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24. What other services, such as beauty, podiatry or dental, are provided either by staff or by independent
contractors? Provide details.
25. Do you require certificates of insurance from all contracted professionals (not employees)?
Yes No
What limits do you require?
26. Is applicant, or any other persons for whom insurance is being requested, aware
Yes No
of any circumstances which may result in a claim? If yes, please provide full details.
27. Has applicant, or any other person for whom coverage is being requested, had any
Yes No
liability application denied, policy canceled or policy not renewed in the past three (3)
years? If yes, please provide full details.
IF SEXUAL MOLESTATION COVERAGE IS DESIRED, PLEASE COMPLETE QUESTIONS 28 THROUGH 32.
If not desired, please sign application at bottom of page.
28. Have you or any employee, volunteer or other person working for you, ever been
Yes No
arrested or convicted of a crime? If yes, please provide details.
29. Has your facility had any incidents or claims brought against it for sexual molestation
Yes No
or any other allegation of misconduct? If yes, please provide details.
30. Has any facility that you have been associated with in the past ever had any incidents
Yes No
occur or claims brought against it while you were there? If yes, please describe.
31. Does your facility do background checks on all employees and volunteers?
Yes No
Describe types of checks done (prior employer, police, etc.)
32. Sexual Molestation sublimit wanted:
$25,000/50,000 $50,000/100,000 $100,000/300,000 $300,000/300,000
Notice to applicants: In most states, any person who knowingly, with intent to defraud, files an application for
insurance containing any materially false information or who, for the purpose of misleading, conceals information
concerning any fact material hereto, commits a fraudulent act, which is a crime.
Applicant’s Signature:
(A quote will not be provided without an applicant’s signature.)
Title:
Date:
Producing Agent:
