The Ohio Plan 
Library Application

(fields in red are required)

 
Name of Entity: Contact Name:   
Address: Phone Number:   
  Fax Number:  
City: Email:  
State: Current Premium: $
Zip Code: Effective Date of Coverage:    (mm/dd/yy)
County: Need By Date:   (mm/dd/yy)

Liability Information
Limit of Liability:    Number of Employees:    
Gross Operating Expenditures: $ Total Payroll: $

 

Property Information
Total Building Limit: $ 
Total Contents Limit: $ 
Please attach a property statement of values if available.
Sprinklered:            
Valuable Papers & Records Limit: $ Materials on Loan to Others Limit: $
Materials on Loan from Others Limit: $ Fine Arts Limit: $
Total Computer Limit: $ Total Inland Marine Limit: $
 
Automobile Information
Number of Vehicles:   
Approximate Value of All Vehicles: $
Please advise if the entity has any bookmobiles:                   
    
Desired Comprehensive Deductible: $ Desired Collision Deductible: $ 
Auto Med Pay Limits:     Uninsured/Underinsured Motorists:    
 
Current Carrier Information
Name of Current Carrier:   
Number of Years with your Current Carrier:   
   
Claim Information

Please provide details regarding all losses over the past 4 years, including the amount paid for each loss.  If possible, please provide loss runs.
 
Notes

Please advise if there are any unique or additional exposures that should be noted.  If so, please describe. (Cooking facilities, Coffee Bar, Book Fairs, Summer Recreation Programs)

      
 

If you have any questions completing this application or if the Ohio Plan has not acknowledged receipt of your application within 24 hours, please contact Laura Hamman, Ohio Plan Underwriter, via email at Laura.Hamman@hylant.com or by phone at 419-724-1919.