General Liability Supplemental Application

Basic Information

GENERAL INFORMATION

If you answer yes, we may require additional information.

Annual Budget Annual Payroll Annual Sales Number of Employees Number of Volunteers
Source(s) of Funding % of Total Budget

If yes, please explain:

If yes, please explain:

If yes, please explain:

If yes, please explain:

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

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

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.)

If yes, please describe

If yes, please explain

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

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.

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

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?

athletics / sports

If yes, please answer the following :

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

Foster Homes

If yes, please answer the following :

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

adoptions

If yes, please answer the following :

premises

If yes, please answer the following :

If yes, please answer the following :

If yes, please answer the following :

Animals

If yes, please answer the following :

If yes, please indicate the number of :

If yes, please answer the following:

If yes, provide annual sales for each:

Type Annual Sales

Performing and Fine Arts

If yes, please answer the following:

Camping/Campgrounds

If yes, please answer the following:

If yes, please answer the following:

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

If yes, please answer the following:

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

Type Annual Sales

Other Exposures

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.