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RELIGIOUS INSTITUTIONS SUPPLEMENT
Applicant's Name:
Mailing Address:
City  State     Zip
Phone:      Fax: 		PROPOSED EFFECTIVE DATE:
From     To

Email:
GENERAL INFORMATION
  1. Does the applicant operate a cemetery?   Yes   No
      If yes, number of acres
  2. Is there playground equipment on the premises?   Yes   No
 
If yes, list/describe equipment
  3. If yes, is there a playground equipment maintenance program?   Yes   No
  4. Square Feet of Buildings:
  5. How many members?
 
PASTORAL LIABILITY
  1. Is the clergy licensed and/or ordained?  Yes   No
  2. Does the clergy perform counseling functions?   Yes   No
  3. Has the clergy received formal training in counseling?   Yes   No
  4. Does the applicant advertise counseling to non-congregation members? Yes   No
  5. Is a fee required for counseling?Yes   No
  6. If other than spiritual counseling is offered, do you have a separate
      professional liability policy?Yes   No
      If yes, carrier:   policy number:
  7. Any past or pending claims against your professional liability coverage?Yes   No
SEXUAL MISCONDUCT 
  1. Do you have a formal screening program of volunteer and compensated
      applicants in place?
 
      If yes, please describe:
 
Yes   No
  2. Must all persons in positions involving the supervision or custody of minors
     be members of the religious institution for a minimum of at least six months?
Yes   No
  3. Are there at least two adults sharing the supervisory responsibilities of the
      children at all times?
Yes   No
  4. Any past or pending claims relating to any form of sexual misconduct?
Yes   No

  5. Indicate optional limits if desired:

      $  100,000 each claim/$   200,000 aggregate
      $  300,000 each claim/$   600,000 aggregate
      $  500,000 each claim/$1,000,000 aggregate
      $1,000,000 each claim/$2,000,000 aggregate
      $2,000,000 each claim/$4,000,000 aggregate

  BUILDING & CONTENTS
  How much coverage is needed?

 DIRECTORS AND OFFICERS LIABILITY COVERAGE
 THIS IS A CLAIMS-MADE COVERAGE.

 COMMERCIAL AUTOMOBILE COVERAGE
 Coverage may be available for cars, vans and buses owned by the institution.

 INCREASED MONEY & SECURITIES COVERAGE
 Coverage for money and securities will automatically double for the period beginning four days preceding Easter,  Thanksgiving, Christmas and one day of choice, and ending four days after these special days.

 Indicate your day of choice:

SPECIAL ACTIVITIES/SERVICES 
Do you operate or sponsor any of the following?
  1. Abbeys, convents, monasteries, seminaries?
Yes   No
  2. Buildings or premises used for commercial purposes?
Yes   No
  3. College or university?
Yes   No
  4. Convalescent homes?
Yes   No
  5. Crisis center (i.e. alcohol, drug, pregnancy)?
Yes   No
  6. Missions?
Yes   No
  7. Nursing homes?
Yes   No
  8. Orphanages?
Yes   No
  9. Residential properties other than clergy house of residence?
Yes   No
10. Retirement homes?
Yes   No
11. Shelters?
Yes   No
12. Soup kitchens?
Yes   No
13. Vacant or unoccupied buildings?
Yes   No
CHILD CARE FACILITIES 
  1. Do you operate any of the following:
 
      a. Before/after school program? *
Yes*   No
      b. Day care? *
Yes*   No
      c. Kindergarten? *
Yes*   No
 2. Do you have a day care as a tenant?
Yes      No
 

 Person Completing Application    Date
 Owner or Officer of Corporation    Title

* If answer to these questions (Child Care Facilities #1. a-c) are "Yes", DO NOT "Send" yet. . .
please complete the CHILD CARE QUESTIONNAIRE below first.

 

 
CHILD CARE QUESTIONNAIRE
TENANT OPERATED
What is the square footage of the day care?  
RELIGIOUS INSTITUTION OPERATED
1. Hours of operation am/pm  TO am/pm
2. Are records kept on all injuries?
Yes   No
3. Is a physical exam or medical certificate required for each child?
Yes   No
4. Is there a written drop-off and pick-up procedure?
Yes   No
5. Are parents free to visit facility at any time?
Yes   No
6. Is corporal punishment practiced?
 
    If yes, explain
Yes   No
7. Specify the applicable number for each age group:
 
 
# Children
# Adults
Infants
Toddlers
3-4
5-6
Kindergarden
8. Are staff members trained in first aid including cardiopulmonary resuscitation?
Yes   No
9. Do you care for children who are physically or emotionally impaired?
Yes   No
10. Are field trips conducted?
 
     If yes, describe the nature and mode of
     transportation:
 
Yes   No
PREMISES
 
1. On what floor level is the day care located?
     B     1     2     Other
 
2. Is there a written evacuation procedure?
Yes   No
3. Are there regular fire drills?
Yes   No
PLAYGROUND 
1. Does the playground have a physical restraint boundary?
 
    If yes, describe:
 
Yes   No
DAY CARE LICENSE 
1. Is the day care currently licensed?
Yes   No
2. Has the license ever been revoked?
Yes   No
EMPLOYEES 
1. Describe the educational background of the Director:  
2. Do hiring practices include:
     completed application?
Yes   No
     pre-employment physical?
Yes   No
     contact personal references?
Yes   No
     tuberculosis test?
Yes   No
     police background check?
Yes   No
3. Do employees dispense medicine?
     If yes, are prescription labels or instructions from medical personnel required?
Yes   No
 Yes   No

 

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