AM-GEN.APP Page 4 of 5 11.1.10
V. LOCATION
INFORMATION
1. Schedule of Locations: If more than five locations, please attach a separate sheet of locations.
Address Types of Services Provided
# 1
# 2
# 3
# 4
# 5
2. a. Are there any camp, adventure/wilderness, ropes courses or any type of recreational
programs? Yes No
b. If Yes, please submit brochure or describe activities:
3. a. Are there any firearms on the premises? Yes No
b. If Yes, please describe:
c. Are the firearms locked in a secure place away from the residents? Yes No
d. If No, please describe:
4. a. Are there any animal exposures on the premises? Yes No
b. If Yes, are the animal exposures: Owned Non-owned?
c. If Yes, please describe, including number of animals and type/breed:
5. a. Are there any lakes, ponds, rivers, pools or other bodies of water on the premises? Yes No
b. If Yes, please describe:
c. Are there any swimming or boating activities? Yes No
d.
e.
If there is a pool or body of water, then is it fenced with a self-locking gate?
If there is a pool or body of water, then is there a diving board and/or slide?
Yes
Yes
No
No
VI. COVERAGE
REQUESTED
1. Complete and attach the appropriate supplemental application with your submission.
2. Check the coverages and limits that the Applicant would like quoted:
a. Coverages: GL Professional Excess (Attach Acord App)
b. Limits: $100,000/$100,000 $300,000/$300,000 $500,000/$500,000
$1,000,000/$1,000,000 $1,000,000/$2,000,000 $1,000,000/$3,000,000
3. a. Do you want physical abuse/sexual molestation coverage to protect you for alleged acts
of your employees?
Yes No
b. If Yes, at what limits? $25,000/$50,000 $50,000/$100,000 $100,000/$300,000
$250,000/$250,000 $500,000/$500,000 Other: