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RELIGIOUS ORGANIZATION SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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RELIGIOUS ORGANIZATION SUPPLEMENTAL APPLICATION
Pages 1 - 4 must be completed on all submissions.
1.
If Applicant owns or provides Child Care services complete page 5
2.
If Applicant owns or operates a Camp, complete page 6.
3.
If Applicant operates a School, complete page 7.
4.
If Applicant sponsors Fund Raising Events, complete page 8.
5.
If Applicant has Security Guards, complete pages 8 & 9.
6.
If Applicant has any Contracting Operations, complete pages 9 & 10.
7.
If Applicant has any building > 100 years old, valued > $500,000 complete pages 11 & 12 for each building.
SUBMISSION REQUIREMENTS
•
ACORD Applications, including Crime (2000) and Umbrella
•
Statement of values if blanket or agreed value on property
•
Currently valued insurance company loss runs for the current policy period plus (3) prior years
•
Photograph of house of worship (front and rear)
•
If the Applicant has more than 10 drivers, MVR’s for each
•
Latest audited financials or latest approved financial budget
Applicant Name:
Specific Denomination:
Number of Members / Parishioners:
Mailing Address:
State:
Zip:
501(c)3?
Yes
No
Website Address:
Risk Management Contact:
Cell Phone:
E-Mail:
SECTION I - LIFE SAFETY
Does all of the Applicant’s facilities (buildings) have the following life safety features:
(Indicate any locations which do not have the following features.)
1.
Fire alarms?
Yes
No
2.
Smoke detectors
Yes
No
Hard Wired
Battery Operated
3.
Emergency lighting?
Yes
No
4.
Sprinklers?
Yes
No
5.
Are evacuation routes posted throughout the building?
Yes
No
6.
Does the Applicant have minimal of 2 means of egress per building?
Yes
No
SECTION II - PROPERTY
1. Are any of the buildings used for something other than what they originally built for? Yes No
If yes, list locations and describe renovation work:
2. Are any of the Applicant’s buildings on a historical register? Yes No
If yes, please list locations and provide an appraisal:
3. Is there is cooking on premises? Yes No
Describe exposure and protections:
4. 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 which one: COPALUM: Yes No Alumiconn: Yes No
Date updated:
Please supply retrofit documentation or statement from installing contractor.
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SECTION III - INLAND MARINE
1.
Any buildings with stained glass?
Yes
No
If yes, value of stained glass: $
Is stained glass included in the building limits provided?
Yes
No
2. Attach a description and value of any religious artifacts or artwork (including stained glass) located
inside or outside of premises. Include any appraisals (required if >$5,000 per item).
3.
Is there an organ or other musical instrument?
Yes
No
Value and description: $
SECTION IV - GENERAL LIABILITY
1.
Is a nursery available during scheduled house of worship activities?
Yes
No
Number of days per week nursery is provided:
Average number of children in nursery each week:
Nursery is staffed by:
Employees
Volunteers
2.
Is a youth group program offered?
Yes
No
Age range of children:
Number in attendance each week:
Youth group is run by:
Lay pastors
House of worship members
Other volunteers
List of activities:
3.
Does the Applicant operate any shelters?
Yes
No
If yes, indicate location number and number of beds for each:
Is the shelter manned by wake staff or volunteers:
What are the hours that the shelter is open:
4.
List all community services provided by the Applicant’s organization:
5.
Does the Applicant lease any of the house of worship’s premises to members or the general
public?
Yes
No
6.
Does the lease contain an indemnification clause and hold harmless agreement in favor
of the house of worship?
Yes
No
7.
Does the Applicant obtain a certificate of insurance for the lessee’s Commercial General Liability
policy?
Yes
No
8.
a.
Does the Applicant have any foreign travel exposure within the next 12 months?
Yes
No
b.
Does the Applicant have a Foreign Liability policy in place?
Yes
No
c.
Does the Applicant obtain signed liability waivers from all participants?
Yes
No
d.
Advise:
Country:
Length of stay:
Number of Patrons attending:
e.
Describe activities that will occur:
9.
Does the house of worship sponsor any athletic leagues?
Yes
No
a.
Sport(s) played:
Number of participants:
Age of participants:
b.
Does the Applicant require all participants or guardians (if minors involved) to sign a waiver of
liability prior to participating?
Yes
No
c.
Does the Applicant require evidence of participant’s personal liability insurance?
Yes
No
d.
Does the Applicant obtain an Accident and Health policy?
Yes
No
If yes, what limit: $
10.
Does the Applicant now use or plan, in the future, to use swimming facilities?
Yes
No
a.
Is the pool:
Owned / operated by the Applicant, or
Operated by other than the Applicant
b.
Is a minimum of one staff member certified in CPR present at swimming areas?
Yes
No
c.
Are lifeguards present?
Yes
No
d.
Are water depths marked?
Yes
No
e.
Is the pool completely fenced?
Yes
No
f.
Is there a self-locking gate?
Yes
No
g.
Is there a diving board
Yes
No
h.
Is there a slide into the pool?
Yes
No
11.
Are all swimming pools and spas compliant with Virginia Graeme Baker Pool and Spa Safety Act?
Yes
No
If no, provide time table and action plan:
12.
Ratio of staff to child when at pools:
13.
Does the Applicant own or have access to a playground area?
Yes
No
a.
Is the area fenced?
b.
Are trampolines present?
Yes
No
c.
Describe playground equipment and surfaces:
No
Yes
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SECTION V - PROFESSIONAL LIABILITY
1.
Does the Applicant’s current insurance program provide Professional Liability coverage?
Yes
No
If yes, indicate the limit of liability: $
2.
Is Professional Liability:
Occurrence
Claims Made
Retroactive Date:
Position
# of Full
Time
# of Part
Time
Position
# of Full
Time
# of Part
Time
Administrators
Clerical
Clergy, Rabbis, Pastor, etc.
Teachers
Counselors
Camp Counselors
Nurses
Other:
Volunteers
3.
What type of counseling is performed by the insured’s clergy, rabbis, pastor, etc.:
Alcohol
Marriage
Religious
Drugs
Pregnancy
Other:
4.
Have all clergy, rabbis, pastor, etc. completed their degree at an accredited theological seminary?
Yes
No
If no, describe training clergy, rabbis, pastor, etc. underwent:
5.
Does the Applicant verify license, education and other credentials for all counselors?
Yes
No
6.
Is the house of worship or clergy, rabbis, pastor, etc. aware of any act, error, omission, fact,
circumstance or situation that might afford valid grounds for a future claim, suit, or action under
professional liability? If yes, please describe:
Yes
No
7.
Does the Applicant use contracted counselors?
Yes
No
8.
Are certificates of malpractice liability insurance obtained and maintained for all contracted
counselors and health care providers?
Yes
No
If yes, indicate the limits of liability:
9.
Is the staff required to report all incidences that may result in a claim?
Yes
No
If yes, is a written record kept?
Yes
No
10.
Are procedures in place to protect confidentiality of clients?
Yes
No
SECTION VI - CRIME
1.
Does the Applicant have poor boxes on premises?
Yes
No
If yes, how often are they emptied:
2.
Are there any seasonal needs for increased money and securities limits?
Yes
No
Dates:
Limit needed:
3.
Is the sanctuary or any other house of worship building left unlocked when no staff is present?
Yes
No
4.
If volunteers are used to count / handle donations, please provide number used and screening required of same.
1. Does the Applicant require employees and volunteers to carry and show evidence of personal auto
insurance? Yes No
2. Describe use of non-company v
ehicles:
3. Does the Applicant provide transportation services? Yes No
4. Yes No Does the Applicant have a formal driving policy in place with MVR standards?
If yes,
a. Is driving policy communicated in writing to all employees? Yes No
b. Yes No Is a signed acknowledgement form kept on file?
If yes, please provide a copy of signed acknowledgement.
c. Do driving standards include the following:
Yes No
Yes No
No major violations including DUI, racing, hit and run, speeding in excess of 20 mph over
posted speed limit, manslaughter?
No more than 2 moving violations within past 3 years?
No more than 1 at fault accident within past 3 years?
Yes No
SECTION VII - AUTOMOBILE
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5.
How often does the Applicant check MVR reports?
6.
Describe any ongoing training provided to drivers:
7.
What is the procedure for dealing with driver accidents or violations?
8.
How often are Applicant’s vehicles inspected:
Daily
Weekly
Monthly
Other:
9.
Estimated yearly mileage:
10.
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:
11.
What percentage of the Applicant’s fleet is provided with these fleet telematics devices? %
SECTION VIII - ABUSE AND MOLESTATION
1.
Does the Applicant’s employment process (for employees, contractors, and volunteers) include
verification of whether the individual has ever been convicted of any crime, including sex-related or
child abuse offenses before an offer is made?
Yes
No
2.
Does the Applicant utilize an application for volunteers?
Yes
No
If yes, does it include questions about whether the individual has ever been convicted of any
felony, including sex-related and / or child abuse related offenses?
Yes
No
If no, completely describe the Applicant’s screening process and guidelines applicable to
volunteers:
3.
Does the Applicant conduct criminal background and reference checks for all employees?
Yes
No
If no, please explain:
4.
Does the Applicant conduct criminal background and reference checks for all volunteers?
Yes
No
If no, please explain:
5.
Does the Applicant conduct criminal background and reference checks on all independent
contractors who interact or have access to children?
Yes
No
If no, please explain:
6.
Is there a new employee and volunteer orientation program that includes training in abuse
awareness?
Yes
No
7.
Does the Applicant require that no minor is ever alone with only one adult in any house of worship
sponsored activity except in a counseling situation?
Yes
No
8.
Describe any closed door counseling provided to individual clients:
9.
Are parents encouraged to visit the premises unannounced and observe children’s activities?
Yes
No
10.
Are any minors in the Applicant’s care overnight?
Yes
No
11.
Have any of the Applicant’s past or present ministers, employees, or volunteers ever been
accused, charged, convicted, had a claim for damages submitted against, or sued in civil court for
any type of sexual misconduct?
Yes
No
If yes, identify the person and submit a detailed written account.
12.
Has the Applicant’s organization ever had an incident which resulted in an allegation of sexual
abuse? If yes, please describe:
Yes
No
a.
Was a claim made against the organization?
Yes
No
If yes, please describe:
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b.
Was a claim made against any employee(s)?
Yes
No
If yes, please describe:
c.
Was the case settled?
Yes
No
If yes, please explain:
13.
Does the Applicant’s current insurance program provide Abuse and Molestation coverage?
Yes
No
14.
Indicate current Abuse and Molestation limit of liability:
Is coverage provided by:
Occurrence
Claims Made
If claims made, retroactive date:
Attach a copy of your abuse procedure guidelines and applications used for employees and volunteers.
SECTION IX - CHILD CARE N/A
STAFF AND CHILDREN: (The ratios of staff-to-children must be at least the state required ratio)
1.
Based on the maximum number of children enrolled on the Applicant’s busiest day OR busiest session, enter the
number of staff and children in each of the following age groups. (Do not duplicate before and after school children if
they stay all day).
2.
Is anyone on staff under 18 years old?
Yes
No
3.
Is a minimum of one staff member certified in first aid present at all times?
Yes
No
4.
Does the Applicant’s center exit directly to the outside?
Yes
No
To ground level?
Yes
No
5.
Do the bathroom doors lock?
Yes
No
Can they be unlocked from the outside?
Yes
No
6.
How often are evacuation drills performed?
7.
Please describe the Applicant’s child release procedures:
8.
OPTIONAL : If male staff, provide details of
a. Length of employment:
b. Any one-on-one activities?
Yes
No
c. Duties performed, including age groups:
HEALTH:
1.
Does the Applicant provide sick child, drop-in, latch-key, boarding or camp services?
Yes
No
If yes, please explain:
2.
How many children require special care and treatment:
Please explain what special care and treatment is provided:
3.
Indicate if a file containing the following information is maintained on each child:
a.
Immunization records of the children being immunized successfully and updated annually?
Yes
No
b.
Signed releases for emergency medical treatment / dispensing of medication obtained from
parents?
Yes
No
c.
Written instructions from child’s physician for dispensing of child’s medication?
Yes
No
4.
Does the Applicant have an Accident and Health policy?
Yes
No
Is coverage mandatory for all children?
Yes
No
Provide Carrier:
Limits:
Policy Term:
AGE GROUP # OF CHILDREN AVERAGE DAILY ATTENDANCE # OF TEACHERS
Infants, ages 0 – 1
Toddlers, ages 1 – 2
Toddlers, ages 2 – 3
Preschoolers, ages 3 – 5
School Age Children
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SPECIAL ACTIVITIES:
1.
Are any pets or animals kept on premises?
Yes
No
If yes, describe animals, caging and type of interaction:
2.
Are special classes provided (gymnastics, dance, karate, tumbling, horseback riding, etc.)?
Yes
No
If yes, please explain:
3.
Classes taught by independent contractors are taught:
on premise
off premises
4.
Does the Applicant request / maintain Certificates of Insurance from all sub-contractors?
Yes
No
5.
Are waivers obtained from all parents?
Yes
No
6.
Does the Applicant offer field trips?
Yes
No
If yes, answer the following:
a.
What is the adult / child ratio on trips?
b.
What is minimum age of child?
c.
Describe field trips:
SECTION X – CAMPS N/A
1.
Is camp owned by insured?
Yes No
If no, is a certificate of insurance required from owner?
Yes No
2.
Is camp accredited by ACA?
Yes No
3.
Is camp accredited by CCI?
Yes No
4.
If no to questions #2 & #3 above, please explain:
5.
Total number of days in operation annually:
6.
Number of children at each camp
Day Camp:
Overnight Camp:
If overnight, what is the average length of stay:
7.
Is written permission / waiver of liability obtained from every child’s parent or guardian?
Yes
No
8.
Does the Applicant carry an Accident and Health policy?
Yes No
9.
What is the number of staff members at each camp?
10.
Number of volunteers:
11.
Are sleeping quarters co-ed?
Yes No
12.
Is the staff trained and certified in CPR?
Yes No
13.
Are restrooms / showers co-ed?
Yes No
14.
Indicate and describe if any of the following exposures exist in the camp operations:
Circus Activities
Pools
Diving Boards
Rock Climbing
Downhill Skiing
Rope Courses
Fireworks
Skateboarding
Guns
Skin or Scuba Diving
Gymnastics
Snowmobiling
Horses
Snow Tubing
Ice Hockey
Tobogganing
Jet Skis
Trampolines
Lakes
Water Skiing
Martial Arts
Water Tubing
Motor Boats
White Water Rafting
Obstacle Course
Grade of rapids:
Paint Ball
Use the below space to describe any activities not addressed above:
15.
Does the camp have a written safety plan for all applicable checked / listed activities above?
Yes No
If yes, please attach a copy for all applicable activities.
16.
Are there any certified medical personnel (Doctors or Nurses) on premises during camp?
Yes No
If yes, how many: Doctors: Nurses: Other:
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If yes, do all certified medical personnel have their own professional liability insurance with
minimum limit of $500,000? If no, please explain medical procedures:
Yes
No
17.
What percent of campers have special needs? %
18.
List the campers’ types of disabilities:
SECTION XI – SCHOOLS N/A
GENERAL INFORMATION:
1.
Type of school:
Private School - Elementary
# of students:
# of teachers:
Private School - Secondary
# of students:
# of teachers:
College / University
# of students:
# of teachers:
2.
Date school was founded or chartered:
3.
Describe security measures on campus:
CORPORAL PUNISHMENT:
1.
Does the Applicant’s school permit corporal punishment?
Yes No
2.
Is there a written policy concerning the use of corporal punishment?
Yes No
3.
Have there ever been any claims for corporal punishment?
Yes No
4.
Does the Applicant’s state permit corporal punishment?
Yes No
DORMITORIES:
1.
How many dormitory buildings are owned by the Applicant’s institution:
2.
What is the maximum number of stories:
3.
Are the dormitories sprinklered in all areas?
Yes No
4.
Is each room equipped with hard-wired smoke detectors?
Yes No
5.
Check any of the following that are allowed in dorm rooms:
Incense Burners
Space Heaters
Hot Plates
Candles
Toasters or Toaster Ovens
Smoking
6.
How many means of egress does each building have:
7.
Are there emergency procedures in place including evacuation?
Yes No
8.
Are there scheduled fire drills and regular testing of fire alarms?
Yes No
9.
Is emergency lighting provided in stairwells and hallways?
Yes No
ATHLETICS:
1.
Does the school obtain a signed release which includes a hold harmless agreement from the
parents / guardians of all participants?
Yes No
2.
Are instructors / coaches trained in physical education?
Yes No
3.
Are medical exams required for all participants in extra-curricular sports?
Yes No
4.
Is someone who is trained in first aid always present during practices or games?
Yes No
5.
Is Student Accident Insurance carried?
Yes No
If yes, what limit is carried: $
If no, is evidence of personal medical insurance for each participant obtained?
Yes No
6.
Does the Applicant have any bleachers or grandstands on the premises?
Yes No
Indoor
Outdoor
Yes No
What is the age of the bleachers / grandstands:
How many bleachers / grandstands are on the property:
7.
Please check all sports played and indicate whether they are interscholastic (O) or Intramural (I):
Sport:
O
I
Sport:
O
I
Sport:
O
I
Archery
Football
Soccer
Baseball
Golf
Softball
Basketball
Gymnastics
Swimming
Bungee Jumping
Ice Hockey
Tennis
Cheerleading
La Crosse
Trampoline
Climbing (Mountain, Rock or Wall)
Polo
Volleyball
Cross Country Track
Rugby
Water Skiing
Diving
Scuba Diving
Wrestling
Equestrian
Snow Skiing
Other:
Field Hockey
Sky Diving
Other:
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SECTION XII - FUND RAISING N/A
1.
Does the Applicant operate or sponsor any events that involve the following exposures? Check all that apply.
Parades
Carnivals and Fairs with Mechanical Rides
Aircraft
Bounce Houses
Motorcycle Runs and Automobile Rallies
Rock, Hip-Hop or Rap Concerts
Fireworks
Events including Contact Sports
Firearms
Rodeos
Animals
Political Rallies
2.
Does the Applicant have any event lasting more than 5 days?
Yes No
3.
Does the Applicant have any event with greater than 500 people at any one time?
Yes No
4.
Does the Applicant have any event with liquor provided or served by the Insured if a license is
required for such activity or a charge is made?
Yes No
If you checked any events or answered “Yes” to questions 1 – 4 we will evaluate the exposure(s) to see if event(s)
coverage can be extended in conjunction with the package policy. Please provide details below for each.
1.
Description of Event(s):
2.
Date(s):
3.
Time:
4.
Number of participants:
5.
Revenue generated: $
6.
Number of volunteers:
7.
Does the Applicant operate or sponsor any event with a swimming exposure?
Yes No
If yes
Are lifeguards on duty?
Yes No
Are they hired by the Applicant at the place event is being held?
Yes No
Are they lifeguard certified?
Yes No
Are they C.P.R. trained?
Yes No
Are certificates received by the Applicant?
Yes No
8.
Does the Applicant operate or sponsor any event where alcohol being served?
Yes No
If yes
Are bartenders hired by the Applicant at the place event is being held?
Yes No
Are they trained in T.I.P.P.S.?
Yes No
How is the drinking limited? Example: Are tickets given out?
Certificate received by the Applicant?
Yes No
9.
Does the Applicant operate or sponsor any event were a sporting activity is being held?
Yes No
If yes
Which sport(s):
Are participants required to sign a waiver?
Yes No
Do participants have to show proof of personal health insurance (participants are currently
excluded under standard CGL)?
Yes No
Are safeguards in place to prevent injury to spectators?
Yes No
SECTION XIII - SECURITY N/A
1.
Describe the nature of security services provided:
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2.
Provide the number of each type of guard, estimated weekly hours utilized, annual payroll, functions and if armed.
Type
Number
Hours
Worked Per
Week
Annual
Payroll
Armed?
Weapon Type?
Functions Performing
Employees
$
Volunteers
$
Off-Duty Police
$
Sub-contractors
$
Other
$
3.
Does the Applicant have a written security handbook?
Yes No
If yes, provide copy of same.
4.
Does the Applicant have a formal training program?
Yes No
If yes, does it outline expectations for use of weapons?
Yes No
Does security have authority to detain, search and / or arrest?
Yes No
If yes, please describe:
5.
Are notices for the public clearly posted including notices in languages appropriate for the
neighborhoods?
Yes No
6.
Are criminal background checks required for all security personnel?
Yes No
If no, describe circumstances that they are not required:
7.
If security is armed with lethal weapons, are current licenses / permits reviewed by the Applicant?
Yes No
Are copies of same kept on file at the Applicant’s premises?
Yes No
8.
Are any firearms stored on the Applicant’s premises?
Yes No
If yes, is storage locked?
Yes No
Are trigger locks on?
Yes No
Is ammunition in a separate locked location from the weapon?
Yes No
9.
If sub-contractors are utilized, is a certificate of insurance provided?
Yes No
What is the limit of Insurance: $
Is the Applicant named as an additional insured on the sub-contractor’s policy?
Yes No
10.
If off-duty police officers, are their superiors made aware of their moonlighting services?
Yes No
Attach copy of written contract insured has with any security personnel.
SECTION XIV - CONTRACTING OPERATIONS N/A
1.
Does the Applicant directly undertake any construction projects charitable or otherwise for any third
parties? If yes, explain scope and purpose:
Yes No
2.
Does the Applicant perform any construction-type activities besides routine maintenance on any of
its owned properties? This can include, but is not limited to, roof repairs, interior renovations,
siding replacement, etc. If yes, please list:
Yes No
3.
Is the person who is responsible for supervising the construction project knowledgeable, qualified,
experienced, certified, and licensed in the trade necessary to complete the project correctly?
Yes No
If yes, please explain:
4.
Is this individual an employee, volunteer, or hired contractor? If yes, please explain:
Yes No
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5.
If they are a hired contractor, are they providing a certificate of insurance showing a minimum of
$1,000,000 General Liability and Products Completed Operations coverage with an A.M Best A-
rated or better carrier and naming your entity as an additional insured?
Yes No
6.
Are professional drawings and plans produced and approved?
Yes No
Is an architect being consulted or hired before a construction project begins?
Yes No
Are they providing a certificate of insurance naming your entity as an additional insured?
Yes No
If yes to any of the above, please advise:
7.
Are all required permits obtained before construction, and inspections obtained after construction is
complete? If yes, please explain:
Yes No
8.
Who takes part in the construction: Employees Volunteers
Are they all above the age of 18? If yes, please explain:
Yes No
9.
Do volunteers sign and understand waivers?
Yes No
10.
Does the Applicant have an Accident and Health policy to cover volunteers for medical payments?
Yes No
11.
Is any training provided?
Yes No
If yes, who conducts training and what are their qualifications:
12.
Is the Applicant providing equipment and tools for the project or are volunteers using their own
equipment:
13.
How are construction debris and other by-products disposed of:
14.
Has prior written consent been obtained from the property owner receiving completed work?
Yes No
Is the recipient of completed work signing a hold harmless agreement releasing the insured, your
entity, from all liability associated with the completed project? If yes, please explain:
Yes No
15.
Are there jobsite rules and procedures in place?
Yes No
Is there an emergency procedure plan in place?
Yes No
Is there a first aid kit and means to contact immediate emergency medical assistance?
Yes No
Please explain:
16.
Who provides transportation for workers and / or volunteers:
Are MVRs run on anyone operating a church vehicle? Please explain:
Yes No
17.
Is there any operating of construction vehicles / equipment like bulldozers, wrecking balls, etc.?
Yes No
If yes, by whom and what is their experience and qualification in operating this type of equipment:
18.
Please give the full address where any new construction will be added:
19.
Inspector name and contact information:
20.
Policy term of Builders Risk policy:
to
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21.
Limit of insurance
at the project site:
in temporary storage:
while in transit:
Extra Expense:
Loss of Rents:
Flood limit:
Earthquake limit:
23.
Contractor name, address, and website:
24.
How many stories:
25.
What is the construction type:
26.
Total square feet:
27.
Is construction: lift slab tilt-up prototype
28.
Is project on filled land?
Yes No
If yes, are pilings used?
Yes No
29.
Will project be:
fenced?
Yes No
lighted?
Yes No
locked?
Yes No
watchman on premises?
Yes No
SECTION XV - 100 YEAR OLD BUILDINGS – RELIGIOUS ORGANIZATIONS N/A
1.
Location Address:
2.
What is the average number of attendees during the main weekly service:
3.
What is the annual budget for building maintenance and upkeep: $
4.
What is the funding source for building maintenance and upkeep:
5.
Does the Applicant have a full-time maintenance staff?
Yes No
If yes, number of employees:
If no, who performs the routine daily, weekly, and monthly maintenance:
6.
What building and grounds maintenance duties are performed by Applicant’s staff:
7.
What building and grounds maintenance duties does Applicant hire a specialist for (i.e. roofing,
plumbing):
BUILDING INFORMATION
1.
Location address of building 100 years old:
2.
Occupancy of building:
3.
Age of original structure and age(s) for additions built if applicable:
4.
Construction type of original structure and construction type(s) for additions built if applicable:
STRUCTURAL INFORMATION
ROOF
1.
Age of roof:
2.
Date of last update:
3.
Detailed description of update(s):
4.
Type of roof (check all that apply)
Asphalt Shingle
%
Flat/Membrane
%
Wood Shingle
%
Slate Shingle
%
Spanish Tile
%
Concrete
%
Metal
%
Other (specify):
%
5.
What is the name of the Applicant’s roofing contractor company:
6.
When was the last roof inspection conducted:
7.
How often is the roof inspected:
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FOUNDATION
1.
Type of foundation:
Wood
Brick
Masonry
Concrete
Other (specify):
2.
If brick or masonry, has the foundation been repointed within the last 50 years?
Yes No
3.
If wood, when was the last termite inspection done:
Was damage found?
Yes No
Describe the repairs:
4.
Is there history of water infiltration through foundation? If yes, describe:
Yes No
5.
Is there vertical or diagonal cracking in the foundation? If yes, describe:
Yes No
6.
Does the foundation wall bulge or bow?
Yes No
If yes, describe:
7.
Has the foundation been inspected by a structural engineer in the last 15 years?
Yes No
If yes, any corrective action needed and performed: (describe)
LOAD-BEARING EXTERIOR WALLS
1.
Year of update:
2.
Detailed description of update(s):
3.
Are the walls leaning, bowing, bulging in any area(s)?
Yes No
If yes, describe:
4.
Are cracks evident on exterior wall?
Yes No
If yes, describe:
5.
Are exterior doors or window openings out of square?
Yes No
If yes, describe:
6.
Have there been any prior structural failures at this location (i.e. collapse)?
Yes No
If yes, describe:
SYSTEMS INFORMATION
ELECTRICAL
1.
Year updated:
2.
Detailed description of updates:
3.
Any knob and tube wiring present?
Yes No
If yes, describe location(s) within the building with same:
4.
Any aluminum wiring present?
Yes No
If yes, describe location(s) within the building with same:
5.
Have you had 3
rd
party thermographic testing done?
Yes No
If yes, by whom and when?
If yes, forward a copy of the testing results with this application.
PLUMBING
1. Age of plumbing system:
2. Type: Copper Pipes % % Brass Pipes
% Plastic Piping
% Galvanized Pipes
% PVC % Mixed (Copper, Brass, Galvanized)
Other: % (specify):
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3.
Year updated:
4.
Detailed description of updates:
5.
Is all plumbing intact and supported?
Yes No
6.
Are there any active leaks? If yes, describe:
Yes No
7.
Does the Applicant have a licensed plumber on file?
Yes No
8.
Is the building equipped with an automatic interior climate control system keeping temperature
within 55°- 85°?
Yes No
If yes, how often is it tested:
If yes, does it protect the entire building?
Yes No
Describe what areas if it is not the entire building.
If no, what other controls are in place to keep pipes above freezing and temperature in the building
regulated (insulated pipes, heat wraps, etc.):
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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 review?
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:
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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
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)
Religious Organization
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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 again
st the Applicant
alleging invasion or interference of rights of privacy or the
inappropriate disclosure 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)
Page 1 of 2
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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.
NAM
E (PLEASE PRINT/TYPE) TITLE
(MUST BE SIGNED BY THE PRESIDENT, CHAIRMAN, CEO OR EXECUTIVE
DIRECTOR)
____________________________________________________
SIGNATURE DATE
SECT
ION TO BE COMPLETED BY THE P
RODUCER/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)
PI-CYBE-APP (11/16)
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RELIGIOUS ORGANIZATION SUPPLEMENTAL APPLICATION (Philadelphia Insurance Companies)

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