Contact Information

Salutation --None--Mr. Ms. Mrs. Dr. Prof. Rev. Rabbi Miss Br.
First Name
Last Name
Title
School Name
Website
Email
Phone
Fax
Address
City
State/Province --None--AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY
Zip

School Profile
Number of Employees: Student Enrollment: Does School Own Its Building?:--None--Yes No If Yes, Value of Building: Value of Contents:	Number of Vehicles: Total Payroll:

Current Coverage/Premiums (Instead, you may send copies of your policy summary pages showing premiums) Fax to 530-236-9569 or email to insurance@privatesafeinsurance.org

Workers' Comp Premium: Carrier:

Property Premium: Carrier:

Liability Premium: Carrier:

School Board Premium: Carrier:

Umbrella Premium: Carrier:

5 Year Loss History (less if newer school)

Check if NO worker's comp losses in ANY prior year
Check if NO liability losses in any prior year
Check if NO property losses in any prior year
Check if there WERE losses--send in loss history that should include date of loss, type of loss, description, amount paid, amount reserved)
Fax to 530-236-9569 or email to insurance@privatesafeinsurance.org

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