Sexual Misconduct and Molestation Liability Insurance Renewal

Application
Instructions

Please answer all questions. If the answer to any question is NONE, please print NONE. Attach separate sheets of paper
as necessary. The application must be signed and dated by the highest ranking clergy or executive. PLEASE
CAREFULLY READ STATEMENT AT THE END OF THE APPLICATION BEFORE SIGNING.

General Information

1 Name of Applicant: Cardinol Transportation Inc.

_______________________________________________________________________

2 Mailing Address: PO Box 47494

_________________________________________________________________________ Los
Angeles CA
City: ___________________________________________ State: __________ Zip Code:
90047
_______________
Phone: ____________________ Fax:___________________ E-mail:
(323) 707-9518
cardinoltrans@gmail.com
_______________________________

Brandon Mosley
3 Person to Contact: _____________________________

✘
4 Type of Operation: ◻ Individual ◻ Partnership ◻ Corporation ◻ Joint Venture ◻
Other:_________________________________________________

5 Employees, Clergy, Teachers, Substitute Teachers, Coaches, Counsellors, Independent Contractors, Sub
Contractors, Volunteers and Other:
Total Average % Male % Female
number(an number (daily)
nual)

a) Full time employees 3 2 25

b) Part time employees 10 1 25 40

Please do not include c) through k) in a) or b)

above

c) Diocesan Priests:

i) Active in Diocese 0 0 0 0

ii) Active outside Diocese 0 0 0 0

iii) Retired, Sick or Absent 0 0 0 0

 d) Religious Priests 0 0 0 0

e) Teachers 0 0 0 0

f) Substitute teachers 0 0 0 0

g) Coaches 0 0 0 0

h) Counsellors 0 0 0 0

i) Independent Contractors 2 1 24 15

Page 1 of 3

j) Sub Contractors 2 1 24 20

k) Volunteers (only those working with/supervising Youths) 4 4 2 1

l) Other – please detail on a separate sheet 0 0

Totals 20 100 100

$25,000.00 Sexual
Misconduct/Molestation $2,000,000
6 Coverage Desired: ____________ Limit of Liability: ____________ Desired Retention: ____________

7 If any of the loss prevention practices declared in your last application form have changed since the inception of your
current policy, please furnish all new information, as applicable.

8 Services / Locations:
(If the services operate in multiple cities or states please attach a list that shows where all services operate.)
0 Child Care Centers 0 0
Exposure Units
1 Churches / Parishes 4 0

0 Sunday Schools 0 0
_________ )
0 Mentoring Programs 0 0
Number Number of
of Youth 0 Counseling Services
0 0
Location
s Types of Services % of Total 0 Residential Treatment Centers 0 0

Schools - Religious 1 0 0 Group Homes 0 0

19 Schools - Public 60 0 0 0 0
Foster Care Services
1 Schools - Private, Elementary 1 0
0 In-Home Social Services
0 0
1 Schools - Private, Secondary 1 0
1 Drop in / Recreation Centers 1
3 YMCA 3 0
0 0 0
0 Hospitals
1 Community Service Organization1

0 Overnight Camps 0 0 0 Nursing Homes 0 0

1 Day Camps 1 0 0 Home Health Care

0 0
0 Assisted Living 0 0 34 Totals

0 0 0
Other (describe)
9. Has the applicant knowledge of any Claims that have not been reported to Underwriters
Page 2 of 3
✘
or Underwriters’ representatives? Yes No

THE APPLICANT WARRANTS TO THE BEST OF ITS KNOWLEDGE AND BELIEF THAT THE STATEMENTS
SET FORTH HEREIN ARE TRUE AND INCLUDE ALL MATERIAL INFORMATION.

THE APPLICANT FURTHER WARRANTS THAT IF THE INFORMATION SUPPLIED ON THIS APPLICATION
CHANGES BETWEEN THE DATE OF THIS APPLICATION AND THE INCEPTION DATE OF THE POLICY
PERIOD, IT WILL IMMEDIATELY NOTIFY US OF SUCH CHANGE. SIGNING OF THIS APPLICATION DOES
NOT BIND THE COMPANY TO OFFER NOR THE APPLICANT TO ACCEPT INSURANCE, BUT IT IS
AGREED THAT THIS APPLICATION SHALL BE THE BASIS OF THE INSURANCE AND WILL BE
ATTACHED AND MADE PART OF THE POLICY SHOULD A POLICY BE
ISSUED. IF AN EXCESS POLICY IS ISSUED THE APPLICATION WILL BECOME
A PART OF THE EXCESS POLICY.

01/08/2024 CEO date applicant's authorized signature of a principal, partner or officer title

date applicant's authorized signature of the individual in charge of title the human resources or
personnel department

Matt Broadway
date applicant's authorized signature of the risk management officer title or loss control officer
Any person who, with intent to defraud or knowing that he is facilitating a fraud against an
insurer, submits an application or files a claim containing a false or deceptive statement is
guilty of insurance fraud.
 Page 3 of 3

Certificate of
Completion

Summary

Title Beazley Sexual Misconduct and Molestation Liability Renewal File name Beazley Sexual Misconduct and Molestation Liability Renewal.pdf

Status Completed

Document guid: kjQxcBdEYiF0QAsTiQNJ4YpvLFCpy5KI

Document History

2024-01-08 02:00:45 PM CST

Signed by Brandon Mosley (cardinoltrans@gmail.com) IP

2600:387:a:15::5e