Return Applications To:
Public Servants Defense Agency
4001 Miller Rd.
Wilmington DE 19802
Tel: 888-304-1201
Fax: 302-765-6037
 
NOTICE: THIS IS A CLAIMS-MADE FORM: EXCEPT TO SUCH EXTENT AS MAY OTHERWISE BE PROVIDED HEREIN, THE COVERAGE OF THIS POLICY IS LIMITED TO LIABILITY FOR ONLY THOSE CLAIMS THAT ARE FIRST MADE AGAINST THE INSURED AND REPORTED IN WRITING TO THE COMPANY WHILE THE POLICY IS IN FULL FORCE. PLEASE REVIEW THE POLICY CAREFULLY.
* denotes required fields
PLEASE SELECT DESIRED LIMIT OF LIABILITY, Based on Profession*
Other coverage enhancements available
 PROFESSION $250,000 LIMIT
Police Officer
Firefighter
EMT/Paramedic
*Rates shown include all applicable premiums, taxes, and fees. Rates in some jurisdictions may be higher. The Chief/Department Head product includes Good Samaritan/24 Hour coverage and Hotline access within the base policy.
Member Information
 First Name:   Middle Initial: 
 Last Name:  
 Street Address:  
 
 
 City:    State:    Zip:  
 Work Phone: Ext.:   Home Phone: 
 Work Email:    Home Email:  
 Date of Birth:    Gender:  
   Preferred Correspondence Method: 
How did you hear about us?: 
Please provide a brief description of your job duties:
 
Do you carry a firearm as part of your job duties?  
 
Has any Professional Liability claim(s), civil suit(s) or internal administrative/disciplinary actions been made against the Applicant over the past five years?  
 
  If "Yes", please provide the following information:
 
Does the Applicant have knowledge or information of any actual or alleged acts, errors, omissions, or circumstances which might reasonably be expected to give rise to a claim against the Applicant?  
 
If "Yes", provide details:  
 
OPTIONAL ENDORSEMENT
Coverage can be tailored to address the unique liability exposures of Applicants through the addition of an optional endorsement.
NOTE: an additional premium applies.  Select the checkbox and provide the requested information to add this coverage.
   
Extends coverage to include services provided outside of the insured’s scope of employment as a firefighter, paramedic, or EMT. In order to secure this additional coverage, please provide the following information:
 
• Description of MoonLighting Activities:
  

• Number of hours worked per week:      

Additional cost dependent on activity type and number of hours worked.
NOTE: Police Officers seeking protection for Moonlighting activities must complete a supplemental application. Coverage may be available through one of PSDA’s affiliates on a stand-alone basis. Visit www.psdains.com to download a copy of the application.

 		 THE APPLICANT WARRANTS THAT THE STATEMENTS AND RESPONSES TO THE QUESTIONS ON THIS APPLICATION ARE TRUE AND COMPLETE.  THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY, NOR DOES IT OBLIGATE THE COMPANY TO ISSUE A POLICY.  SUCH POLICY MAY BE CANCELLED BY THE COMPANY FROM INCEPTION UPON DISCOVERY THAT THE POLICY WAS OBTAINED THROUGH A FRAUDULENT STATEMENT, OMISSION, OR CONCEALMENT OF THE FACTS MATERIAL TO THE ACCEPTANCE OF THE RISK OR HAZARD ASSUMED.