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9624702a

EXHIBIT A GENERIC APPLICATION for (AGENCY NAME) PUBLIC OFFICIALS LIABILITY INSURANCE FOR WRONGFUL ACTS

1.

(a) Name and Address of Organization:

(b) Legal Structure:

(c) Purpose and Nature of Operations:

(d) Date of Organization:

2. Does the Organization have any shareholders or persons who profit from the operation except as salaried employee? _____ YES _____ NO

3. Are any Directors, Officers or Trustees indebted to the Organization? _____ YES _____ NO

4. Within the last five years, has the Organization received any inquiry, complaint or notice of hearing from any State or Federal Regulatory or Congressional or Legislative committee? _____ YES _____ NO

5. Does the Organization perform any of the following services?

Item Question Yes No
a negotiate labor contracts?
b engage in or sponsor product or service research, standards development, experimentation or performance testing?
c conduct professional ethics or peer review activities?
d take any disciplinary action or recommended disciplinary action as a result of peer review group?
e publish any magazines, periodicals, newsletters or technical manuals?
f set professional standards?
g certify, endorse or license any product/services?
h sponsor or operate a political action committee?
i provide a referral service, legal aid service or computer service to the public?
j promote, sponsor or provide any form of insurance to its members or non-members?
k engage in lobbying activities?
l promote or sponsor any type of group travel, convention, parade, or similar event?
If the answer to any of the questions in Item 5 above it "YES", provide details. Attach additional page(s) if needed.
Item Details
____ ____________________________________________________________________________
____ ____________________________________________________________________________
____ ____________________________________________________________________________
6.
(a) Please give details of all directors and officers liability insurance carried for the last five years:
Insurer Limit Retention Premium Policy Period
________________ ________________ ________________ ________________ ________________
________________ ________________ ________________ ________________ ________________
________________ ________________ ________________ ________________ ________________
________________ ________________ ________________ ________________ ________________
________________ ________________ ________________ ________________ ________________
(b) Have any loss payments been made under any prior or current directors and officers liability policy or similar insurance, including under the deductible? _____ YES _____ NO

(c) Has any insurer declined, canceled or non-renewed any policy or application for directors and officers liability or similar insurance? _____ YES _____ NO

(d) Has the Organization or any director or officer given written notice under the provisions of any prior or current directors and officers liability insurance of specific facts or circumstances which might give rise to a claim being made against any director or officer? _____ YES _____ NO

(e) Does the Organization currently carry General Liability Insurance? _____ YES _____ NO

The State of Texas and its agencies of government posses immunity from civil lawsuits except where the legislature has given permission for such claims to be brought. This is known as Sovereign Immunity. The legislature has passed a law popularly known as the Texas Tort Claims Act (101.021) which waives this immunity for certain types of lawsuits with additional limitations on liability.

Where this statute does not apply, and no other statute or legislative act waives the doctrine of Sovereign Immunity, the state cannot be sued. Where Section 101.021 applies, Section 101.023, CIVIL PRACTICES AND REMEDIES CODE governs the amount of liability exposure the state incurs.

Individuals, if they commit torts while acting within the course and scope of their authority as employees or members of a government body are protected from personal liability exposure by a principal known as immunity. In these types of cases, the state government is responsible for the actions of its employees or members of government.

If individuals commit torts while acting outside of the course and scope of their employment responsibilities, they can be sued as individuals rather than as members of state government.

7. Has any claim been made, or is any now pending, against the Organization or any person proposed for insurance in the capacity of either Director, Trustee, or Officer which fall within the scope of the insurance being applied for? _____ YES _____ NO

8. Is any person proposed for coverage cognizant of any facts or circumstances (a) which he or she has reason to believe might afford valid grounds for any future claim(s) such as would fall within the scope of the proposed coverage or (b) which indicate the possibility of any such claim(s)? ___ YES ___ NO

9. Has the Organization and/or its Directors, Trustees, or Officers been involved in or have any knowledge of pending federal, state or local legal actions or proceedings against the Organization and/or its Directors, Trustees, or Officers? _____ YES _____ NO

10.

(a) Does the Organization receive donations or contributions from the general public? ____ YES ____ NO

(b) Are contributions generally solicited? _____ YES _____ NO

(c) Out of the total contributions received, what is the net percentage available for charitable purposes? ________________________________________________________________________________

11.
(a) Total amount of outstanding bonds: __________________________________________

(b) Latest Moody's and/or Standard and Poor's Bond rating: ______________________________

12. The Organization's directors and officers to be covered by this insurance will be limited to:
Position Number
Commissioners _________________________
Executive Director _________________________
Chief of Staff _________________________
Division Directors _________________________
In comparison to a private corporation, the Commissioners are equivalent to the Board of Directors; the Executive Director is equivalent to the President; and the Chief of Staff is equivalent to the Senior Vice President for Administration. The divisions are (Agency provide):

_________________________________________________________________

_________________________________________________________________

_________________________________________________________________

13. The person designated as agent of the Organization and of all the Directors, Trustees and Officers to receive any and all notices from the insurer or their authorized representatives concerning this insurance is:
Name: ____________________________________________

Agency:___________________________________________

Address:___________________________________________

__________________________________________________

Phone:____________________________________________

Fax:______________________________________________

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