Local Government Risk Management Plan - Commonwealth Of Virginia

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Revised 11/2000
COMMONWEALTH OF VIRGINIA
LOCAL GOVERNMENT RISK MANAGEMENT PLAN
VaRISK 2 Application
Division of Risk Management * P.O. Box 1879, Richmond, VA 23218-1879 * 1.800.678.4924
A. Legal Name of Entity _______________________________________________________
______________________________________________________________________________
B. Address of Entity __________________________________________________________
City, State, Zip ____________________________________________________________
Telephone Number ______________________ Fax Number________________________
C. Budget:
(for current fiscal year, excluding capital expenditures)
FY____ Revenues $___________________
Expenditures $_____________________
D. Does Entity administer Transit Authority
; Utility
; or Social Services Agency
?
(Check boxes that apply and attach description and budget separately, excluding budget from Section B)
E. Does Entity carry Public Official’s
; Medical Malpractice
, Law Enforcement
;
Educator’s
, or General Liability Insurance
?
(Check boxes that apply and attach list of
companies and policy limits. )
F. 1. Has any employee or applicant made a claim alleging unfair or improper treatment
regarding hiring, remuneration, advancement or termination of employment?
Yes
No
(If yes, attach separate sheet with date, nature, any costs and present status of each
claim.)
2. Has the entity been sued regarding discrimination, ADA, sexual harassment or other
civil rights claims, excluding law enforcement claims? Yes
No
(If yes, attach separate
sheet with date, nature, any costs and present status of each claim. )
3. Have other claims been made for anything other than the above, Workers’
Compensation, auto or police liability? Yes
No
(If yes, attach separate sheet with date,
nature, any costs and present status of each claim.)
G. Complete if Medical Malpractice coverage is requested
(Please provide full information on work of
all medical personnel to be covered. Attached additional pages as necessary.)
Number
Full Time
Part Time
Hours Per Week
Psychiatrist
______
______
_______
___________
Dentist
______
______
_______
___________
Psychologist
______
______
_______
___________
General Practitioner
______
______
_______
___________
RNs
______
______
_______
___________
LPNs
______
______
_______
___________
Family Practice:
______
______
_______
___________
Pediatrician
______
______
_______
___________
Internal Medicine
______
______
_______
___________
Other (specify)

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