ROW 84 - ACE elite School Liability Proposal Form - New Address

Chubb Elite School Liability Insurance
Proposal Form
Important Notice
Statement pursuant to Section 25 (5) of the
Insurance Act (Cap. 142) (or any subsequent
amendments thereof) - You are to disclose in
this Proposal Form fully and faithfully all
facts which you know or ought to know,
otherwise the policy issued hereunder may
be void.
1) Your Duty of Disclosure
Before you enter into a contract of general
insurance with an insurer, you have a duty
under the law to disclose to the insurer every
matter within your knowledge that is
material to the insurer's decision whether to
accept the risk of the insurance and, if so, on
what terms. If you are unsure whether a
matter is material, you should disclose it.
You have the same duty to disclose those
matters to the insurer before you renew,
extend, vary or reinstate a contract of
general insurance.
It is important that all information contained
in this application is understood by you and
is correct, as you will be bound by your
answers and by the information provided by
you in this application. You should obtain
advice before you sign this application if you
do not properly understand any part of it.
Your duty of disclosure continues after the
application has been completed up until the
contract of insurance is entered into.
3) Claims Made Contract
Subject to its terms and conditions, the
policy will cover your legal liability for any
claim:
• First made by you during the policy
period;
• Resulting from any circumstance of which
you become aware during the policy
period which may give rise to a future
claim against you, provided you
immediately inform us in writing of such
circumstances within the policy period.
4) Change of Risk or Circumstances
You should advise the insurer as soon as
practicable of any change to your normal
business as disclosed in this application, such
as changes in business activities, location,
acquisitions and new overseas activities.
5) Subrogation
Where you have agreed with another person
or company (who would otherwise be liable
to compensate you for any loss or damage
which is covered by the contract of
insurance) that you will not seek to recover
such loss or damage from that person, the
insurer will not cover you, to the extent
permitted by law, for such loss or damage.
2) Non-Disclosure
If you fail to comply with your duty of
disclosure, the insurer may have the option
of avoiding the contract of insurance from its
beginning. If your non-disclosure is
fraudulent, the insurer may also have the
right to keep the premium that you have
paid.
Page 1 of 7
Instructions to the School
Before completing this section, please read the important notices starting on page 1.
This proposal should be answered after detailed enquiry of all persons to be covered.
A. This proposal must be completed, signed and dated by a Principal or Director.
B. You must answer all the questions in this form. If a question is not applicable, state ‘N.A’. If more space is required to answer a question, continue on
a new sheet with your school’s letterhead.
C. If you have any questions regarding this proposal, please contact your insurance broker or advisor to discuss.
Additional Information to send with your proposal
Attach a copy of the following:
Included?
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
Audited financial statement for the most recent available fiscal year
Current employee handbook
Current student handbook
Copy of the school’s employment termination procedures
Resumes or CVs of your Principals or Directors
☐No
☐No
☐No
☐No
☐No
Part 1 – Information About The School
1.
Name of Applicant
___________________________________________________________________________________________________________________________________________________________________________________________
Name of School
___________________________________________________________________________________________________________________________________________________________________________________________
Address
___________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________ Postal Code ______________________________
2.
Tel No. (Office) _______________________________________________________________________
Tel No. (Mobile) ____________________________________________________________________
Fax No.
_______________________________________________________________________
Year Established ____________________________________________________________________
Email
______________________________________________________________________________________________________________________________________________________________________
Type of School (check all boxes that apply)
☐Kindergarten
☐Whole-day Primary School
☐Bi-sessional Primary School
☐Secondary School
☐College / University
☐Special School
☐International School
☐Boarding School
☐Vocational / Technical
☐Public School
☐Private for Profit
☐Private not for Profit
☐Others (Explain) _________________________________________________________________________________________________________________________________________________________________
3.
Please provide the following details if coverage for your subsidiary is required. Special audited financial statement is required if its financials are not
consolidated in your statement.
Company Name
Principal Activities
Total Assets
Total Revenue
Net Profit
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4.
No. of Board Members ___________________________________________________________
Board Members are:
Length of Term __________________________________________________________________________
☐Elected ☐Appointed
If Board Members are appointed, by whom are they appointed?
___________________________________________________________________________________________________________________________________________________________________________________________
5.
Enrolment and Employment Information
Enrolment
Current Year
Prior Year
2nd Prior Year
Current Year
Prior Year
2nd Prior Year
Full Time Students
Part Time Students
Special Education
Disabled Students
Others
Total
Employment
Full Time Professors / Teachers
Part Time Professors / Teachers
Non-certified Professors / Teachers
Administrative Personnel, including
officials, principals, administrators etc.
Other Professional Staff
Social Workers
Volunteers
Total
6.
☐Yes ☐No
☐Yes ☐No
Have you had any staff reductions in the past 24 months?
a.
b.
Were Professors / Teachers involved in this reduction?
If Yes, how many Professors / Teachers were involved?
____________________________________________________________________________________________________________________________________________________________________________________________
c.
How was it decided which Professors / Teachers would be let go?
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
Part 2 – Financial Information
7.
a. Budget for current and prior fiscal years
Current Year (SGD)
Prior Year (SGD)
2nd Prior Year (SGD)
Revenues
Government Grants
Expenditures
Budget Surplus (Deficits)
Accumulated Budget Surplus / Deficits
b. Provide an explanation for any budget deficits in the past three years and anticipated steps to address accumulated deficits.
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
Page 3 of 7
Part 3 – Operations and Policy
8.
☐Yes ☐No
Any accreditation provided?
☐N/A
If Yes, which body is the accreditation provided by?
____________________________________________________________________________________________________________________________________________________________________________________________
Date of last accreditation:
DD / MM / YYYY
Has any accrediting body threatened or taken any probationary activity?
☐Yes ☐No
If Yes, please explain.
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
9.
Have any expansions or reductions in study courses or programmes, including music, athletic or other
☐Yes ☐No
courses or programme, taken place in the past 12 months, or are any anticipated in the next 12 months?
If Yes, please explain.
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
10. Does the School have a disaster planning document in place and in practice for natural disasters, terrorist
acts, acts of violence, or unauthorised intrusions?
☐Yes ☐No
☐Yes ☐No
11. Do you perform background checks on all employees before employment?
If Yes, please explain.
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
12. Which of the following processes and policies have you adopted?
A. As pertains to Professors / Teachers:
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐No
☐No
☐No
☐No
☐No
☐No
☐No
☐In Writing
☐In Writing
☐In Writing
☐In Writing
☐In Writing
☐In Writing
☐In Writing
Public displays of affection
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐No
☐No
☐No
☐No
☐No
☐No
☐No
☐No
☐In Writing
☐In Writing
☐In Writing
☐In Writing
☐In Writing
☐In Writing
☐In Writing
☐In Writing
C. Have the above policies and procedures been reviewed by the council?
☐Yes
☐No
☐Some
☐Yes
☐No
Student suspensions or expulsions
Use of corporal punishments
Disciplinary action
Testing standards
Teacher / student relationships
Sexual harassment/molestation
Drug testing
B. As pertains to Students
Suspensions or expulsions
Corporal punishments
Possession of weapons
Drugs testing and searches
Internet access
Students with disabilities
Special education
13. Does the School maintain any pension scheme outside Singapore for its employees?
If Yes, please attach full details.
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☐Yes ☐No
14. Does the School have any activities in North America?
If Yes, please attach full details.
15. Did the School hold any study tour activities in the past or will be doing so in the coming
12 months? If Yes, please attach full details.
16. Have all recommendations, advice or criticism of the examination conducted by the Ministry of
Education, Ministry of Manpower or any other similar regulatory body been complied with?
☐Yes ☐No
☐Yes ☐No
If No, please provide details by attachment.
17. Has a subcontractor or independent contractor been hired?
If Yes, please attach full details and state what procedure and selection criteria does the School
☐Yes ☐No
have in place when selecting the appropriateness of the subcontractor and/or independent
contract if applicable?
____________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________
Part 4 – Employment Practices Liability
18. During the last 3 years, has any School or unit thereof been involved in any employment or
labour related litigation?
19. During the last 3 years, has any educational organisation or unit thereof been involved in any
administrative proceedings with:
a) the Tripartite Alliance for Fair and Progressive Employment Practices
b) the Ministry of Manpower
c)
any state or local government agency whose purpose is to address employee-related claims
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
If the answer to question 18 or 19 is ‘Yes’, please state the type and number of each proceeding and, for each proceeding (including claims expenses),
attach full details.
20. Who is responsible for providing employment counsel for employment advice?
☐External Legal Counsel
☐In-house Legal Counsel
Name of Firm: ____________________________________________________________________________________________________________________
☐Other, please explain _______________________________________________________________________________________________________
21. a) How often are your human resources documents, policies, guidelines and procedures reviewed?
☐Annually
☐Semi-annually
☐Other _______________________________________________________________________________________
b) Who is responsible for the review?
☐External Legal Counsel
☐In-house Legal Counsel
Name of Firm: ____________________________________________________________________________________________________________________
☐ Other, please explain ______________________________________________________________________________________________________
22. Does the educational organisation have written guidelines, policies, or procedures for addressing human resources or personnel management in the
following areas?
a) Hiring or interviewing?
b) Employee contract disclaimer?
c)
Performance appraisals?
d) Discipline?
e) Discharge?
f)
Accommodating for the disabled?
g) Non-union grievance procedures?
h) Sexual harassment?
i)
Use of Educational Organisation’s electronic mail, voice mail and internet access?
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐No
☐No
☐No
☐No
☐No
☐No
☐No
☐No
☐No
Page 5 of 7
23. Do all employees receive a copy of these guidelines, policies, or procedures, and acknowledge such
receipt in writing?
☐Yes ☐No
☐Yes ☐No
24. Does the School have a full-time human resources manager?
If No, who is responsible for human resources?
___________________________________________________________________________________________________________________________________________________________________________________________
Part 5 – Insurance Information
25. Please provide School Liability and / or Director and Officers Liability and / or Employment Practices Liability policy information.
Year
Professional Liability Carrier
Limits
Deductible/Retention
Premium
Current Year
Prior Year
2nd Prior Year
3rd Prior Year
4th Prior Year
26. Current Liability Carrier and Limits:
___________________________________________________________________________________________________________________________________________________________________________________________
27. Has any insurance been declined, cancelled or not renewed in the past 5 years? If Yes, please explain.
☐Yes ☐No
___________________________________________________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________________________________________________
28. Limit of Liability requested:
☐SGD 1,000,000
☐SGD 7,000,000
☐SGD 2,000,000
☐SGD 10,000,000
☐SGD 3,000,000
☐SGD 5,000,000
☐Other: ____________________________________________________________
29. Optional extensions requested:
Fraud and Dishonesty Cover
Public Relations Expenses Cover
Parent-Teacher Association Liability Cover
Alumni Association Liability Cover
Student Association Liability Cover
Governing or Management Body Liability Cover
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐Yes
☐No
☐No
☐No
☐No
☐No
☐No
Part 6 – Claims Experience
30. Do any principals, directors, committee members, officers, senate, or employees of the School have
knowledge or information of any act or omission which might reasonably be expected to give rise to a claim?
If Yes, please attach full details.
31. Has the School, or any of its predecessors in educational services, subsidiaries, or affiliates, or any of its
principals, directors, committee members, senate or employees, ever been the subject of a disciplinary
action as a result of professional activities? If Yes, please attach full details.
32. During the past 5 years, have any claims been made or suits brought against the School, any predecessors in
educational services, subsidiaries, or affiliates, or any of its principals, directors, committee members, senate
or employees? If Yes, please attach full details.
☐Yes ☐No
☐Yes ☐No
☐Yes ☐No
Page 6 of 7
Declaration
We have read and understood the
Important Notices contained in this
application.
We agree that this proposal, together with
any other information or documents
supplied with this proposal, will form the
basis of any contract of insurance.
We acknowledge that if this application is
accepted, the contract of insurance will be
subject to the terms and conditions as set
out in the policy wording as issued or as
otherwise specifically varied in writing by
the insurer.
We declare, after inquiry of all relevant
persons within our organisation, that the
statements, particulars and information
contained in this application and in any
documents accompanying this application
are true and correct in every detail and that
no other material facts have been misstated,
suppressed or omitted.
We undertake to inform the insurer of any
material alteration to those facts before
completion of the contract of insurance.
Commission Disclosure
The Proposer understands, acknowledges,
and agrees that, as a result of the applicant
purchasing and taking up the policy with
Chubb Insurance Singapore Limited
(Chubb), Chubb will pay the authorised
insurance broker commission during the
continuance of the policy including
renewals, for arranging the said policy.
When the Proposer is a body corporate, the
authorised person who signs on behalf of
the applicant further confirms to Chubb
that he / she is authorised to do so.
This form must be reviewed, signed and
dated by a duly authorised Principal or
Director.
By signing this form, I / We hereby declare
that the above information provide by me /
us or on my / our behalf in the application
and other relevant information/document
submitted for this application are true and
complete and I / We agree that this
application shall be the basis of the contract
between me / us and Chubb Insurance
Limited, otherwise the policy issued may be
void or voidable.
Contact Us
Chubb Insurance Singapore Limited
Co Regn. No.: 199702449H
138 Market Street
#11-01 CapitaGreen
Singapore 048946
O +65 6398 8000
F +65 6298 1055
www.chubb.com/sg
The insurance applied for shall only take
effect when the application has been
approved by Chubb Insurance Singapore
Limited.
________________________________________________________
Signature of Principal / Director
________________________________________________________
Name and Designation of Principal /
Director
________________________________________________________
Date
The Proposer further understands that the
above agreement is necessary for Chubb to
proceed with the application.
The above Disclosure Statement is only
applicable in situations where an insurance
broker is used to purchase / place a policy.
© 2016 Chubb. Coverages underwritten by one or more subsidiary companies. Not all coverages available in all jurisdictions. Chubb® and its
respective logos, and Chubb. Insured.SM are registered trademarks.
Published 04/2016.
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