Fillable ABUSE OR MOLESTATION SUPPLEMENTAL APPLICATION (Residential and Affordable (Philadelphia Insurance Companies)

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ABUSE OR MOLESTATION SUPPLEMENTAL APPLICATION (Residential and Affordable (Philadelphia Insurance Companies)

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ABUSE OR MOLESTATION SUPPLEMENTAL APPLICATION
(Residential and Affordable Housing)
Applicant Name:
Mailing Address:
City:
State:
Zip:
SECTION I – APPLICANT SERVICES AND PROGRAMS
1.
Does the Applicant provide any of the following services? (check all that apply)
Social or Community Services
Day Care
Medical Services
Foster Care/ Adoption
If yes to any of the above, please describe and explain if the program is operated by the Applicant. If not,
please confirm if the Applicant verifies insurance and they are named as an Additional Insured on the
operator’s policy:
2.
Please provide the age of tenants served as a percent of total annual tenant population.
Tenants
Percentage
Tenants
Percentage
Children (under 13)
%
Adults (18 - 65)
%
Adolescents (13 -17)
%
Adults (over 65)
%
SECTION II – EMPLOYEE, TENANT, VOLUNTEER, AND INDEPENDENT CONTRACTOR SCREENING PROCESS
1.
Does the Applicant’s employment process include verification of whether the individual has ever
been convicted of any crime, including sex related or child-abuse related offenses, before an offer
of employment is made?
Yes
No
2.
Does the Applicant’s state permit them to do criminal background investigations?
Yes
No
a.
Does the Applicant conduct background investigations prior to hire?
Yes
No
b.
Does the Applicant conduct background investigations annually?
Yes
No
If not, how often?
c.
Does the background investigation include checking the sex abuse registry?
Yes
No
3.
Does the Applicant verify employment history?
Yes
No
4.
Does the Applicant verify employment related references?
Yes
No
5.
Does the Applicant conduct a personal interview?
Yes
No
6.
Does the Applicant’s employment application include warnings that background checks, reference
checks, employment history, and/ or abuse registry checks will be conducted?
Yes
No
7.
Are criminal background checks conducted on all tenants?
Yes
No
8.
Do volunteers or independent contractors work directly with tenants?
Yes
No
If yes, which screening processes does the Applicant use?
Volunteers
Independent Contractors
a.
Questionnaire or Employment Application
Yes
No
Yes
No
b.
Background Check
Yes
No
Yes
No
c.
Abuse Registry Check
Yes
No
Yes
No
d.
Employment Verification
Yes
No
Yes
No
e.
Reference Check
Yes
No
Yes
No
f.
Personal Interview
Yes
No
Yes
No
9.
How many years does the Applicant keep records on file?
Real Estate - Abuse or Molestation
Supplemental Application
Page 1 of 3
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
SECTION III – POLICIES, PROCEDURES, AND AWARENESS TRAINING
1.
Has the Applicant participated in abuse awareness training?
Yes
No
a.
If yes, who conducted the training?
b.
Are newly hired employees given abuse awareness training?
Yes
No
c.
Are volunteers given abuse awareness training?
Yes
No
2.
Does the Applicant have written procedures to make sure no relationship occurs between
employees, volunteers and tenants?
a.
Do the procedures address inappropriate touching, language and one-on-one interaction
between employees, volunteers and tenants?
Yes
No
b.
Do the procedures include a definition of sexual abuse/ molestation?
Yes
No
c.
Do the procedures prohibit contact with minor participants outside of the Applicant’s operations
(including social media)?
Yes
No
d.
When were the procedures last updated?
3.
Does the Applicant have written investigation procedures?
Yes
No
4.
Does the Applicant have written disciplinary procedures?
Yes
No
5.
Does the Applicant have a written process for reporting incidents within the organization?
Yes
No
6.
Does the Applicant have a written process for communicating to the appropriate law enforcement
or administrative agencies?
Yes
No
7.
Does the Applicant have a written crisis plan for responding to an abuse claim?
Yes
No
SECTION IV – MONITORING AND OVERSIGHT
1.
Does the Applicant use surveillance cameras on its premises?
Yes
No
If yes,
a.
Is the video saved?
Yes
No
b.
For how long:
2.
Will any employees, volunteers, or independent contractors have access to tenants in the following
situations?
a.
One-on-one interactions that take place privately?
Yes
No
If yes, please explain.
b.
Performing operations where they will be physically touching another person?
Yes
No
If yes, please explain.
SECTION V – LOSS HISTORY AND EXPOSURES
1.
Has the Applicant’s organization ever had an incident which resulted in an allegation of sexual
abuse?
Yes
No
If yes, please explain.
a.
Was a claim made against the organization?
Yes
No
b.
Was the case settled?
Yes
No
c.
Was the case taken to trial?
Yes
No
d.
How much money was paid as damages to the victim? $
2.
Does the Applicant know of any fact, circumstance or situation which may result in a claim under
the coverage for which they are applying?
Yes
No
Yes No
Real Estate - Abuse or Molestation
Supplemental Application
Page 2 of 3
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
FRAUD STATEMENT AND SIGNATURE SECTIONS
The Undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief
and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true
and complete and may be relied upon by Company * in quoting and issuing the policy. If any of the information in this Application changes
prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the
quote or binder.
The signing of this Application does not bind the Company to offer, or the Applicant to purchase the policy.
*Company refers collectively to Philadelphia Indemnity Insurance Company and Tokio Marine Specialty Insurance Company
VIRGINIA APPLICANT: READ YOUR POLICY. THE POLICY OF INSURANCE FOR WHICH THIS APPLICATION IS BEING MADE, IF ISSUED,
MAY BE CANCELLED WITHOUT CAUSE AT THE OPTION OF THE INSURER AT ANY TIME IN THE FIRST 60 DAYS DURING WHICH IT IS IN
EFFECT AND AT ANY TIME THEREAFTER FOR REASONS STATED IN THE POLICY.
FRAUD NOTICE STATEMENTS
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 AND SUBJECTS THAT PERSON TO
CRIMINAL AND CIVIL PENALTIES (IN OREGON, THE AFOREMENTIONED ACTIONS MAY CONSTITUTE A FRAUDULENT INSURANCE ACT WHICH MAY
BE A CRIME AND MAY SUBJECT THE PERSON TO PENALTIES). (IN NEW YORK, THE CIVIL PENALTY IS NOT TO EXCEED FIVE THOUSAND DOLLARS
($5,000) AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION). (NOT APPLICABLE IN AL, AR, AZ, CO, DC, FL, KS, LA, ME, MD, MN,
NM, OK, PA, RI, TN, VA, WA AND WV).
APPLICABLE IN AL, AR, AZ, DC, LA, MD, NM, RI AND WV: ANY PERSON WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS A FALSE OR
FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR WHO KNOWINGLY (OR WILLFULLY IN MD) PRESENTS FALSE INFORMATION IN AN
APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO FINES OR CONFINEMENT IN PRISON.
APPLICABLE IN COLORADO: 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.
APPLICABLE IN FLORIDA AND OKLAHOMA: 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 (IN FL, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).
APPLICABLE IN KANSAS: AN ACT COMMITTED BY ANY PERSON WHO, KNOWINGLY AND WITH INTENT TO DEFRAUD, PRESENTS, CAUSES TO BE
PRESENTED OR PREPARES WITH KNOWLEDGE OR BELIEF THAT IT WILL BE PRESENTED TO OR BY AN INSURER, PURPORTED INSURER, BROKER
OR ANY AGENT THEREOF, ANY WRITTEN, ELECTRONIC, ELECTRONIC IMPULSE, FACSIMILE, MAGNETIC, ORAL, OR TELEPHONIC COMMUNICATION
OR STATEMENT AS PART OF, OR IN SUPPORT OF, AN APPLICATION FOR THE ISSUANCE OF, OR THE RATING OF AN INSURANCE POLICY FOR
PERSONAL OR COMMERCIAL INSURANCE, OR A CLAIM FOR PAYMENT OR OTHER BENEFIT PURSUANT TO AN INSURANCE POLICY FOR
COMMERCIAL OR PERSONAL INSURANCE WHICH SUCH PERSON KNOWS TO CONTAIN MATERIALLY FALSE INFORMATION CONCERNING ANY FACT
MATERIAL THERETO; OR CONCEALS, FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO.
APPLICABLE IN KENTUCKY: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSONS
FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS, FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.
APPLICABLE IN MAINE, TENNESSEE, VIRGINIA AND WASHINGTON: 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.
APPLICABLE IN PENNSYLVANIA: 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.
APPLICABLE IN VERMONT: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE STATEMENT IN AN APPLICATION FOR INSURANCE MAY BE GUILTY
OF A CRIMINAL OFFENSE AND SUBJECT TO PENALTIES UNDER STATE LAW.
APPLICABLE IN NEW YORK: 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 BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATE VALUE OF THE CLAIM FOR EACH
SUCH VIOLATION.
NA
ME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE DIRECTOR)
_____
________________________________________________________
SIGNATURE DATE
SE
CTION TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Florida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
Real Estate - Abuse or Molestation
Supplemental Application
Page 3 of 3
© 2020 Philadelphia Consolidated Holding Corp.
03/2020
Clear Application
Print Application
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ABUSE OR MOLESTATION SUPPLEMENTAL APPLICATION (Residential and Affordable (Philadelphia Insurance Companies)

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Completed 11 February 2021

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