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IMPORTANT: Follow these four steps when filling out the application:

1) Print out this form

2) Fill out the application form.

3) Find your premium under the pricing section and submit your check payable to: The John A. Barclay Agency, Inc. (For certain activities as shown, an additional premium may apply.)

4) Mail application and check to:

The John A. Barclay Agency, Inc.
PO Box 2274
4000 Medical Parkway, Suite 210
Austin, Texas 78756
Phone: 512/476-6566

3939 Bee Caves Road
Building A, Suite 1B
Austin, Texas 78746

Telephone: 512-328-6812
Toll-free: 888-842-7491
Fax: 512-327-9775
Email: admin@texasmuseums.org

Home > Membership > DOEO Insurance Program > Application

Application for (D&O) Liability Insurance Program

     Name of Museum (please print) ____________________________________
     Address __________________________________________________________
     City _____________________________________________________________ 
     State _____________________________   Zip ________________________
     Business Phone __________________     Business FAX________________


Select Your Coverages: D&O Insurance, $1 million limit of liability
          ( ) Revenues up to $1,000,000 Premium:$800
          ( ) Revenues from $1,000,001 - $2,000,000 Premium $950

Please send me additional information about the following:
          ( ) Fiduciary Liability Insurance*         ( ) Crime Insurance
	  (*Subject to underwriter review on an individual basis.  
      Please obtain an application from the John A. Barclay Agency, Inc.)
	  Note: Higher limits for D&O Insurance available upon request.
	  
Please answer the following:
   1.  Does the Applicant provide appraisal or authentication services 
	  for others for a fee, commission, or other compensation?		
		( ) Yes			( ) No
	
	  2.  Does the Applicant have written policies with respect to 
	  the acquisition, management, conversion, insuring, lending, 
	  and deaccessioning for its collection?
		( ) Yes			( ) No
		
WE UNDERSTAND THE FOLLOWING:
In consideration of the premium charged, no coverage will be available 
under this Policy for Loss, including Defense Expenses, from Claims 
arising from any fact, circumstances, or situation of which, as of the 
effective date of this Policy, any Insured had knowledge and had reason 
to suppose might afford grounds for any Claim that would fall within 
the scope of the insurance afforded by the Policy.
There will be monthly sign-up periods with prorated premiums and coverage 
effective the first of each month.  Application will become effective if 
approved by the underwriter.

I HEREBY AGREE TO THE ABOVE SAID STATEMENTS AND AGREE TO SUCH TERMS:
     Print Applicant's Name and Title ___________________________________
     Applicant's Signature _____________________________    Date ________
	 

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