General Liability Supplemental Application

Basic Information

Organization’s Name *

Contact Person

Title *

Phone

Fax

Check here if none available

Website

Date quote is needed?

FEIN #

Billing Address

GENERAL INFORMATION

1. Does the organization have any General Liability Insurance Currently ? *

If you answer yes, we may require additional information.

Yes

2. What type of Entity is the Organization? *

501(c)3 Nonprofit

C- Corporation

S Corporation

LLC

3. What state is the organization incorporated? *

4. In what states will the organization operate? *

5. Complete the following *

Annual Budget	Annual Payroll	Annual Sales	Number of Employees	Number of Volunteers

6. Specify major sources of funding and indicate approximate proportion of budget from each source (for example: private foundations 20%, city 60%, fee for services 20%)

Source(s) of Funding		% of Total Budget

7. Is Organization presently in bankruptcy or has Organization contemplated filing
bankruptcy during the past six months? *

If yes, please explain:

Yes

8. List any licenses or accreditation Organization is required to maintain *

9. In the past five years, has the organization received any citations, violations,
penalties or fines by any administrative or licensing organization?*

If yes, please explain:

Yes

10. Does the organization have any subsidiaries or control any other entity or organization
for which coverage is desired? *

If yes, please explain:

Yes

a. Name of other entity for which coverage is desired

b. Address (if different from Organization)

c. What is the relationship between the organization and the other organization(s) ?

11. In the past three years has any insurance carrier declined, cancelled or non-renewed any coverage
for which Organization is applying? *

If yes, please explain:

Yes

12. Please provide a description of Organization operations and programs *

13. Is the Organization exclusively an information and referral service (i.e., no direct services) ? *

Yes

15. Does Organization perform any engineering or restoration work (e.g,
waterway or stream restoration) ? *

Yes

16. Is Organization planning any renovations or new construction during the next two years ? *

If yes, describe the type of property accepted including usage (e.g., residential home for rental)

Yes

17. Does Organization accept donations of real property (land or buildings) on a regular basis ? *

If yes, describe the type of property accepted including usage (e.g., residential home for rental)

Yes

18. Does Organization accept donations of vehicles ? *

If yes, explain how Applicant uses these donated vehicles (e.g., used in Applicant’s daily operations, sold to a
third party; repaired by Applicant and resold, etc.)

Yes

19. Are any clients held in locked down facilities ? *

If yes, please describe

Yes

20. Does Organization provide any Medical Services ? *

If yes, please explain

Yes

21. Does Organization employ counselors or other Social Service Professionals
(veterinarians, teachers, nurses, etc.) ? *

If Social Services Professional Coverage is desired, please complete the “Social Services Professional” Supplemental Application

Yes

Special Events/Fundraisers

Complete the section below to include all of your events and fundraisers

Note:We define a “Fundraiser” as any event sponsored or co-sponsored by you with the primary purpose of raising monetary contributions.

22. Does organization hold events/activities outside of Applicant’s normal programs and/or operations?

a. If yes, please complete the table below. If additional space is needed, please attach Special Event form or additional pages

Yes

Event Name & Date	Describe Applicant’s Activities Taking Place	# of Expected Attendees	Gross Revenue	Is Applicant a Participant or Host of the Event?	Is Alcohol Served or Sold By Applicant?	Does Applicant Require a Waiver from Participants?

b. If yes, are vendors/exhibitors required to provide proof of General Liability insurance naming the Organization as an Additional Insured?

Yes

c. Which events listed in 22.a. above have bounce houses, inflatables and/or climbing structures?

Name of Event:

# of Structures:

Name of Event:

# of Structures:

Name of Event:

# of Structures:

d. Describe the security and safety procedures in place for the events listed in 22.a. above:

Name of Event:

Procedures:

Name of Event:

Procedures:

Name of Event:

Procedures:

ATHLETIC/SPORTS (If Applicable)

23. Does organization offer athletics/sports programs? *

If yes, please answer the following :

Yes

a. Describe all athletic activities provided:

b. Number of annual participants:

c. Indicate type of sports offered (e.g., basketball, flag football, boxing, soccer, cheerleading):

d. Does your organization sponsor competitions or teams that participate in competitions?

Yes

If yes, is organization responsible for insuring these competitions or teams?

Yes

e. Are waiver/release/hold harmless agreements obtained for all participants?

Yes

ADOPTIONS (If Applicable)

25. Does organization provide adoption services? *

If yes, please answer the following :

Yes

a. Are any adoptions “closed?”

Yes

If yes, please explain :

b. Number of adoptions performed annually :

c. Number of adoptions that are international :

d. Are you a member of the Joint Council on International Adoption or another similar organization?

Yes

Other

If other, please specify :

ANIMALS (If Applicable)

33. Does organization have any exposures involving animals? *

Yes

34. Does Organization have any saddle animal operations?

If yes, please answer the following :

Yes

a. Are animals used solely for therapeutic purposes?

Yes

If no, explain other usage:

b. Are safety helmets required?

Yes

c. Are animals :

Owned by Applicant

Furnished to Applicant by third party

d. Number of animals owned by or used by Organization :

35. Does organization provide animal shelter/rescue services?

If yes, please indicate the number of :

Yes

a. Spaces, cages or kennels on Applicant’s premises available to animals:

b. Animals placed in foster care annually:

c. Foster homes used annually:

d. Offsite adoptions held annually:

e. Are all animals vaccinated and held for observation prior to being placed in any homes (adoptive or foster)?

Yes

f. Is a health assessment of the animal conducted by a professional qualified to assess communicable disease?

Yes

g. Are behavioral evaluations performed by a qualified professional of all animals prior to placement (foster or adoption)?

Yes

h. Does Organization place animals with known (current or historical) biting issues into homes (foster or adoption)?

Yes

i. Are waivers for volunteers of adoptive/foster homes maintained and do they include hold harmless language that specifically discloses that the animal may cause bodily injury to the volunteer, and that the volunteer will not hold the nonprofit responsible for any injury to themselves or family members that arise from the foster/adoptive relationship

Yes

j. Does Organization have accident coverage in place?

Yes

l. How many years experience does the Applicant's leadership have in this field?

k. How long has Organization been in business?

36. Does Organization employ animal control officers?

If yes, please answer the following:

Yes

a. How many?

b. Do they carry firearms?

Yes

c. Do these officers carry separate professional liability insurance?

Yes

37. Does Organization operate any of the following?

If yes, provide annual sales for each:

Yes

Type	Annual Sales
Pet Training
Pet Grooming

Food or Merchandise Distribution (E.G. FOOD BANKS, THJRIFT STORES, MEAL DELIVER, ETC.) (If Applicable)

42. Does Organization distribute or sell any food or merchandise? *

Yes

Type	Annual Sales
Food
Used Merchandise
Other (describe) :

OTHER EXPOSURES

43. Does Applicant have any premises, operations or exposures that are not stated in this application? *

Yes

If yes, describe and state whether they are insured elsewhere:

SIGNATURES

Notice: This risk pooling contract is issued by a pooling arrangement authorized by California Corporations Code Section 5005.1. The pooling arrangement is not subject to all of the insurance laws of the State of California and is not subject to regulation by the Insurance Commissioner. Insurance guaranty funds are not available to pay claims in the event the risk pool becomes insolvent.

Applicant’s Signature

Producer’s Signature

Print or type applicant’s name

Applicant’s Title

General Liability Supplemental Application

Basic Information

GENERAL INFORMATION

Special Events/Fundraisers

Complete the section below to include all of your events and fundraisers

ATHLETIC/SPORTS (If Applicable)

FOSTER HOMES (If Applicable)

ADOPTIONS (If Applicable)

PREMISES (If Applicable)

ANIMALS (If Applicable)

PERFORMING AND FINE ARTS (If Applicable)

CAMPING/CAMPGROUDS (If Applicable)

MENTORING PROGRAMS (E.G. BIG BROTHER AND BIG SISTERS) (If Applicable)

Food or Merchandise Distribution (E.G. FOOD BANKS, THJRIFT STORES, MEAL DELIVER, ETC.) (If Applicable)

OTHER EXPOSURES

SIGNATURES