Oklahoma Schools Insurance Group
Oklahoma Schools Insurance Group
P. O. Box 3068 ( Tulsa ( Oklahoma ( 74101
Phone- 918-764-1686
Toll Free- 866-444-0061
Fax- 918-582-5887
|Named Insured: |
|(as should appear on policy): |
|Mailing Address: |Street Address: |
|City: |County: |State: OK Zip: |
|Superintendent : |Phone #: | |
|Other Contact : | |
|Federal ID# : | Fax #: |
|Superintendent E-mail Address: |
|Coverages Requested: |
| | | | | | |
| Property | Auto Liability | General Liability |
| | | | | | |
| Umbrella | Auto Physical Damage | E & O |
Umbrella Limit Requested
|Normal Renewal Date: |
|School Board Meeting Date : |
|Date Proposal Needed By: |
|Expiring Property Premium: |
|Expiring Auto Premium: |
|Expiring General Liability Premium: |
|Expiring E&O Premium: |
|Expiring Umbrella Premium: |
|Total Expiring Premium: |
Section 1- Property
Please complete spreadsheet attached. All sections must be completed.
|Current Carrier: | | |
|Current Property Ded. : _____ |Current Wind/Hail Ded. : | __________ |
Miscellaneous Property:
|Description of Property |Value |
|Band Uniforms: | |
|Musical Instruments: | |
|Computer Equipment: | |
|Extra Expense: | |
|Mobile Equipment: | |
|Other: | |
|Boiler & Machinery Inspection Needed? Yes No |
|If Yes, for boilers or hot water heaters? |
| |
|Flood Zone A or V: Yes No |
|If Yes, please list locations: |
Section 2- General Liability
|Current Carrier: | | |
| |No. of Schools |No. Full Time Students |No. Part Time |No. Teachers |
| | | |Students | |
|Daycare/ | | | | |
|Preschool | | | | |
|Elementary | | | | |
|K-8 | | | | |
|High School | | | | |
|9-12 | | | | |
Underwriting Information:
|1. No. of Employees excluding teachers: |
|2. Gross Operating Budget: |
|3. Do you contract security from local police or other security service? |
|Yes No |
|4. Do you employee security from local police or other security service? |
|Yes No |
|If so, how many? Are they armed? Yes No Police or Private ? |
|5. Does the school district run a day care facility for employees children? |
|Yes No |
|6. Does the school district run before and after school care for students |
|Yes No |
|7. Are students employed to care for the children? |
|Yes No |
|8. Is day care operation on your premises operated by others? |
|Yes No |
|If yes, please provide Certificate of Insurance |
|9. Does the school district provide a healthcare facility? |
|Yes No |
|10. # of Playground sites: |
|11. Any rodeo grounds owned by school? |
Athletic Participation:
|Name of Sport |Estimated No. of Participants |
|Baseball | |
|Basketball | |
|Football | |
|Soccer | |
|Softball | |
|Tennis | |
|Wresting | |
|Swimming | |
|Volleyball | |
|Track & Field | |
|Golf | |
|Other (please specify) | |
|Is there a pool on premises? Yes No If so, which location: |
| |
|Diving Board? Yes No If yes, height; |
| |
|Grandstand Bleachers Stadiums |
| |
|Number of Locations: |
|Location # per Statement |Grandstand/ |Seating |Construction |Use Example: Football/ |
|of Values |Bleachers/ |Capacity | |Baseball |
| |Stadium | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
Section 3 - Automobile
Vehicle Summary- Please attach schedule of all automobiles/trailers to be insured. Schedule should include actual cash value of vehicles which you wish to insure for physical damage coverage (Comprehensive & Collision) AND seating capacity of all buses.
|Current Carrier: | | |
|Current Physical Damage Deductible: | | |
|Number of Buses | |
|Number of Pickups/Vans/Suburbans/Trailers | |
|Number Private Passenger Cars | |
Section 4 - Public Officials’ Errors and Omissions/ School Board Errors & Omissions
|Current Carrier: | | |
|School Professional Liability Retro Date: |
|School Board Professional Liability Deductible: $ |
|Do you employ a school nurse? Yes No |
|If so, how many? |
Any known incidents/claims? Yes No
If yes, please describe:
Any pending litigation? Yes No
If yes, please describe:
# of Board Members:
Please attached 6 years hard copy loss runs valuation date must be last 90 days.
|Submitting Agency: |
|Producer: |CSR: |
|Mailing |Street |
|Address: |Address: |
|City: |State: |Zip: |
|Fed Tax ID No.: |Phone #: |
|Option Phone #: |Fax #: |
|Email Address: | |
| |
|Are you the incumbent agent ? |
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