Contact Authorization - PennPRIME Insurance Trust

General Information

Municipality Entity Name*

Mailing Address*

Street Address City State ZIP Code

Physical Address*

Street Address City State ZIP Code

Main Phone*

Main Fax

Web Address

General Email*

Highest Elected Official

(Official with insurance oversight i.e.Chairman, Council President, Mayor.)

Highest Elected Official Name*

Title*

Phone

Email Address*

Preferred Method of Contact

Manager/Administrator

Manager/Administrator Name*

Title*

Phone

Email Address*

Preferred Method of Contact

Main Contact Person

(Person who receives all PennPRIME mail correspondence for internal distribution.)

Main Contact Person Name*

Title*

Phone

Email Address*

Preferred Method of Contact

Voter

(Individual who receives proposed Trust Agreement amendments; receives notice, attends and votes at the PennPRIME Annual Membership Meetings; must be an officer or employee of the municipal entity.)

Voter Name*

Title*

Phone

Email Address*

Preferred Method of Contact

Loss Control Contact

(Individual as defined in Loss Control Standard #2; designated management level employee responsible for safety, who will work with PennPRIME's Loss Control Program directives, as well as identify, prioritize and control the risks in your entity; receives all Loss Control information forwarded to your entity from PennPRIME .)

Loss Control Contact Name*

Title*

Phone

Email Address*

Preferred Method of Contact

Additional Loss Control Contact

(Individual who interacts with PennPRIME on Loss Control visits and other activities.)

Additional Loss Control Contact Name*

Title*

Phone

Email Address*

Preferred Method of Contact

Public Works Director

(Supervisor, Superintendent, etc.)

Public Works Director Name

Title

Phone

Email Address

Preferred Method of Contact

Police Chief

Police Chief Name

Title

Phone

Email Address

Preferred Method of Contact

Safety Committee Chairman

(Individual responsible for state-certified safety committee meetings and requirements.)

Safety Committee Chairman Name

Title

Phone

Email Address

Preferred Method of Contact

Other Safety Committee Contact

Other Safety Committee Contact Name

Title

Phone

Email Address

Preferred Method of Contact

Underwriting Contact

(Individual who receives annual renewal application and documents; interacts with PennPRIME on application and underwriting questions.)

Property/Liability Underwriting Contact

Property/Liability Underwriting Contact Name

Title

Phone

Email Address

Preferred Method of Contact

Workers' Compensation Underwriting Contact

Workers' Compensation Underwriting Contact Name

Title

Phone

Email Address

Preferred Method of Contact

Claims Contacts

(Individual who receives correspondence from PennPRIME's Claims Administrator or Coordinator and PennPRIME-assigned defense counsel on claims against the member; gives input on behalf of the member on claims settlements and defense decisions; has the ability to file claims and access municipal entity claim reports online.)

Property/Liability Claims Contact

Property/Liability Claims Contact Name

Title

Phone

Email Address

Preferred Method of Contact

Workers' Compensation Claims Contact

Workers' Compensation Claims Contact Name

Title

Phone

Email Address

Preferred Method of Contact

Authorization

Signature*

Title

Date

By clicking YES below, I am authorizing the use of my electronic signature to verify that the facts in this document are true and accurate.

Yes