R91-15 AUTHORIZING APPLICATION - PUBLIC OFFICIALS' LIABILITY INSURANCE

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15. Have any of the following situations occurred within the last three years? (a) Strike, slowdown or other disruption by the employees Yes — No � (b) Layoff of employees or reduction in services Yes — No � (c) Allegations of unfair or improper treatment regarding employee hiring, remuneration, advancement, or termination of employment Yes — No X (d) Disputes involving integration, segregation, discrimination, or violation of civil rights Yes _ No X (e) Any grand jury investigation, recall proceedings or indictments of any public officials Yes — No X If the answer to any of the above is yes, please give full details on a separate sheet of paper. 16. During the past five years have there been any incidents, claims, litigations or threats of litigation (including any Federal, State or Local actions against the Public Entity and/or its officials) which would have fallen within the scope of this insurance had it been in effect? � Yes ❑x No (If answer is Yes, attach full particulars.) 17. No fact,circumstance or situation indicating the probabiliry of a claim or action against which indemnification is or would be afforded by the proposed insurance is now known to any official or member of this entity; and it is agreed by all concerned that if there be knowledge of any such fact, circumstance, or situation, any claim or action subsequently emanating therefrom shall be excluded from coverage under the proposed insurance. 18. The undersigned who are authorized to sign this Application declare to the best of their knowledge,the statements set forth herein are true. Signing of this Application does not bind the undersigned or the Insurer to complete the insurance, but it is agreed that this form shall be the basis of the contract should a policy be issued. NOTICE TO NEW YORK APPLICANTS: Any Person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime. TWO SIGN ES R UI � Signed � ' " Date� � l� �� hie xecutrve Hicer) (Title) / ' �'— Y �j Sign d Q— / Date� — / � / � (Name) (T�tle) Submitted by (Name o(Agem Broker) AGENT/BROKER: Attach a copy of bid specifications, if any.