Fillable Application - Head Start36-9275

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Application - Head Start36-9275

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HEAD START SUPPLEMENTAL APPLICATION
SUBMISSION REQUIREMENTS
•
ACORD Applications for all lines requested
•
Resume on Director of New Venture
• Copy of current child care license(s) • Currently valued insurance company loss runs for the current
policy period plus three (3) prior years
• Statement of Values if blanket coverage is requested
• Financial statement if for-profit • Photographs of Applicant’s location(s)
SECTION I - GENERAL INFORMATION
Applicant:
Location Address:
Commercial Church School
Private Home (NOT Eligible)
Other (describe):
Hours of operation:
1. Is the Child Care center licensed? Yes No
2. If licensing is NOT state required, why is the center exempt?
3. Has a license to operate ever been denied, suspended or revoked? Yes No
If yes, please explain thoroughly on a separate document.
Attach copies of licenses.
4. Have there been 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:
5. Annual operating budget: $ Annual Payroll: $
Primary funding: Federal State County Other:
6. Does Applicant operate any locations not included in this application? Yes No
If yes, please explain:
7. List all accreditations, association memberships and /or affiliations:
SECTION II - BUILDING SPECIFICS
1. Does the child care center exit directly to the outside? Yes No
To ground level? Yes No
2. Do the bathroom doors lock? Yes No
Can they be unlocked from the outside? Yes No
3. Does the child care center have smoke detectors? Yes No
If yes, are they: battery operated or hard-wired to the building
4. Are doors equipped with pinch guards to prevent fingers from getting caught? Yes No
5. Has a lead abatement been performed since 1978? Yes No
6. Have asbestos materials been: not present removed protected to prevent flaking
SECTION III - STAFF AND CHILDREN
1. Based on the maximum number of children enrolled on your busiest day, what is your actual breakdown of total staff
to total number of children by age group (excluding director)
AGE GROUP # OF STAFF # OF CHILDREN AVERAGE DAILY ATTENDENCE
Infants, ages 0 – 1
Toddlers, ages 1 – 2
Toddlers, ages 2 – 3
Preschoolers, ages 3 – 5
School Age Children
Web Address: E-mail:
Risk Management Contact:
Years in business:
Email:
Non-Profit For-Profit
Phone Number:
Number of years under present management:
This Child care center is located in which type of building?
Head Start Supplemental Application
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2. Are children allowed to use the restroom without a teacher present? Yes
No
If yes, how many children are allowed in the restroom at one time:
3. Is a minimum of one staff member certified in first aid present at all times? Yes
No
4.
If male staff, provide details of:
a) length of employment:
b) any one-on-one? Yes
No
c) duties performed, including age groups:
SECTION IV - PROFESSIONAL LIABILITY
1. Hiring Practices:
a. Does Applicant conduct a personal interview for each prospective staff member? Yes
No
b. Does Applicant verify references? Yes
No
c. Does Applicant require drug tests on all staff members, including drivers? Yes
No
If yes: Before hiring After hiring Random
2. What is the staff turnover rate for the last 12 months?
3. Is the staff required to report to the administrator all incidences that may result in a claim? Yes
No
If yes, is a written record kept? Yes No Are they reviewed? Yes
No
4. Does Applicant’s current insurance program provide professional liability coverage? Yes
No
If yes: Occurrence Claims-made - Retroactive Date: Limits of Liability: $
Carrier: Effective dates:
5. Annual Staffing – Employees, Independent Contractors and Volunteers
Total number of: Full time employees: Part Time Employees: Volunteers:
Staffing
# of Employees # of Contracted
Total Annual Volunteer
Hours Worked
FT PT FT PT
Psychologist
Medical Director (Admin Only)
Nurse Practitioner
Physician Assistant
Pharmacist
Paramedic EMT
Psychiatrist
Physician-Hospice
Pediatrician
Physician-No Surgery
Dentist
Optometrists/Ophthalmologist
Licensed Social Worker
Sociologist
Registered Nurse (RN)
Licensed Practical Nurse (LPN)
Physical Therapist
Optician
Orthotics & Prosthetics (O&P)
Certified Practitioner
Counselor (Guidance, Vocational)
Social Worker
Occupational Therapist
Speech Therapist
Clergy / Rabbi / Pastor
O&P Certified Technician
Teacher
Nutritionist / Dietician
Residential Manager
Home Health Aide
Day Care Worker
O&P Certified Fitter
O&P Certified Assistant
Adoptions
Foster Care
*Other (describe):
*Other (describe):
F/T = Full Time – over 20 hours per week/ P/T = Part Time – up to 20 hours per week.
Please describe “other” staff positions not listed in the above chart in the provided area.
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SECTION VI - CORPORAL PUNISHMENT
1. What is the Applicant’s policy on corporal punishment? Allowed Prohibited
If allowed, please submit a copy of the written policy concerning the use of corporal punishment.
2. Have there ever been any claims for corporal punishment? Yes No
SECTION VII - SEXUAL ABUSE
1. Does the Applicant’s employment process (for employees and volunteers) include verification if
Application has ever been convicted of any crime, including sex related or child-abuse related
offenses, before an offer of employment is made?
Yes No
SECTION VIII - HEALTH AND SAFETY
1. Does the Applicant provide sick child or drop in services? If yes, please explain: Yes No
2. How many children require special care and treatment? Please explain:
6.
If the Applicant is requesting primary medical professional coverage for any of above noted Physicians,
Psychiatrists, Dentists or Opticians, the Applicant must submit a completed and signed Medical Professional
application. Coverage for such professional is subject to Underwriting review and approval.
7.
If the above noted employed or volunteer Physicians, Psychiatrists, Dentists or Opticians carry their own
medical malpractice insurance, we may provide vicarious medical professional coverage for the entity as
respects to the professional services rendered on the insured’s behalf. Coverage for the entity will require
the following: The Professional’s name, medical license number, medical specialty and proof that the
professional carries adequate limits of insurance (at least $1million limit of liability). Proof of insurance may
be satisfied by submitting a copy of the professional’s declaration page and/or certificate of insurance.
SECTION V - MANAGEMENT PRACTICES
1. Does Applicant have sign in / sign out procedures for:
Staff Clients / Residents Visitors / Public
2. Type of security provided for the protection of Applicant’s children?
Guards Video Cameras Other:
3. Does Applicant have incident reporting procedures and / or committee reviews? Yes No
4. What methods does Applicant use for de-escalation?
2. Yes No Does Applicant’s current insurance program provide professional liability coverage?
If yes: Occurrence or Claims-made - Retroactive Date:
Carrier:
Limits of Liability: $
Effective dates:
3. During new staff orientation, does the Applicant discuss child/sexual abuse, how to recognize the
signs and what to do if a child reports that someone molested him or her? Yes No
4.
Yes No
Does the Applicant perform national criminal background investigations and is a sex offender register
check completed on all current employees and volunteers?
If no, please explain:
5. How long has the Applicant been performing these checks? years
6. For how many years does the Applicant keep these records on file after employee leaves: years
7. Does the Applicant verify employment-related references? Yes No
8. Does the Applicant conduct a personal interview? Yes No
9. Does the Applicant’s supervision plan monitor staff in day-to-day relationships with children both on
and off premises? Yes No
10. How is the staff monitored? Video Windows Other:
11. Yes No Does the Applicant have written procedures for dealing with sexual abuse?
MANDATORY: Provide a copy of procedures.
12. Yes No Has the Applicant ever had an incident which resulted in an allegation of sexual abuse?
If yes, please complete:
a. Was a claim made against the organization? Yes No
b. Is that individual still employed with your organization? Yes No
c. What changes were made to prevent recurrence?
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SECTION IX - AUTOMOBILE N/A
1. Does the Applicant provide regular transportation for children? Yes No
If yes: Maximum distance: Miles Minimum age:
2. Is a walk-around vehicle checklist used prior to transporting children? Yes No
3. Are all drivers put through specialized drivers training in transporting children? Yes No
4. How are children accounted for getting on and off the bus?
5. How often do employees or volunteers drive their own vehicles for transporting children?
6. Does the Applicant require evidence that they have their own auto insurance? Yes No
If yes, limit required: $
SECTION X - SPECIAL ACTIVITES N/A
1. Are special classes provide, on premises or off Premises (select all that apply)
Gymnastics Dance Karate
Tumbling Birthday Parties - # of children: Other:
If yes, please explain:
Yes No
2. Are special classes taught by an independent contractor on your premises? Yes No
3. Does the Applicant request/maintain Certificates of Insurance from all sub-contractors? Yes No
4. Does the Applicant have any operations other than child care? Yes No
If yes, please explain:
SECTION XI - PLAYGROUNDS N/A
1. Is the area fenced? Yes No
2. Are any trampolines and inflatables present? Yes No
3. Describe playground surface:
SECTION XII - FIELD TRIPS / OFF PREMISES TRAVEL N/A
1. How many field trips are taken per year:
2. Describe the field trips.
3. Are parental waivers obtained? Yes No
4. Minimum age taken on trips.
5. How are children transported: Child Care vehicle Parent Other:
SECTION XIII - CAMPS N/A
1. Is written permission/waiver of liability obtained from every child’s parent or guardian? Yes No
2. Does the camp provide overnight services? Yes No
If yes, what is the average length of stay?
3. Total number of days in operation annually: Number of children at each camp:
3. Indicate if a file containing the following information is maintained on each child:
a. Are there Immunization records of the children being updated annually? Yes No
b. Are there records for each child indicating unusual conditions the child has? Yes No
c. Are signed releases for emergency medical treatment/dispensing of medication obtained from
parents? Yes No
d. Written instructions from child’s physician for dispensing of child’s medication? Yes No
4. Yes No
5. Yes No
Yes No
Is food properly covered, stored and served in according to government requirements?
Does the Applicant have an accident / health policy?
Is coverage mandatory for all children?
Provide carrier limits of liability: Policy term:
6. Does the Applicant require evidence of personal medical insurance for all children? Yes No
7. Does the Applicant have a written emergency evacuation plan in effect? Yes No
8. Please describe the Applicant’s daily check in and release procedures:
9. Yes No Are any pets or animals kept on premises?
Describe animals, caging, and type of interaction:
10. Does the Applicant permit staff, volunteers, or clients to carry open or concealed weapons on your
premise? Yes No
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Answer the following questions for pool to be used:
4. Are water depths marked? Yes No
5. What is the maximum depth? feet
6. Is there a diving board? Yes No Is there a slide into the pool? Yes No
7. Is the pool area completely fenced? Yes No
8. Are lifeguards present? Yes No Is there a self-locking gate? Yes No
9. Ratio of staff to child when at pools?
10.
Minimum age of children allowed in the water:
11.
Minimum age of children in the water:
12. Walking surface in good shape and non-slip? Yes No
SECTION XV - PLANNED EVENTS / FUND RAISERS N/A
Complete a Special Events Supplement for each event that involves any of the below activities:
• Aircraft • Rock, Hip-Hop or Rap concerts – with admission
• Animals – other than house pets
over 500 people
• Carnivals and fairs with mechanical rides sponsored • Any event lasting more than 5 days (including otherwise
by the Applicant acceptable events).
• Events including contact sports • Any event with liquor provided by the Applicant if a license
• Firearms
is required for such activity.
• Fireworks • Any event with greater than 500 people at any one
• Motorcycle runs and automobile rallies
time (including otherwise acceptable events).
• Parades sponsored by the Applicant • Any activities by third party telemarketing, direct mail,
• Rodeos sponsored by the Applicant
or internet advertising (including spam) firms.
• Political Rallies
SECTION XVI - MEDICAL FACILITIES N/A
1. The facilities are for: Staff Clients/Residents General Public
2. Does Applicant provide more than immediate care/first aid? Yes No
SECTION XVII - FOOD PREPARATION FACILITIES N/A
1. The food preparation equipment is: Electric Gas Propane Other:
Total number of cooking areas:
2. Cooking equipment is equipped with:
Nothing Hoods Ducts Exhaust fans Automatic fuel shutoff controls
Automatic fire suppression systems Other:
3. How often is the cooking equipment cleaned?
Cleaned by: Applicant Cleaning contractor
4. Number of staff members at each camp:
5. Indicate and describe if any of the following exposures exists in the camp operations:
Obstacle course Motor boats Jet skis Pools Guns Rock climbing
Water skiing Horses Lakes Archery Other:
1. Number of children (other than children in the childcare program): Ages:
2. Number of weeks attending:
3. Number of additional staff:
4. Describe outings away from camp location:
2. Is the pool you use, or plan on using, located: on Applicant’s premises at a separate location
3. Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa Safety Act? Yes No
If no, provide timetable and action plan:
1. Does the Applicant now use or plan in the future to use
swimming facilities? Yes No
SECTION XIV - SWIMMING POOLS N/A
Diving boards
Summer Camp:
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SECTION XVIII - 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 period 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.
Yes No
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?
If yes, please provide details:
2.
Yes No
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?
If yes, please provide details:
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SECTION XIX - DIRECTORS & OFFICERS / EMPLOYMENT PRACTICE LIABILITY
N/A
THIS SECTION IS AN APPLICATION FOR A CLAIMS MADE POLICY.
PLEASE READ YOUR POLICY CAREFULLY.
DIRECTORS & OFFICERS LIABILITY INFORMATION
1.
Does the Applicant have a tax-exempt status under the U.S. Internal Revenue Code?
Yes
No
If no, provide an explanation:
2.
FINANCIAL INFORMATION
CURRENT FISCAL YEAR
PREVIOUS FISCAL YEAR
Total Assets:
$
$
Net Assets / Fund Balance:
$
$
Annual Revenue:
$
$
Net Revenue:
$
$
3.
Provide a list of all direct and indirect subsidiaries or any other entity or organization the Applicant controls:
Name / Type of Business
Percent the Applicant
Owns/Controls
Date Created /
Acquired
For Profit / Non-
Profit
I.E.: ABC Foundation / Charitable Foundation
100%
01/01/2000
Non-Profit
%
%
%
Additional entities listed by attachment
4.
Has the Applicant or any person proposed for coverage herein been the subject of, or involved in, any
of the following in the past five (5) years? If yes, please attach details.
Yes
No
Any disciplinary action by any regulatory agency or association?
Yes
No
Any administrative proceeding charging violation of a federal or state law or regulation?
Yes
No
Any other criminal actions?
Yes
No
5.
In the past 24 or next 12 months has the Applicant been, or anticipate being involved in any merger,
acquisitions or consolidation with another entity?
Yes
No
If yes, please attach details.
EMPLOYMENT PRACTICE LIABILITY INFORMATION:
1.
Please provide the following employee count information:
U.S. based employees:
Total Full-Time:
Total Part-Time:
Volunteers:
Temporary:
Leased:
Total Non U.S. based employees:
TOTAL SUM OF ABOVE:
2.
Has a reduction in employees or change in of status occurred in the past 12 months or is anticipated
in the next 12 months?
Voluntary:
Involuntary:
Layoffs:
3.
Does the Applicant have an employment handbook that includes an “At Will” statement?
Yes
No
4.
Does the Applicant use an employment application for every potential employee?
Yes
No
5.
Does the Applicant use outside employment counsel for employment advice?
Yes
No
6.
Does the Applicant have a full time, dedicated human resource staff?
Yes
No
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7.
Total number of current employees with annual compensation greater than $100,000:
CURRENT COVERAGE:
COVERAGES
Insurance Company
Limit of
Liability
Deductible
Policy Effective
Dates
Premium
D & O
$
$
$
EPLI
$
$
$
Fiduciary
$
$
$
Workplace Violence
$
$
$
Internet Liability
$
$
$
WARRANTY INFORMATION:
1.
With respect to this coverage, has any Underwriter refused, canceled or non-renewed coverage? (Not
Applicable in Missouri)
Yes
No
If yes, please provide details:
2.
Has the Applicant given written notice under the provisions of any prior policies providing similar
insurance or claims, or of specific facts or circumstances which might give rise to a claim being made
against any person or entity applying for this insurance?
If yes, complete a Claim Supplemental for each incident.
Yes
No
3.
No person applying for this coverage is aware of any facts or circumstances which he or she has
reason to suppose might give rise to a future claim that would fall within the scope of any of the
proposed coverages for which the Applicant has applied, except: None or as noted below.
With regard to questions 2. and 3., it is understood and agreed that if any such claim, act, error, omission, dispute
or circumstance exists, then such claim and/or claims arising from such act, error, omission, dispute or
circumstan
ce is excluded from coverage that may be provided under this proposed insurance and, further, failure
to disclose such claim, act, error, omission, dispute or circumstance may result in the proposed insurance being
void, and/or subject to rescission.
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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 TO BE COMPLET
ED 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)
Head Start Supplemental Application
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.
CYBER SECURITY LIABILITY ENDORSEMENT – SUPPLEMENTAL
QUESTIONNAIRE
Name of Applicant:
Address of Applicant:
City: State: Zip:
Website: www:
Nature of Operations:
1. Annual sales or revenue: $
2. Does the Applicant collect, store or otherwise handle any Personally Identifiable Information (PII)
belonging to customers, clients, or other third parties, other than employees?
If yes, please indicate the types of Personally Identifiable Information held (check all that apply):
Yes No
a. Social Security Numbers, Bank or Other Financial Account Details, Driver’s License or
other State Identification Numbers
b. Non-public Medical or Healthcare Data, including Protected Health Information (PHI)
c. Credit or Debit Card Information
3. a. During the last three (3) years, has anyone alleged that the Applicant was responsible for
damage to their computer system(s) arising out of the operation of the Applicant’s computer
system(s)?
Yes No
b. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a
lawsuit against the Applicant alleging invasion or interference of rights of p
rivacy or the
inappropriate d
isclosure of Personally Identifiable Information (PII)?
Yes No
c. During the last three (3) years, has the Applicant been the subject of an investigation or
action by any regulatory or administrative agency for privacy-related violations?
Yes No
d. Is the Applicant aware of any circumstance that could reasonably be anticipated to result in a
claim being made against them for the coverage being applied for?
Yes No
PI-CYBE-APP (11/16)
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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
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, 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 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 TO BE COMPLETED BY THE PRODUCER/BROKER/AGENT
PRODUCER AGENCY
(If this is a Florida Risk, Producer means Flor
ida Licensed Agent)
PRODUCER LICENSE NUMBER
(If this a Florida Risk, Producer means Florida Licensed Agent)
ADDRESS (STREET, CITY, STATE, ZIP)
PI-CYBE-APP (11/16)
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Application - Head Start36-9275

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Completed 2 July 2020

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