Non Profit Social Services Product Application

Applicant may qualify for an INSTANT QUOTE by completing Section I below. All other Section answers will be required prior to binding and are subject to underwriting approval.

I. INSTANT QUOTE INFORMATION

Instant quote is not available for accounts with losses in the past 5 years. If there is loss history, please complete Section I and submit details in a claims supplement

Organization's Name:*

Location Address:*

Street Address Address Line 2 City State ZIP Code

Same as Location Address

Please check if Mailing Address is Same as Location Address.

Mailing Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website Address:*

1. Is this a Non Profit Organization with a tax exempt status as defined by the Internal Revenue Service?*

Yes
No

2. Does Organization operate as an Abortion Clinic, Adoption Agency, Adult Daycare, Children's Camping Yes No (overnight), Foster Care Service, Halfway Housing for Ex-Felons, Nursing Home, Political Action Committee, Scouts or Suicide Hotline?*

Yes
No

3. Has Organization had any bankruptcies, tax or credit liens against it in the past 5 years?*

Yes
No

4. Has Organization had its license suspended or revoked in the past three years or is it currently under Yes No investigation for wrongdoing by any licensing agency or other authority?*

Yes
No

5. Has Organization ever had any officers or board members convicted of the felony of arson?*

Yes
No

6. Functioning and operational smoke and/or heat detectors in all units and/or occupancies?*

Yes
No

7. For any building built prior to 1978, 100% of the electrical wiring is connected to functioning and operational circuit breakers?*

Yes
No

8. For any building built prior to 1978, no aluminum or knob & tube wiring?*

Yes
No

General Liability/Professional Liability Rating Section (Check all that apply)

Animal Shelter/Rescue

(If checked, complete the Social Services Animal Shelter Supplemental Application)

Number of cages:

Average occupancy rate of cages:

Number of animals at foster homes:

Big Brother/Big Sister

(If checked, complete the Social Services Youth Center Supplemental Application)

Office square footage:

Number of Volunteer Mentors:

Botanical Garden

(If checked, complete the Social Services Botanical Garden Supplemental Application)

Number of acres:

Office square footage:

Annual number of admissions:

Caregiver

(If checked, complete the Social Services Hospice/Caregiver Supplemental Application)

Annual number of client contacts:

Office square footage:

Number of caregivers:

Conservation Group

Office square footage:

Number of members:

Counseling & Referral

Office square footage:

Number of professionals:

Food Bank/Soup Kitchen

Annual meals provided:

Square footage:

Office:

Warehouse:

Meal service area:

Group Home

(If checked, complete the Social Services Botanical Garden Supplemental Application)

Office square footage:

Number of members:

(If checked, complete the Social Services Hospice/Caregiver Supplemental Application)
Hospice (In Home)
(If checked, complete the Social Services Hospice/Caregiver Supplemental Application)

Office square footage:

Number of professionals:

Annual number of client contacts:

(If checked, complete the Social Services Hospice/Caregiver Supplemental Application)
Hospice Facility
(If checked, complete the Social Services Hospice/Caregiver Supplemental Application)

Number of licensed beds:

Hospice square footage:

Number of professionals:

(If checked, complete the Social Services Residential Facilities Supplemental Application)
Residential Shelters (Battered Women, Halfway Houses, Homeless Shelters):
(If checked, complete the Social Services Residential Facilities Supplemental Application)

Number of licensed beds:

Shelter square footage:

Number of professionals:

(If checked, complete the Social Services Senior Center Supplemental Application)
Senior Activities Center
(If checked, complete the Social Services Senior Center Supplemental Application)

Club square footage:

Number of members:

Number of professionals:

Thrift Store

Revenues:

Square footage:

(If checked, complete the Social Services Vocational Supplemental Application)
Vocational Sheltered Workshop/ Specialty Training School:
(If checked, complete the Social Services Vocational Supplemental Application)

Square footage:

Number of students:

Number of professionals:

(If checked, complete the Social Services Youth Center Supplemental Application)
Youth Community Center
(If checked, complete the Social Services Youth Center Supplemental Application)

Square footage:

Number of registrants:

Number of professionals:

Organizations with Professionals, provide number of each:

Caregiver/Home Companion:

Psychologists:

Teacher/Tutor:

RNs:

LPNs:

Nutrionists:

Nurse Practitioners:

Social Workers:

Therapists:

Veterinarians:

Other Degreed Professionals:

Full Time Professionals:

Part Time Professionals:

Property Section

Construction:*

Frame

All Other

Protection Class:*

Requested Cause of Loss:*

Basic

Special

Requested Valuation:*

Replacement Cost

Actual Cash Value

Deductible:*

$1,000

$2,500

$5,000

Coinsurance:*

80%

90%

100%

Building Limit:*

Year Constructed:*
MM slash DD slash YYYY

Square Footage:*

Business Personal Property:*

II. General Liability/Professional Liability - Eligibility Criteria

9. Does Organization provide Accident insurance or Workers Compensation insurance for employees and volunteers?*

Yes

No

10.Does Organization contract with Physicians (including psychiatrists) and Nurses that do not provide certificates of malpractice insurance?*

Yes

No

11. Are there two or more means of egress from each floor having public access?*

Yes

No

12. Number of years Organization has been in business?*

13. Does Organization require background checks on employees or volunteers (which include sex related or child abuse claims)?*

Yes

No

14. Does Organization employ or accept the services of persons with a criminal background?*

Yes

No

15. Does Organization permit continued involvement of anyone who has ever been accused of an abuse or molestation claim?*

Yes

No

16. Does Organization have a formal orientation program for new hires/volunteers which includes a review of the Organization's sexual abuse policy?*

Yes

No

17. Does Organization monitor staff's day-to-day interaction with volunteers and clients, both on and off the premises?*

Yes

No

18. Abuse & Molestation limit?:*

$100,000

$300,000

$500,000

$1,000,000

19. Does Organization operate as a Thrift Store or Food Bank? If yes, please advise on the following:*

Yes

No

a. Are items refurbished, repaired, repackaged, re-labeled or modified prior to sale/distribution?*

Yes

No

b. Are items sold/distributed under the Organization's name or label?*

Yes

No

c. Does Organization provide any warranties of quality or safety on any merchandise?*

Yes

No

20. Ratio of staff to clients:*
(staff)

to:*
(clients)

Loss History for General Liability/Professional Liability for the past five (5) years:
If none, check here

Please use the + button to the right to add additional Loss History.*
Date of Loss Type/Description Paid ($) Reserved ($) Open/Closed

Please use the + button to the right to add additional Loss History.

List expiring General Liability/Professional Liability Carrier, term, limits and premium:*
Carrier Policy Term Limits Premium

III. Hired / Non Owned Auto - Eligibility Criteria

21. Does Organization have a motor vehicle liability insurance policy in place?*

Yes

No

22. Does Organization own any motor vehicles or lease any motor vehicles on a long term basis?*

Yes

No

23. Does Organization use hired or non-owned vehicles with passenger capacities exceeding 15 passengers?*

Yes

No

24. Does Organization use hired or non-owned vehicles for emergency medical transportation or emergency medical services?*

Yes

No

25. Does Organization transport non-ambulatory persons?*

Yes

No

26. Does Organization require evidence of insurance from employees and volunteers?*

Yes

No

27. Does Organization require a minimum of $100,000 CSL or $100,000/$300,000 personal auto liability limits from employees and volunteers?*

Yes

No

28. Number of Volunteer/Employed Drivers:*

29. Average driving frequency per week by volunteer and/or employed drivers:*

Once

2-3 Times

Daily

IV. Property

30. Do any of the following exposures exist for the Oranization's building(s): Building partially constructed; Wood burning stoves or fireplaces; Temporary heating devices; Building currently damaged by fire or otherwise; Building(s) without functioning/operating smoke/heat detectors; Building(s) without functioning/operating fire extinguishers?*

Yes

No

If the applicant owns the building and it is older than 10 years, please complete the following:

31. If the applicant owns the building and it is older than 10 years, please complete the following:*
Age of Roof (yrs): Plumbing Updated (yr): Electrical Updated (yr): Heating Updated (yr):

Roof Type:*
Flat
Wood Shake
Shingle
Metal
Tile
Slate
Other

Plumbing Type:*
PVC
Copper
Lead
Galvanized
Other

Burglar Alarm:*
Central Station
Local
None
Other

32. Are building(s) sprinklered?*

Yes

No

Is there commercial cooking on the premises? If yes, please answer the following:*

Yes

No
If yes, please answer the following:

a. Is cooking area protected by an approved automatic extinguishing system and smoke detectors?

Yes

No
If yes, please answer the following:

b. What type of extinguishing system is functioning and operational?

Yes

No
If yes, please answer the following:

c.Is there a deep fat fryer on the premises?

Yes

No
If yes, please answer the following:

d. Is there a cleaning contract in force with an outside firm?

Yes

No
If yes, please answer the following:

e. Describe cooking equipment used:
Grills
Open Flame
Oven
Deep Fat Fryers
Charcoal Grill

f. Are the cooking area, hood and duct system protected per NFPA 96 guidelines?

Yes

No

Loss History for Property for the past three (3) years:
If none, check here

Please use the + button to the right to add additional Loss History.
Date of Loss Type/Description Paid ($) Reserved ($) Open/Closed

Please use the + button to the right to add additional Loss History.

List expiring Property carrier, term, limits and premium:*
Carrier Policy Term Limits Premium

V. Non Profit Directors & Officers

33. Is the Organization involved in product research, development, testing and/or certification?*

Yes

No

34. Does Organization engage in any disciplinary actions as a result of peer review activities?*

Yes

No

35. Does Organization administer or sponsor any insurance programs?*

Yes

No

36. Is the Organization involved in any accreditation or standard setting activities?*

Yes

No

37. Is the Organization involved in any labor/union negotiations or collective bargaining activities?*

Yes

No

38. Total number of Employees:*
Full-time Part-time Volunteer Seasonal

39. Does Organization have any Subsidiaries requiring coverage?*

Yes

No

40. Does Organization currently carry General Liability Insurance?*

Yes

No

41. Please provide the following financial information for the last three (3) years. (If organization in existence less than 3 years, please provide Budgeted Revenue/Expense statement for next 3 years.)*
Year Total Revenues ($) Net Income (Loss) ($) Current Fund Balance * ($)

* Fund balance = Total Assets - Total Liabilities

42. Within the last 5 years, has any inquiry, complaint, notice of hearing, claim or suit been made (including, but not limited to, Equal Employment Opportunity Commission, State Human Rights Boards, Municipal, State or Federal Regulatory Authorities), against the Organization, or any person proposed for Insurance in the capacity of Director, Officer, Trustee, Employee or Volunteer of the Organization?*

Yes

No
If yes, please forward a completed USLI supplemental claims application.

43. Is any person proposed for this insurance aware of any fact, circumstance or situation, which may result in a claim against the Organization or any of its Directors, Trustees, Officers, Employees or Volunteers?*

Yes

No
If yes, please forward a completed USLI supplemental claims application.

VI. Fiduciary Liability (Available for 100 employees or less)

44. Does each Pension Plan use an outside Investment Manager? (If No, Fiduciary will not be offered.)*

Yes

No
(If No, Fiduciary will not be offered.)

45. Does each Plan subject to ERISA comply with all applicable requirements of ERISA and the Internal Revenue Code of 1982, as amended (the "Code") including eligibility, participation, vesting, fiduciary responsibility and funding standards?*

Yes

No

(If no, please attach details)

46. . In the past two (2) years has there been or is there now under consideration any material changes to a Plan or termination / consolidation of a Plan?*

Yes

No

(If yes, please attach details)

47. Has there been or is there now pending any claim(s) against any proposed Insured arising out of any Plan?*

Yes

No

(If yes, please attach details):

48. Does any proposed Insured have knowledge or information of any act, error or omission which might give rise to a claim under the proposed Fiduciary Liability Coverage?*

Yes

No

(If yes, please attach details):

Arizona Notice: Misrepresentations, omissions, concealment of facts and incorrect statements shall prevent recovery under the policy only if the misrepresentations, omissions, concealment of facts or incorrect statements are; fraudulent or material either to the acceptance of the risk, or to the hazard assumed by the insurer or the insurer in good faith would either not have issued the policy, or would not have issued a policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application for the policy or otherwise.

Florida and Illinois Notice: I understand that there is no coverage for punitive damages assessed directly against an insured under Florida and Illinois law. However, I also understand that punitive damages that are not assessed directly against an insured, also known as “vicariously assessed punitive damages”, are insurable under Florida and Illinois law. Therefore, if any Policy is issued to the Applicant as a result of this Application and such Policy provides coverage for punitive damages, I understand and acknowledge that the coverage for Claims brought in the State of Florida and Illinois is limited to “vicariously assessed punitive damages” and that there is no coverage for directly assessed punitive damages.

Minnesota Notice: Authorization or agreement to bind the insurance may be withdrawn or modified only based on changes to the information contained in this application prior to the effective date of the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for nonpayment of premium.

Missouri Notice: Pursuant to Section IV, Paragraph R., some Defense Costs are within the Limit of Liability. Any Defense Costs paid under this coverage will reduce the available Limits of Insurance and may exhaust them completely. Defense Costs means reasonable and necessary legal fees and expenses incurred by the Company, or by any attorney designated by the Company to defend any Insured, resulting from the investigation, adjustment, defense and appeal of a Claim. Defense Costs includes other fees, costs, costs of attachment or similar bonds (without any obligation on the part of the Company to apply for or furnish such bonds), but does not include salaries, wages, overhead or benefits expenses of any Insured.

New York Disclosure Notice: This policy is written on a claims made basis and shall provide no coverage for claims arising out of incidents,occurrences or alleged wrongful acts that took place prior to the retroactive date, if any, stated on the declarations. This policy shall cover only those claims made against an insured while the policy remains in effect and all coverage under the policy ceases upon termination of the policy except for the automatic extended reporting period coverage unless the insured purchases additional extend reporting period coverage. The policy includes and automatic 60 day extended claims reporting period following the termination of this policy. The Insured may purchase for an additional premium an additional extended reporting period of 12 months, 24 months or 36 months following the termination of this policy. Potential coverage gaps may arise upon the expiration for this extended reporting period. During the first several years of a claims-made relationship, claims-made rates are comparatively lower than occurrence rates. The insured can expect substantial annual premium increases independent overall rate increases until the claims-made relationship has matured.

Utah Notice: I understand that Punitive Damages are not insurable in the state of Utah. There will be no coverage afforded for Punitive Damages for any Claim brought in the State of Utah. Any coverage for Punitive Damages will only apply if a Claim is filed in a state which allows punitive or exemplary damages to be insurable. This may apply if a Claim is brought in another state by a subsidiary or additional location(s) of the Named Insured, outside the state of Utah, for which coverage is sought under the same policy.

Virginia Notice: You have an option to purchase a separate Limit of Liability for the extension period, policy common conditions I. If you do not elect this option, the Limit of Liability for the extension period shall be part of and not in addition to the limit specified in the declarations. Statements in the application shall be deemed the insured's representations. A statement made in the application or in any affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such statement was material to the risk when assumed and was untrue.

Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies.

District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

Florida Fraud Statement: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree.

Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime.

Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits

New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

If your state requires that we have information regarding your Authorized Retail Agent or Broker, please provide below.

Producer Name:*

Retail Agency Name:*

License #:*

Main Agency Phone Number:*

Agency Mailing Address:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

The signer of this application acknowleges and understands that the information provided in this Application is material to the Insurer's decision to provide the requested insurance and is relied on by the Insurer in providing such insurance. The signer of this application represents that the information provided in this Application is true and correct in all matters. The signer of this Application further represents that any changes in matters inquired about in this Application occurring prior to the effective date of coverage, which render the information provided herein untrue, incorrect or inaccurate in any way will be reported to the Insurer immediately in writing. The Insurer reserves the right to modify or withdraw any quote or binder issued if such changes are material to the insurability or premium charged, based on the Insurer's underwriting guides. The Insurer is hereby authorized, but not required, to make any investigation and inquiry in connection with the information, statements and disclosures provided in this Application. The decision of the Insurer not to make or to limit any investigation or inquiry shall not be deemed a waiver of any rights by the Insurer and shall not stop the Insurer from relying on any statement in this Application in the event the Policy is issued. It is agreed that this Application shall be the basis of the contract should a Policy be issued and it will be attached and become part of the Policy.

Applicant's Signature:*
(President, Chairperson or Executive Director)

Title:*

Date:*
MM slash DD slash YYYY

Social Services Non Profit Package Application

Social Services Non Profit Package APP

Non Profit Social Services Product Application

Applicant may qualify for an INSTANT QUOTE by completing Section I below. All other Section answers will be required prior to binding and are subject to underwriting approval.

I. INSTANT QUOTE INFORMATION

II. General Liability/Professional Liability - Eligibility Criteria

III. Hired / Non Owned Auto - Eligibility Criteria

IV. Property

V. Non Profit Directors & Officers

VI. Fiduciary Liability (Available for 100 employees or less)

Year	Total Revenues ($)	Net Income (Loss) ($)	Current Fund Balance * ($)