TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings

Transcription

1 SERFF Tracking Number: SEPX State: Wisconsin Filing Company: Sentry Insurance a Mutual Company State Tracking Number: Company Tracking Number: ML WI F01 TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings Product Name: Project Name/Number: Commercial Interline 2009 Multi Line/ML WI F01 Filing at a Glance Company: Sentry Insurance a Mutual Company Product Name: Commercial Interline SERFF Tr Num: SEPX State: Wisconsin TOI: 35.0 Interline Filings SERFF Status: Closed State Tr Num: Sub-TOI: Commercial Interline Filings Co Tr Num: ML WI F01 State Status: Filing Type: Form Co Status: Reviewer(s): Shasta Hoffhein Author: SPI SentryInsurancePC Disposition Date: 05/12/2009 Date Submitted: 05/08/2009 Disposition Status: Filed Effective Date Requested (New): 06/07/2009 Effective Date (New): Effective Date Requested (Renewal): 06/07/2009 Effective Date (Renewal): General Information Project Name: 2009 Multi Line Status of Filing in Domicile: Project Number: ML WI F01 Domicile Status Comments: Reference Organization: Reference Number: Reference Title: Advisory Org. Circular: Filing Status Changed: 05/12/2009 State Status Changed: Deemer Date: 06/06/2009 Corresponding Filing Tracking Number: Filing Description: SENTRY INSURANCE A MUTUAL COMPANY NAIC # FEIN # COMMERCIAL INTERLINE FORM FILING IMPLEMENTATION: UPON APPROVAL We wish to submit the following form for your review: " A (WI) Ed Acceptance Form - Coverage Review The A (WI) 0509 replaces the 0309 edition. This signature form is used in conjunction with previously approved application, (WI-SBP) Application Created by SERFF on 05/13/ :07 AM

2 SERFF Tracking Number: SEPX State: Wisconsin Filing Company: Sentry Insurance a Mutual Company State Tracking Number: Company Tracking Number: ML WI F01 TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings Product Name: Project Name/Number: For Insurance. Commercial Interline 2009 Multi Line/ML WI F01 A major revision was made to this form to provide better instructions to our producers to ensure more thorough and accurate completion of the form. It also allows them more space to provide the information needed to process the new business policy. Company and Contact Filing Contact Information Janel Danczyk, Compliance/Development Sr. Janel.Danczyk@sentry.com Analyst 1800 North Point Drive (715) [Phone] Stevens Point, WI (715) [FAX] Filing Company Information Sentry Insurance a Mutual Company CoCode: State of Domicile: Wisconsin 1800 North Point Drive Group Code: 169 Company Type: Stevens Point, WI Group Name: Sentry Insurance State ID Number: Group (715) ext. [Phone] FEIN Number: Filing Fees Fee Required? Retaliatory? Fee Explanation: Per Company: No No No Created by SERFF on 05/13/ :07 AM

3 SERFF Tracking Number: SEPX State: Wisconsin Filing Company: Sentry Insurance a Mutual Company State Tracking Number: Company Tracking Number: ML WI F01 TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings Product Name: Commercial Interline Project Name/Number: 2009 Multi Line/ML WI F01 Correspondence Summary Dispositions Status Created By Created On Date Submitted Filed Shasta Hoffhein 05/12/ /12/2009 Created by SERFF on 05/13/ :07 AM

4 SERFF Tracking Number: SEPX State: Wisconsin Filing Company: Sentry Insurance a Mutual Company State Tracking Number: Company Tracking Number: ML WI F01 TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings Product Name: Project Name/Number: Disposition Commercial Interline 2009 Multi Line/ML WI F01 Disposition Date: 05/12/2009 Effective Date (New): Effective Date (Renewal): Status: Filed Comment: Used with form filings that are subject to file & use under s (1)(c) and (1m) Wis. Stat. Effective July 1st, 2008, changes in insurance law exempted certain policy forms from receiving prior approval before use. This filing may be used 30 days after receipt by OCI. USE DATE: 06/06/2009 Rate data does NOT apply to filing. Created by SERFF on 05/13/ :07 AM

5 SERFF Tracking Number: SEPX State: Wisconsin Filing Company: Sentry Insurance a Mutual Company State Tracking Number: Company Tracking Number: ML WI F01 TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings Product Name: Commercial Interline Project Name/Number: 2009 Multi Line/ML WI F01 Item Type Item Name Item Status Public Access Supporting Document Certification of Compliance Filed Yes Supporting Document Appraisal or Arbitration Provision Filed Yes Form Acceptance Form - Coverage Review Filed Yes Created by SERFF on 05/13/ :07 AM

6 SERFF Tracking Number: SEPX State: Wisconsin Filing Company: Sentry Insurance a Mutual Company State Tracking Number: Company Tracking Number: ML WI F01 TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings Product Name: Project Name/Number: Form Schedule Commercial Interline 2009 Multi Line/ML WI F01 Review Status Filed Form Name Form # Edition Review Ed. Date Form Type Action llment Action Specific Data Previous Filing #: Readability Attachment Acceptance Form A 0509 Application/ Replaced Replaced Form #: A - Coverage (WI) 0509 Binder/Enro A (WI) 0509 Ed_.PDF Created by SERFF on 05/13/ :07 AM

7 ACCEPTANCE FORM - COVERAGE REVIEW Producer Name & Territory: Field Bound Yes Section Add Yes No No Insured: Account #: City & State: Effective Date: Federal ID#: (9 digits) Premium Accepted: $ Pay Plan: Check Amount: $ Check #: Insured Name Exactly as Shown on Deposit Check: ACCOUNT INFORMATION Reviewed? (check one for each) Yes No N/A Reviewed? (check one for each) Yes No N/A Named Insureds Mortgagees Additional Insureds Loss Payees Terrorism Information Certificate Holders Financial Statements Drivers List Claims History Payroll Amounts Location Descriptions Gross Sales GENERAL COVERAGES BOUND Property: Inland Marine: Crime: GL Auto Umbrella EPLI (Stand Alone) (check one for each) COVERAGE OPTIONS Accepted? Yes No N/A (check one for each) Building Coverages Inflation Guard Flood Agreed Value Mine Subsidence (IL, IN, KY, WV) Earthquake Permanently Attached Equipment Coverages Inflation Guard Flood Agreed Value Mine Subsidence (IL, IN, KY, WV) Earthquake Business Personal Property Coverages Inflation Guard Flood Agreed Value Earthquake Personal Property of Others Coverages Inflation Guard Flood Agreed Value Earthquake Business Income Coverages Business Income (w/ Extra Expense) Annual Business Income: Business Income (w/o Extra Expense) Months: Rental Value Coinsurance Extra Expense Max Period of Indemnity Flood Monthly Limit: Earthquake 1/3 1/4 1/6 Accepted? Yes No N/A Page 1 of A (WI) Sentry Insurance a Mutual Company 05/09

8 (check one for each) Miscellaneous Property Coverages Special Broadened Property Electronic Media & Records Employee Property Inland Marine Accounts Receivable Valuable Papers Crime Coverages Employee Theft ERISA Plan Coverage Plan Name: Forgery or Alteration Credit Card Coverage General Liability Products Completed Operations Personal & Advertising Injury Damage to Premises Rented to You Medical Expense Employee Benefits Broad Form Endorsement COVERAGE OPTIONS - continued Accepted? (check one for each) Yes No N/A Customers Patterns/Dies/Molds Printing & Graphic Arts Customers Property Inside Premises Theft of Money Outside the Premises Money Orders & Counterfeit Currency Accepted? Yes No N/A Printers Errors & Omission Customers Patterns, Dies, & Molds Optional Property Damage Product Recall and Retrofit Manufacturers Errors & Omission Limited Employment Practices Extension** **Note: The Limited Employment Practices Extension provides coverage on a claims made basis with defense and settlement costs included in and subject to the coverage limits of insurance. Business Auto Liability Medical Payments Uninsured Motorists Underinsured Motorists P.I.P. No Fault Comp Deductibles Specified Perils Collision Deductibles Towing (Private Passenger Only) Other Coverages Commercial Umbrella Employment Related Practices Liability Rental Reimbursement Audio, Visual and Data Equipment Garagekeepers Liability Drive Other Car Non-Owned Auto Liability Hired Car Liability Hired Car Physical Damage Page 2 of A (WI) Sentry Insurance a Mutual Company 05/09

9 ACCEPTANCE FORM - COVERAGE CHANGES Insured Name: Account #: Important Note for BPS: Any and all changes made to the original application should be summarized in the following sections. Please indicate if any alternate quotes were accepted or declined. If adding a coverage section not previously quoted, you must complete and submit the corresponding pages of the application. Other Named Insureds List if not previously listed on the Application Name Relationship to Insured Address/City/St/Zip Federal ID # Property Attach applicable Application pages if required Include a list of any permanently attached equipment along with the corresponding value of each item if applicable. Include form CP Statement of Values if using Agreed Value. Loc # List Changes Property Additional Insureds/Loss Payables (Attach list or expiring copies if available.) Loc # Item Type Name and Address Description of Property Building Business Pers. Prop. Mortgagee Loss Payee Lender Loss Payee Additional Insured Contract of Sale Building Business Pers. Prop. Building Business Pers. Prop. Mortgagee Loss Payee Lender Loss Payee Additional Insured Contract of Sale Mortgagee Loss Payee Lender Loss Payee Additional Insured Contract of Sale Inland Marine - Attach applicable Application pages if required Loc # List Changes Page 3 of A (WI) Sentry Insurance a Mutual Company 05/09

10 Crime - Attach applicable Application pages if required If the intent is to cover an ERISA plan under Employee Theft coverage, be sure to include the official ERISA plan name Loc # List Changes General Liability - Attach applicable Application pages if required Reminder: If Product Liability, Designated Products or Aircraft Products are excluded from the policy, a separate signature form ( x) will be sent with the new business policy. This form must be signed by the insured and returned promptly. List Changes Liability Additional Insureds & Certificates of Insurance (Attach list or expiring copies if available.) Reminder: Some additional insureds require additional premium charges. Please contact your underwriter for pricing if adding an additional insured not previously listed on the application. Loc # Type Name, Address and any Special Instructions Certificate of Insurance Manager/Lessor of Premises Lessor of Leased Equipment Describe Equipment: Vendor Description of product sold and the amount of sales sold through this vendor: Describe Interest: Certificate of Insurance Manager/Lessor of Premises Lessor of Leased Equipment Describe Equipment: Vendor Description of product sold and the amount of sales sold through this vendor: Describe Interest: Certificate of Insurance Manager/Lessor of Premises Lessor of Leased Equipment Describe Equipment: Vendor Description of product sold and the amount of sales sold through this vendor: Describe Interest: Page 4 of A (WI) Sentry Insurance a Mutual Company 05/09

11 Auto - Attach applicable Application pages if required Reminder: Please include the 17 digit Vehicle Identification Numbers (VIN) for all vehicles and a complete drivers list on the charts below if not previously included on the application. List Changes Vehicle Identification Numbers Unit # Year Make Model VIN (17 digits) Driver Information Note: List all drivers including personal use drivers, family members, and employees using their own vehicle for company business. Name Sex M/F Date of Birth DOC Driver Y/N Driver License Number State of License Auto Loss Payables or Additional Insureds (Attach list or expiring copies if available.) Reminder: Some additional insureds require additional premium charges. Please contact your underwriter for pricing if adding an additional insured not previously listed on the application. Unit Type Name, Address and Special Instructions Loss Payable Additional Insured Lessor Loss Payable Additional Insured Lessor Umbrella - Attach applicable Application pages if required Page 5 of A (WI) Sentry Insurance a Mutual Company 05/09

12 Reminder: If Sentry is not the WC carrier, we need the WC carrier information to schedule on the Umbrella Dec page. Please provide: o WC Carrier Name: o WC Policy Number: o Employers Liability Limits: $ / $ / $ (Must be a minimum of $500K Each Accident/$500K Each Employee/$500K Policy Limit) List Changes EPLI - Attach applicable Application pages if required Reminder: Please attach the following information if not previously provided: o A copy of the written discrimination and harassment policy. o A copy of the written complaint procedures with two or more reporting channels. (Note: These items are not required for Limited Employment Practices Extension on General Liability) List Changes Other Notes: Page 6 of A (WI) Sentry Insurance a Mutual Company 05/09

13 ACCEPTANCE FORM GENERAL FRAUD STATEMENT Insured Name: Account #: NOTICE TO APPLICANTS COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. GEORGIA APPLICANTS: I hereby authorize the company to obtain from the Georgia Department of Public Safety a copy of the Motor Vehicle reports for all drivers on this policy and certify that those other drivers have authorized me to give this consent on their behalf. I understand that these motor vehicle records will be used in the rating and/or underwriting of this insurance for which I am here applying, and any renewal thereof. I understand that a consumer reporting agency may be used to obtain such reports and do hereby authorize such use. HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss of benefit is a crime punishable by fines or imprisonment, or both. OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud again an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. OKLAHOMA APPLICANTS: Warning: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. SOUTH CAROLINA APPLICANTS: CANCELLATION INFORMATION: The insurer can cancel this policy for which you are applying without cause during the first 90 days. That is the insurer s choice. After the first 90 days, the insurer can only cancel this policy for reasons stated in the policy. UTAH APPLICANTS: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison. WISCONSIN APPLICANTS: GL and Excess/Umbrella apps: Wisconsin Underinsured Motorists Coverage Disclosure Wisconsin Underinsured Motorists coverage is not available. Auto and Garage apps: Wisconsin Underinsured Motorists Coverage Disclosure Wisconsin Underinsured Motorists coverage is available for selection if coverage is provided for owned autos including vehicles that are leased for a term of six months or longer. Underinsured Motorists coverage is an optional coverage in Wisconsin and is not required. Wisconsin Uninsured and Underinsured Selection Form explains the coverage options available and should be completed for coverage selection or rejection. Wisconsin Underinsured Motorists coverage is NOT available for selection, if the coverage provided is limited to autos you do not own. Fraud Warning: Any person who knowingly presents a false or fraudulent claim or payment of a loss or benefit or knowingly presets false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. Page 7 of A (WI) Sentry Insurance a Mutual Company 05/09

14 ACCEPTANCE FORM SIGNATURE PAGE Insured Name: Account #: ALL OTHER APPLICANTS: 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 the person to criminal and [NY: substantial] civil penalties. (Not applicable in CO, FL, HI, MA, NE, OH, OK, OR, VT or WA; in DC, LA, ME, TN, and VA, insurance benefits may also be denied) In Florida, any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. In Massachusetts, Nebraska, Oregon and Vermont, 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 may subject the person to criminal and civil penalties. In Washington, it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines, and denial of insurance benefits. Includes copyright material of Acord, Premium Audit: Your initial premium is based on your estimates of rating information, such as inventory, payroll, sales, or number of employees. After your policy expires you will need to provide us with requested information or let us examine and audit all your records that relate to your insurance. The final premium will be reported to you on a statement of audit. If the final premium is more than what you paid, you must pay us the balance. If the final premium is less, we will credit your account or refund the balance to you. ALL APPLICANTS: By my signature below, I attest that: 1. I am an authorized representative of the applicant; 2. I have reviewed this form; 3. The information provided is true and accurate; 4. I have not willfully concealed or misrepresented any material fact or circumstance concerning this form; and 5. I have read the applicable items above and agree to all terms or conditions stated therein. 6. I understand that the insurance companies may apply, against unpaid balances applicant may owe any of them, amounts owed to applicant by any of the insurance companies, including any dividends declared by such companies. APPLICANT SIGNATURE LICENSED SENTRY INSURANCE A MUTUAL COMPANY AGENT NAME* LICENSED SENTRY INSURANCE A MUTUAL COMPANY AGENT SIGNATURE DATE LICENSE ID* DATE *Florida requires that the Insurance Company Name, legibly printed company representative s name and company representative s ID number be completed. Property and casualty insurance coverages are underwritten by Sentry Insurance a Mutual Company, Stevens Point, Wisconsin. Page 8 of A (WI) Sentry Insurance a Mutual Company 05/09

15 SERFF Tracking Number: SEPX State: Wisconsin Filing Company: Sentry Insurance a Mutual Company State Tracking Number: Company Tracking Number: ML WI F01 TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings Product Name: Commercial Interline Project Name/Number: Rate Information 2009 Multi Line/ML WI F01 Rate data does NOT apply to filing. Created by SERFF on 05/13/ :07 AM

16 SERFF Tracking Number: SEPX State: Wisconsin Filing Company: Sentry Insurance a Mutual Company State Tracking Number: Company Tracking Number: ML WI F01 TOI: 35.0 Interline Filings Sub-TOI: Commercial Interline Filings Product Name: Commercial Interline Project Name/Number: 2009 Multi Line/ML WI F01 Supporting Document Schedules Review Status: Satisfied -Name: Certification of Compliance Filed 05/12/2009 Comments: Attachment: WI - CERTIFICATE OF COMPLIANCE.PDF Review Status: Bypassed -Name: Appraisal or Arbitration Provision Filed 05/12/2009 Bypass Reason: N/A Comments: Created by SERFF on 05/13/ :07 AM

17 Ins 6.05 Appendix A CERTIFICATE OF COMPLIANCE I, Williams O Reilly, (name), an officer of Sentry Insurance a Mutual Company (company name), hereby certify that I have authority to bind and obligate the company by filing this (these) form(s). I further certify that, to the best of my information, knowledge and belief: 1. The accompanying form(s) as identified by the attached listing comply(ies) with all applicable provisions of the Wisconsin Statutes and with all applicable administrative rules of the Commissioner of Insurance; 2. The form(s) does (do) not contain any inconsistent, ambiguous, or misleading clauses; 3. The form(s) does (do) not contain specification or conditions that unreasonably or deceptively limit the risk purported to be assumed in the general coverage of the policy form(s); 4. The only variations from a form currently on file with the commissioner of insurance and the only unconventional policy provisions are clearly marked or otherwise indicated pages of the attached form(s) or in an attachment; and 5. The attached form(s) is (are) in final printed format or typed facsimile and is (are) as will be offered for issuance or delivery in Wisconsin after approval by the Commissioner of Insurance, except for hypothetical data and other appropriate variable material. (signature) VP-General Counsel&Corp Sec (title) 05/08/09 (date) Individual responsible for this filing: Name: Janel Danczyk Title: Compliance/Development Sr. Analyst Address: 1800 North Point Drive Stevens Point WI Phone Number: Date: 05/08/09 Register, March, 2008, No. 627 INS02291