Creech Roddey Watson Insurance_Teacher's Professional Liability

Teacher's Professional Liability

Creech Roddey Watson Insurance
THE CINCINNATI INSURANCE COMPANYTHE CINCINNATI CASUALTY COMPANYTHE CINCINNATI INDEMNITY COMPANY
Name of Applicant:*

First NameLast Name
Email Address:*
example@example.com
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Policy Number:
Size of school system:
(If more than 10,000 children, please submit prior to binding.)
Have you incurred any losses or suits in the past five years related to teaching or providing special instruction of any kind?
What other functions are performed by you in addition to teaching? Any administrative duties, counseling,coaching, chaperoning, business, etc., in or out of the school?
Do you act as an instructor in any capacity outside the classroom mountain climbing, horseback riding, ski trips, scuba diving, or other field trips, etc.?
* Are you a member of any Teachers Association or Union OEA, etc ?
Any officer responsibilities?
List university or college from which you graduated:
Degree:
Year:
Do you have a valid teaching certificate?
How long have you been a teacher?
What level of education do you teach? (Check all that apply):

Day CareKindergartenElementaryMiddle SchoolHigh SchoolCollege
*PLEASE NOTE: There is no coverage under this policy for losses arising out of your activities as respects teachers associations, unions, or groups.

WARNING: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR ANOTHER 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 SUBJECTS (VT: MAY BE COMMITTING A CRIME SUBJECTING) THE PERSON TO CRIMINAL AND (NY: SUBSTANTIAL) CIVIL PENALTIES IN THE DISTRICT OF COLUMBIA, LOUISIANA, MAINE, TENNESSEE, VIRGINIA AND WASHINGTON, INSURANCE BENEFITS MAY ALSO BE DENIED.

NOTICE TO OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE / SHE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.
Applicant’s Signature:*

Clear
Date Signed (Applicant):*

MonthDayYear
Agency and Code Number
Agent’s Name and License Number (Florida only):
Verification Code - Enter the message as it's shown*
IA 005 (9/06)
Should be Empty: