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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