Fillable Application - Food Bank36-9274

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Application - Food Bank36-9274

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FOOD BANK SUPPLEMENTAL APPLICATION
Applicant Name:
Mailing Address:
City:
State:
ZIP:
Total Staff (including office, janitorial, maintenance, etc.):
Full Time:
Part Time:
SIC #:
FEIN #:
Non-Profit
For-Profit
Annual Revenue: $
Number of years this facility has been: In Operation:
Under current Executive Director:
Risk Management Contact:
Number:
Email:
SUBMISSION REQUIREMENTS
• ACORD applications, including Crime & Umbrella
• Statement of Values
• Photographs of the Applicant’s location(s)
SECTION I – GENERAL APPLICATION INFORMATION
1.
Please provide a narrative of the Applicant’s operations:
2.
Any mergers or operations under another name within the past five (5) years?
Yes
No
Are any mergers planned / anticipated for the coming year?
Yes
No
If yes to either, explain:
3.
Annual budget excluding food donations: $
Annual value of donated food: $
Funding sources (check all that apply):
Federal
State
County
Other (please specify):
4.
Does the Applicant operate any locations not included in this application?
Yes
No
If yes, provide addresses separately and explain:
5.
Does the applicant currently maintain state and or governmental licenses and certifications required to
operate as food handler, food salvager, and, or food distributor?
Yes
No
If no, explain:
6.
Has the Applicant ever had any licenses or certifications required to operate as a food bank revoked
or placed under suspension?
Yes
No
If yes, explain:
7.
Is the Applicant aware of any claims that have alleged negligence or failure to comply with any
regulatory / licensing guidelines?
Yes
No
If yes, explain:
8.
Indicate whether the applicant’s employees or independent contractors provide services other than
food handling and food acquisition and distribution, and food rescue?
Yes
No
If yes, explain:
Food Bank Supplemental
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01/2018
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9.
Does the Applicant lease, sub-lease, or rent to others?
Yes
No
If yes, please provide a copy of such contract.
10.
Has the Applicant discontinued any programs in the past five (5) years?
Yes
No
If yes, explain:
SECTION II - PREMISES / LIFE SAFETY
1.
If the building the Applicant occupies was built prior to 1971; has it been inspected for lead paint?
Yes
No
If no, what is the plan for abatement?
2.
Does the Applicant have any plans for renovations or new construction?
Yes
No
If yes, explain:
3.
Does the Applicant have the following in place:
Fire alarms?
Yes
No
Central Station?
Yes
No
Security alarm?
Yes
No
Central station?
Yes
No
Smoke detectors?
Yes
No
Are smoke detectors:
Hard wired
Battery operated
4.
Are all fire extinguishers annually inspected?
Yes
No
5.
How many means of egress are there?
Are all exits clearly marked & illuminated?
Yes
No
6.
Are all exit doors equipped with panic hardware?
Yes
No
7.
Does the Applicant have a written emergency evacuation plan?
Yes
No
If yes, are the emergency evacuation procedures and floor plan posted?
Yes
No
Has the Applicant established a central meeting point outside the building?
Yes
No
Does the emergency plan include notification to the fire department?
Yes
No
How often are drills held?
8.
Does the Applicant have emergency lighting or backup generators in the event of a power failure?
Yes
No
9.
Does the Applicant have a formal maintenance housekeeping program in place?
Yes
No
10.
Has the Applicant’s facility been inspected by an insurance company or independent inspection firm
such as AIB, Inc.?
Yes
No
If yes, provide a copy of such report.
11.
Does the property have aluminum wiring?
Yes
No
If yes, has it been retrofitted with one of the PHLY approved connectors by a licensed Electrician?
Yes
No
(indicate with one): COPALUM? Yes No AlumiConn?
Yes
No
Date updated:
Please supply retrofit documentation or statement from installing contractor.
SECTION III - MANAGEMENT PRACTICES
1.
Does the Applicant have incident reporting procedures and / safety reviews?
Yes
No
2.
Is the Applicant’s staff made aware of reporting procedures?
Yes
No
3.
Does the Applicant have a plan for medical emergencies?
Yes
No
4.
Is there someone trained in CPR and first aid on the premises during usual operating hours?
Yes
No
5.
Does the Applicant have Automatic External Defibrillator(s)?
Yes
No
6.
Are there trained employees to use AED on premises?
Yes
No
7.
Do monthly staff meetings include food safety, workplace safety topics, and Operational
improvements?
Yes
No
If yes, explain:
8.
Does the Applicant have a written and enforced no smoking policy?
Yes
No
9.
Are “no smoking” signs posted in all areas not designated for smoking?
Yes
No
SECTION IV - HIRING / SCREENING PRACTICES
1.
a.
Does the Applicant require all staff to complete an employment application?
Yes
No
b.
Does the Applicant require all volunteers working 500 hours per year to complete an employment
application?
Yes
No
2.
Does the Applicant conduct a personal interview for each prospective staff member?
Yes
No
3.
Does the Applicant verify educational degrees of job applicants?
Yes
No
4.
Does the Applicant verify employment related references?
Yes
No
5.
Does the Applicant verify licenses and other credentials pertinent for food bank operations?
Yes
No
6.
Does the Applicant obtain criminal background checks on all staff members before hiring them, where
allowable by law?
Yes
No
7.
Does the Applicant require drug tests on all staff members, including drivers?
Yes
No
If yes:
Before hiring
After hiring
Random
Food Bank Supplemental
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© 2018 Philadelphia Consolidated Holding Corp.
01/2018
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8.
What are the Applicant’s procedures for evaluating all these reports?
9.
Does the Applicant share written job descriptions with all staff members?
Yes
No
10.
Are any staff members under 18 years of age?
Yes
No
If yes, list their position(s) and how they are supervised:
11.
What is the staff turnover rate for the last 12 months?
12.
Does the Applicant provide workers compensation for :
All staff members
Workshop Employees
Contractors
Consultants
SECTION V - ABUSE AND MOLESTATION
1.
Does the Applicant’s current insurance program include Abuse and Molestation Coverage?
Yes
No
If yes, Occurrence or Claims Made – Retro Date:
Limits of Liability: $
Carrier:
Effective Date:
2.
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, subject to any applicable legal limitations in the jurisdiction of employment?
Yes
No
3.
Does the Applicant have a written crisis plan in place for dealing with employees, victims, parents,
authorities, and the media if the Applicant has incident of abuse?
Yes
No
4.
Are there written complaint procedures and are they displayed prominently?
Yes
No
If yes, explain:
5.
Have any incidents resulted in an allegation of sexual abuse?
Yes
No
Was the case settled?
Yes
No
Was the case taken to trial?
Yes
No
Amount paid for damages to the victim: $
6.
Does the Applicant run background checks on volunteers?
Yes
No
If yes, explain:
SECTION VI - CLAIMS MADE
N/A
Notice: This section is being completed as an application for a Claims-Made policy. Only claims which are first
made against the Applicant and reported to us during the policy peri
od or Extended Reporting Period will be
covered, subject to policy provisions. Various provisions in the policy restrict coverage. Read the entire policy
carefully to determine the Applicant’s rights, duties and what is and is not covered.
Policy Effective Date:
Line of Business:
1.
Within the past 5 (five) years has the Applicant given written notice under the provisions of any current
or prior policy providing similar insurance of any claim or of any specific facts or circumstances which
might give rise to a claim being made against the Applicant?
Yes
No
If yes, please provide details:
2.
With respect to the coverages applied for, upon inquiry of any of person qualifying as a Named
Insured under the proposed policy, are there any facts, circumstances, or situations which might give
rise to a claim under the coverage(s) for which the Applicant is applying?
Yes
No
If yes, please provide details:
Food Bank Supplemental
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© 2018 Philadelphia Consolidated Holding Corp.
01/2018
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SECTION VII - AUTOMOBILE
N/A
1.
Are all vehicles listed on the ACORD application titled to the applicant?
Yes
No
If no, explain:
2.
Where does the Applicant keep owned vehicles?
Garage
Driveway
Parking lot
Other:
3.
Are keys locked and secured away from non-drivers when not in use?
Yes
No
4.
Are vehicles with eight or more seating capacity equipped with an audible backup warning device?
Yes
No
5.
Does the Applicant provide pickup or delivery of donated merchandise?
Yes
No
6.
Are all vehicles that transport food equipped with hot and cold holding equipment to maintain proper
food temperatures of food?
Yes
No
7.
Does the Applicant require seat belts to be worn by all occupants?
Yes
No
8.
Does the Applicant have a vehicle maintenance program in place?
Yes
No
9.
Does the Applicant’s organization utilize GPS fleet telematics devices?
Yes
No
If yes, please check off the fleet telematics being utilized:
Plug in
Hard wired
Mobile Phone
Other:
10.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
SECTION VIII – DRIVERS
N/A
1.
Does the Applicant obtain a written authorization to release driver information from all of staff upon
hiring?
Yes
No
Does the Applicant obtain MVRs on all CLD drivers?
Yes
No
If yes, how often?
2.
What are the Applicant’s procedures for dealing with driver accidents or violations?
3.
Are all drivers at least 21 years of age?
Yes
No
4.
How many drivers (employees and volunteers) aged 21 to 25 transport clients in agency vehicles?
5.
Do any drivers have a Commercial Driver’s License?
Yes
No
6.
Explain the Applicant’s driver safety program:
7.
Does anyone besides employees or volunteers drive the Applicant’s vehicles?
Yes
No
If yes, explain:
8.
Does the Applicant allow personal use of the Applicant’s vehicles?
Yes
No
If yes, by whom and for what reasons?
SECTION IX - HIRED AND NON-OWNED VEHICLES
N/A
1.
Does the Applicant contract any delivery services with vendors?
Yes
No
If yes, explain:
If yes, what types of vehicles does the Applicant hire?
Does the Applicant obtain certificates of insurance?
Yes
No
What minimum limits does the Applicant require? $
2.
Does the Applicant hire from a transportation company?
Yes
No
If yes, with drivers?
Yes
No
3.
Total number of hired vehicles: Annual cost of hire: $
4.
How many drive personal vehicles for business use regularly?
F/T:
P/T:
Vol:
How many drive personal vehicles for business use occasionally?
F/T:
P/T:
Vol:
Does the Applicant obtain proof of insurance for employees/volunteers who use their own autos?
Yes
No
Does the Applicant update these records at least yearly?
Yes
No
What minimum limits does the Applicant require? $
Food Bank Supplemental
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01/2018
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SECTION X - FOOD BANK
N/A
1.
Are proper personal hygiene practices in place such as proper hand washing?
Yes
No
2.
Are potentially hazardous foods properly stored in a temperature controlled environment?
Yes
No
3.
Does any food come from approved food sources, i.e., licensed restaurants, food processors,etc.?
Yes
No
4.
Are powered material handling equipment operators properly trained and supervised?
Yes
No
5.
Are there food cross contamination procedures in place?
Yes
No
6.
Does the Applicant pick up from homes or businesses?
Yes
No
7.
What radius does the Applicant drive?
8.
Does the Applicant have a loading dock or appropriate place to unload goods?
Yes
No
9.
Are product expiration dates monitored?
Yes
No
SECTION XI – FOOD PREPARATION FACILITIES
N/A
1.
Yes
No
2. The food preparation equipment is in:
One common area Each floor Individual rooms Other:
Total number of cooking areas:
3. Who has access to the cooking area: Staff Clients/Residents Visitors/Public
4. For who is the food prepared? Staff Clients/Residents Visitors/Public
If for the public, explain:
5. Is the food properly covered, stored and served? Yes No
6. Do the Applicant’s staff members supervise the cooking area? Yes No
7. Are there fire extinguishers in the cooking area? Yes No
8. The cooking equipment is: Residential Commercial
9. Cooking equipment is equipped with: Nothing Hoods Ducts Exhaust Fans
Automatic fuel shut off controls Automatic fire suppression system Other:
10. How often is the cooking equipment cleaned:
Cleaned by: Applicant Cleaning contractor
11. Do the hoods have removable filters? Yes No
SECTION XXII - PLANNED EVENTS / FUND RAISERS** N/A
** If Insured has more than five (5) events planned for the upcoming policy period, photocopy this page and add additional events.
QUESTIONS
EVENT #1 EVENT #2 EVENT #3 EVENT #4 EVENT #5
Describe the type of event*
* Insert letter for type of event: A = Wine tasting B = Golf outing C = Other sporting event (specify) D = Picnic
E = Banquet F = House tour G = Bingo H = Walkathon I = Fashion show J = Concert (specify) K = Other (specify)
Date(s) the event is held.
Daily hours of operation.
Total anticipated revenue. $ $ $ $ $
Held at Applicant’s premises? If not, specify
where it is held.
Number of participants.
Number of staff members.
Are certificates of insurance obtained from
everyone providing products / services?
If there will be drinking at the event, how does
the Applicant control the amount allowed?
Who provides / serves the alcohol?
Liquor license required?
Are the bartenders hired by the Applicant or by
the place where the event is held?
Are bartenders TIPS certified?
If applicable, list all sporting activities to be a
part of this event.
What safeguards are in place to prevent
spectator injury?
Do participants sign a waiver?
If sporting activity, do participants show proof
of personal health insurance?
Does the Applicant repackage food?
If yes, do all refrigerators, freezers, cooking and hot holding equipment meet NSF International
Standards and have NSF marking?
As all other food and beverage equipment is replaced, are they required to meet NSF standards and
have NSF marking?
Yes No
Yes No
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WINTER WEATHER FREEZE-UP PROTECTION
1. Fire Protection and Testing
a. Is the building provided with an Automatic Fire Sprinkler System (AS)? Yes No N/A
i. If yes, approximately what percentage (%) of the building is sprinklered? %
ii. If yes, what type of sprinkler system is installed? Wet-Pipe Dry-Pipe Both
iii. If yes, when possible, is the sprinkler piping primarily run within conditioned
areas designed to ensure the temperature remains above the 45°F minimum
Yes No N/A
iv. If yes, is the testing & inspection by qualified sprinkler contractor completed
within past 12 months & includes a formal winterization revi
ew?
Yes
No
N/A
v. If yes, are the alarms tied to a 24 hour UL listed monitoring company?
Yes
No
N/A
2. Emergency Water Response (domestic and AS water lines)
a. Are water shutoff valves (domestic and AS water lines) marked and readily
accessible?
Yes
No
N/A
b. Are water shutoff valves exercised (closed and reopened) at least annually?
Yes
No
N/A
c. Is the staff qualified to respond and shut off the water main during normal business
hours and off hours?
Yes
No
N/A
3. Automatic Water Shutoff Devices
a. For domestic water lines, is there a water flow detection, notification and automatic
shutoff?
Yes
No
N/A
4. Unused/Vacant Spaces
a. Does Applicant have a formal process to turn off and drain domestic water lines for
these spaces?
Yes
No
N/A
5. Unheated Areas (attics, crawl spaces, exterior wall joists)
a. Are all domestic water lines located in areas heated to at least 45°F?
Yes
No
N/A
i. If no, please describe freeze prevention measures (e.g. temperature monitoring,
heat trace, full insulation):
This section must be completed by all risks that have a location in one of the following states: AR, CT, DC, DE,
GA, IL, IN, KY, ME, MD, MA, MI, MO, NH, NY, NJ, NC, OH, PA, RI, SC, TN, TX, VT, VA, WV, WI
temperature?
1. If no, please describe freeze prevention measures (
e.g. temperature
monitoring,
heat trace, full insulation on piping or roof):
6.
General Comments:
Food Bank Supplemental
Page 6 of 7
© 2018 Philadelphia Consolidated Holding Corp.
01/2018
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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, VT, 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 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.
NAME (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
______________
_______________________________________________
SIGNATURE DATE
SECTION T
O 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)
Food Bank Supplemental
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01/2018
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