECOMES A PART OF THE ASSOCIATION PROFESSIONAL LIABILITY APPLICATION. I UNDERSTAND THAT AN INCORRECT OR INCOMPLETE STATEMENT COULD VOID COVERAGE

Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act.

Notice to New York Applicants: any person who knowingly and with intent to defraud any insurance company or other person files an 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, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Name: ___________________________________ Signature:________________________________ (Please print)

Title:____________________________________ Date:____________________________________ (Authorized Representative)

Underwritten by: Chicago Insurance Company, a member of the Interstate National Corporation, one of the Fireman's fund Insurance Companies.

P.O. Box 87, Traverse City, MI 49685-0087 ? P: 800-922-4050 ? F: 231-941-8227 ? WWW.

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