General Liability Supplemental Application

Basic Information

Organization’s Name :-

Contact Person :-

Title :-

Phone :-

Fax :-

Email :-

Website :-

Date quote is needed?

FEIN # :-

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:

athletics / sports

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

Foster Homes

24. Does Organization certify Foster Homes?

If yes, please answer the following :

Yes

a. Does Organization purchase Foster Parent Liability (FPL) insurance for foster parents?

If no, please note that we usually require this be purchased concurrent with our liability coverage.

If yes, please provide a copy of Organization’s current FPL declaration page

Yes

b. Address (if different from Organization)

Number of homes that Organization has decertified over the past five years:

c. Number of children placed in homes by Organization annually:

d. Number of years experience of Organization executive director in this field:

e. Are Organization foster care procedures/practices subject to state regulation?

Yes

f. Total number of training hours for each family prior to placement of each child:

g. Does Organization provide follow-up visits to homes after children are placed?

Yes

If yes, how frequently?

Are the visits unannounced?

Yes

Do home visits include a private consultation with the foster children?

Yes

When do these visits stop?

h. Does Organization conduct checks of criminal records of foster parents and other residents prior to approval of home?

Yes

Are foster parents or other residents in the home who have criminal records, or any history of physical or sexual abuse immediately disapproved or decertified?

Yes

If no, please explain :

i. Does Organization have written procedures for responding to reports of abuse?

Yes

j. What is the average case load per employee/social worker?

adoptions

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 :

premises

26. Does Organization provide lodging or operate residential facilities?

If yes, please answer the following :

Yes

a. Number of beds for which Organization is licensed, and square footage of each facility:

b. Number of stories in each building:

c. If two stories or more, number of means of egress:

d. Average length of stay per resident:

e. Age range of residents :

0 - 10

11 - 18

19 - 65

Over 65

g. Is there a 24-hour resident manager?

Yes

h. Is staff trained in a formal procedure for medical emergencies?

Yes

i. Is skilled nursing or medical care provided?

Yes

27. Does Organization have a fire alarm system?

Yes

28. Does Organization have smoke detectors on premises?

Yes

29. Is smoking allowed inside any premises?

Yes

30. Does Organization have a swimming pool?

If yes, please answer the following :

Yes

a. Is pool fenced with a self-closing gate?

Yes

b. Is there a diving board?

Yes

c. Is there life-saving equipment accessible?

Yes

31. Does Organization own, lease or rent any vacant buildings?

Yes

If yes, please explain reason for vacancy, plans and time frame for occupancy:

32. Does Organization offer your premises to others, either for rent or for free?

If yes, please answer the following :

Yes

a. Please explain general use and frequency :

b. Does organization obtain certificates of insurance showing proof of liability insurance from all who use the facility?

Yes

Animals

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:

Type	Annual Sales
Pet Training
Pet Grooming

Performing and Fine Arts

38. Does Organization offer Performing or Fine Arts?

If yes, please answer the following:

Yes

a. Description of performances (e.g., dance, musical, plays) :

b. Annual number of performances :

c. Average attendance at each performance:

d. Are performances held at premises owned or leased by Organization?

Yes

e. Are any performances held away from premises owned or leased by Organization?

Yes

f. Does Organization provide concessions?

Yes

If yes, please provide annual receipts: $

g. Does Organization provide classes to the public?

Yes

Camping/Campgrounds

39. Does organization own or operate a campground?

If yes, please answer the following:

Yes

a. Is a caretaker present during off-season(s) (i.e., when camp sessions are not in session)?

Yes

b. Is camp located in a wilderness area?

Yes

c. Is camp located in an area at risk of wildfires?

Yes

40. Does organization provide camping experiences for clients?

If yes, please answer the following:

Yes

a. Describe any special focus and/or activities offered (river rafting, ropes courses, climbing walls, etc.):

b. Annual number of campers per day:

c. Number of days camp has campers on location each year:

d. Is there overnight exposure?

Yes

Mentoring programs (e.g. Big Brothers Big Sisters)

41. Does Organization have any mentoring programs that match youth with mentors

If yes, please answer the following:

Yes

a. How many matches are made annually ?

b. Is there a formal training and screening program in place?

Yes

c. Are any matches made of opposite genders?

Yes

If yes, explain :

d. Are permission slips obtained for all mentors/mentees under 18?

Yes

e. Are mentors allowed to take mentees to their private residence?

Yes

Food or Merchandise Distribution (e.g. Food Banks, Thrift Stores, Meal Delivery, etc.)

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

Date

Producer’s Signature

Date

Print or type applicant’s name

Applicant’s Title