PO Box 8481, Semnole FL 33775 Shppng Address: 12551 Indan Rocks Rd Sute 12, Largo FL 33774 Phone: 727-366-9334 Fax: 727-596-5192 Emal: CustomerServce@agwa.us Webste: www.agwa.us Dear AGWA Member, We are proud to announce a group Errors and Omssons Polcy now avalable from Unted States Lablty Insurance Group. Ths coverage s desgned specfcally for our members at the Group Rates shown on the enclosed applcaton. We recommend that any AGWA member wthout E & O coverage revew ths nformaton, and become aware of the lablty exposure. Unted States Lablty has the hghest A.M. Best ratng n the ndustry, so you can be sure your clam wll be handled quckly, and wth confdence by traned professonals. They also nclude defense costs outsde the lmt of lablty. If you choose the opton, you can also get Full Pror Acts coverage for just a few dollars more. A Busnessowners Lablty Package s also avalable that ncludes coverage for Bodly Injury arsng out of your professonal servces. For more Coverage Hghlghts, see the enclosed Grant Wrtng Servces Errors and Omssons Lablty Insurance Informaton sheet. If you are nterested n ths AGWA program, complete the applcaton and select the desred amount of coverage*. Note that Florda resdent must add a 1% surcharge for the FCAT fund. Sgn the applcaton and mal t, along wth your premum check made payable to: Insurance Underwrters & Assocates 2100 5 th Avenue North St Petersburg, FL 33713 Our agent, Davd Hollowell, can be reached for any questons or concerns at the followng: Tampa/St Pete 727-384-0096 Toll Free 866-524-7526 Emal Dave@INSunderwrters.com Sncerely, John G. Porter, Ph.D., CGW Executve Drector
Gr a ntwr t ngse r v c e ser r or s Gr antwr t ngser v ces SPGREO NR 12/ 09
Amercan Grant Wrters Assocaton P.O. Box 8481 Semnole, FL 33775-8481 Phone: 727-366-9334 Grant Wrters Specfed Professons Professonal Lablty Applcaton Answers wll be requred pror to bndng and are subject to underwrtng approval. Ths s an applcaton for a clams made polcy. 1. Applcant s Name: 2. Locaton Address: Cty: State: Zp: Phone: Fax: Emal Address of prmary contact: Webste: 3. Is the applcant controlled, owned, afflated or assocated wth any other grant wrtng frm, corporaton or company? Yes No 4. Does the Applcant: Have less than two (2) years of experence n grant wrtng or a related feld? Yes No We defne Grant Wrtng, Grant Opportunty Research and Grant Management to nclude the followng servces: Wrtng of letters, proposals and applcatons for grant opportuntes Wrtng of busness plans Preparaton of Power Pont presentatons for clents Preparaton of Applcaton for exempt status for nonproft organzatons Wrtng of artcles for newsletters or webstes Wrtng for publc relatons for nonproft organzatons Wrtng for fundrasng lterature for nonproft organzatons Wrtng evaluaton plans and creatng data collecton forms for programs Program evaluaton servces for proft and nonproft organzatons Does applcant provde servces other than Grant Wrtng, Grant Opportunty Research or Grant Management? Yes No Generate more than $375,000 n recepts from grant wrtng servces? Yes No Have any dscretonary control over dspensng any grants? Yes No 5. Is over 50% of the Applcant s work performed by ndependent contractors? Yes No 6. Durng the past fve (5) years, has any clam been made or sut brought aganst the Applcant, ts Yes No predecessor(s) n busness or any of ts present or former owners, partners, offcers, drectors, employees or ndependent contractors? 7. Is any owner, partner, offcer, drector, employee or ndependent contractor aware of any crcumstance, Yes No allegaton, contenton, or ncdent whch may result n a clam beng made aganst the Applcant, ts predecessor(s) n busness or any of ts present or former partners, owners, offcers, drectors, employees or ndependent contractors? Accounts wth No answers for questons 3 through 7 are elgble for a quote wth the followng rate optons. If any of the above questons have yes answers, please submt ths applcaton wth addtonal nformaton for further consderaton. Note: not avalable n Lousana. The followng are per clam and per aggregate lmts. All States except Calforna Calforna $0 Deductble $1,000 Deductble $1,000 Deductble $250,000/$250,000 $505 $481 $250,000/$250,000 $801 $500,000/$500,000 $647 $616 $500,000/$500,000 $1,026 $1,000,000/$1,000,000 $788 $750 $1,000,000/$1,000,000 $1,250 $1,000,000/$2,000,000 $988 $750 $1,000,000/$2,000,000 $1,500 Professonal GWAPP 02/2010 - Unted States Lablty Insurance Group page 1 of 3
Florda and Illnos Notce: I understand that there s no coverage for puntve damages assessed drectly aganst an nsured under Florda and Illnos law. However, I also understand that puntve damages that are not assessed drectly aganst an nsured also known as vcarously assessed puntve damages. are nsurable under Florda and Illnos law. Therefore, f any polcy s ssued to the Applcant, as a result of ths applcaton and such polcy provdes coverage for puntve damages, I understand and acknowledge that the coverage for Clams brought n the State of Florda and Illnos s lmted to vcarously assessed puntve damages and that there s no coverage for drectly assessed puntve damages. Mnnesota Notce: Authorzaton of agreement to bnd the nsurance may be wthdrawn or modfed only based on changes to the nformaton contaned n ths applcaton pror to the effectve date of the nsurance appled for that may render naccurate, untrue or ncomplete any statement made wth a mnmum of 10 days notce gven to the nsured pror to the effectve date of cancellaton when the contract has been n effect for less than 90 days or s beng canceled for nonpayment or premum. New York Dsclosure Notce: Ths polcy s wrtten on a clams made bass and shall provde no coverage for clams arsng out of ncdents, occurrences or alleged wrongful acts that took place pror to the retroactve date, f any, stated on the declaratons. Ths polcy shall cover only those clams made aganst an nsured whle the polcy remans n effect and all coverage under the polcy ceases upon termnaton of the polcy except for the automatc extended reportng perod coverage unless the nsured purchases addtonal extended reportng perod coverage. The polcy ncludes an automatc 60 day extended clams reportng perod followng the termnaton of ths polcy. The nsured may purchase for an addtonal premum an addtonal extended reportng perod of 12 months, 24 months or 36 months followng the termnaton of ths polcy. Potental coverage gaps may arse upon the expraton of ths extended reportng perod. Durng the frst several years of a clams-made relatonshp, clams-made rates are comparatvely lower than occurrence rates. The nsured can expect substantal annual premum ncreases ndependent overall rate ncreases untl the clams-made relatonshp has matured. Utah Notce: I understand that Puntve Damages are not nsurable n the state of Utah. There wll be no coverage afforded for Puntve Damages for any Clam brought n the State of Utah. Any coverage for Puntve Damages wll only apply f a Clam s fled n a state whch allows puntve or exemplary damages to be nsurable. Ths may apply f a Clam s brought n another state by a subsdary or addtonal locaton(s) of the Named Insured, outsde the state of Utah, for whch coverage s sought under the same polcy] Vrgna Notce: Ths Polcy s wrtten on a clams-made bass. Please read the polcy carefully to understand your coverage. You have an opton to purchase a separate lmt of lablty for the extended reportng perod,. If you do not elect ths opton, the lmt of lablty for the extended reportng perod shall be part of the and not n addton to lmt specfed n the declaratons. If you have any questons regardng the cost of an extended reportng perod, please contact your nsurance company or your nsurance agent. Statements n the applcaton shall be deemed the nsured s representatons. A statement made n the applcaton or n any affdavt made before or after a loss under the polcy wll not be deemed materal or nvaldate coverage unless t s clearly proven that such statement was materal to the rsk when assumed and was untrue. Colorado Fraud Statement: It s unlawful to knowngly provde false, ncomplete, or msleadng facts or nformaton to an nsurance company for the purpose of defraudng or attemptng to defraud the company. Penaltes may nclude mprsonment, fnes, denal of nsurance, and cvl damages. Any nsurance company or agent of an nsurance company who knowngly provdes false, ncomplete, or msleadng facts or nformaton to a polcyholder or clamant for the purpose of defraudng or attemptng to defraud the polcyholder or clamant wth regard to a settlement or award payable from nsurance proceeds shall be reported to the Colorado dvson of nsurance wthn the department of regulatory agences. Dstrct of Columba Fraud Statement: WARNING: It s a crme to provde false or msleadng nformaton to an nsurer for the purpose of defraudng the nsurer or any other person. Penaltes nclude mprsonment and/or fnes. In addton, an nsurer may deny nsurance benefts f false nformaton materally related to a clam was provded by the applcant. Florda Fraud Statement: Any person who knowngly and wth ntent to njure, defraud, or deceve any nsurer fles a statement of clam or an applcaton contanng any false, ncomplete, or msleadng nformaton s gulty of a felony of the thrd degree. Kentucky Fraud Statement: Any person who knowngly and wth ntent to defraud any nsurance company or other person fles an applcaton for nsurance contanng any materally false nformaton or conceals, for the purpose of msleadng, nformaton concernng any fact materal thereto commts a fraudulent nsurance act, whch s a crme. Mane and Washngton Fraud Statement: It s a crme to knowngly provde false, ncomplete or msleadng nformaton to an nsurance company for the purpose of defraudng the company. Penaltes may nclude mprsonment, fnes or a denal of nsurance benefts. New Jersey Fraud Statement: Any person who ncludes any false or msleadng nformaton on an applcaton for an nsurance polcy s subject to crmnal and cvl penaltes. New York Fraud Statement: Any person who knowngly and wth ntent to defraud any nsurance company or other person fles an applcaton for nsurance or statement of clam contanng any materally false nformaton, or conceals for the purpose of msleadng, nformaton concernng any fact materal thereto, commts a fraudulent nsurance act, whch s a crme and shall also be subject to a cvl penalty not to exceed fve thousand dollars and the stated value of the clam for each such volaton. Oho Fraud Statement: Any person who, wth ntent to defraud or knowng that he s facltatng a fraud aganst an nsurer, submts an applcaton or fles a clam contanng a false or deceptve statement s gulty of nsurance fraud. Oklahoma Fraud Statement: WARNING: Any person who knowngly, and wth ntent to njure, defraud or deceve any nsurer, makes any clam for the proceeds of an nsurance polcy contanng any false, ncomplete or msleadng nformaton s gulty of a felony. Pennsylvana Fraud Statement: Any person who knowngly and wth ntent to defraud any nsurance company or other person fles an applcaton for nsurance or statement of clam contanng any materally false nformaton or conceals for the purpose of msleadng, nformaton concernng any fact materal thereto commts a fraudulent nsurance act, whch s a crme and subjects such person to crmnal and cvl penaltes. Tennessee and Vrgna Fraud Statement: It s a crme to knowngly provde false, ncomplete or msleadng nformaton to an nsurance company for the purpose of defraudng the company. Penaltes nclude mprsonment, fnes and denal of nsurance benefts.]\ Vermont Fraud Statement: Any person who knowngly presents a false or fraudulent clam for payment of a loss or beneft or knowngly presents false nformaton n an applcaton for nsurance may be subject to fnes and confnement n prson. Fraud Statement (All Other States): Any person who knowngly presents a false or fraudulent clam for payment of a loss or beneft or knowngly presents false nformaton n an applcaton for nsurance s gulty of a crme and may be subject to fnes and confnement n prson. Grant Wrters APP 2/2010 page 2 of 2
If your state requres that we have nformaton regardng your Authorzed Retal Agent or Broker, please provde below. Retal Agency Name: Lcense #: Man Agency Phone Number: Agency Malng Address: Cty: State: Zp: Broker s Sgnature: Name of authorzed Agent or Broker Address Mal complete applcaton through local agent or broker to: The sgner of ths applcaton acknowledges and understands that the nformaton provded n ths Applcaton s materal to the Insurer s decson to provde the requested nsurance and s reled on by the Insurer n provdng such nsurance. The sgner of ths applcaton represents that the nformaton provded n ths Applcaton s true and correct n all matters. The sgner of ths Applcaton further represents that any changes n matters nqured about n ths Applcaton occurrng pror to the effectve date of coverage, whch render the nformaton provded heren untrue, ncorrect or naccurate n any way wll be reported to the Insurer mmedately n wrtng. The Insurer reserves the rght to modfy or wthdraw any quote or bnder ssued f such changes are materal to the nsurablty or premum charged, based on the Insurer s underwrtng gudes. The Insurer s hereby authorzed, but not requred, to make any nvestgaton and nqury n connecton wth the nformaton, statements and dsclosures provded n ths Applcaton. The decson of the Insurer not to make or to lmt any nvestgaton or nqury shall not be deemed a waver of any rghts by the Insurer and shall not estop the Insurer from relyng on any statement n ths Applcaton n the event the Polcy s ssued. It s agreed that ths Applcaton shall be the bass of the contract should a polcy be ssued and t wll be attached and become a part of the Polcy. Applcant s Sgnature: (Prncpal, Partner, or Offce of the Frm) Name: Ttle: Date: Grant Wrters APP 2/2010 page 3 of 3