General Insurance Application

Our Address

750 Terrado Plaza, Suite 238 Covina, CA 91723
lillian@bakerromero.com
(626) 332-2258
Everyday 9:00am - 5:00pm
[]
1
General Insurance Application

Please complete and return this general application sothat we can assist you with your insurance needs. Pleasealso provide a brochure and five years of claim history (ifapplicable).

Requesting quotes for the following coveragepick one!
Other
0 /
IRS 501 3cPlease submit a coppy of your IRS 501 c 3 letter
Upload
Name of Oganization
Tax ID Number
Street Adreess
Phone Number
Mail Address
Street Address
PhoneBusiness
Phone
Fax
# of Years in Business
Website
Contact Person & Title
If No, What Type of Organization:
Description of ALL Services in DetailPlease describe all services offered or attach brochure
0 /
BrochureAttach brochure of all services (if applicable)
Upload
# of Employees
# of Volunteers
# of Interns
Are Interns Compensated
If yes, anual payroll $
# of Contractors
Annual Payroll $
Annual Budget $
Services provided by independent Contractors
Services provided by independent contractors
Do you require independent contractors (1099’s) to provide proof of General Liability Insurance?
Do you offer Youth Service or after school program?
If yes, do guardians or parents sign a hold harmless waiver agreement?
If yes, do guardians or parents sign a hold harmless waiver agreement?
# of Students
Age Range of Students
# of teachers
Do you provide in-home services?
If yes, # of employees:
Describe in-home services
0 /
Do you provide counseling services
If yes, # of annual counseling visits
Do you prescribe medications?
Do you provide crisis intervention (hotline, inpatient, etc.)
Do any professional counselors carry their own professional liability coverage?
Do you provide any mentoring programs:
IF yes, is contact required in a group setting:
List Additional Insureds ( ie. Funders, Mortgage, etc.) and provide copy of lease or agreement:
0 /
Describe any services you provide “off site” i.e. home visits, meals on wheels, community centers, school sites, etc.:
0 /
Payroll for staff that work off-site: $
# of Staff:
Do employees or volunteers drive their own vehicles on behalf of the organization?
Do employees or volunteers drive their own vehicles on behalf of the organization?
# of Staff with personal autos
Indicate type of usage
Average number of people transported per week?
Other
Does your organization run or require an annual MVR for drivers that drive their personal autos?
Does your organization require proof of personal auto insurance on vehicles driven for your organization, at each policy renewal?
Crime Questionnaire
How handles or has custody of money, securities or other property:
Employee Dishonesty Limit Requested:
Forgery or Alteration limit Requested
ERISA: $
Is there an annual audit by:
Other
Are bank accounts reconciled by someone not authorized to deposit or withdraw?
Explain
Is countersignature of check required
IF not, who signs controls?
List All Locations (street address) & Square Footage:
Location 1 Name
Sq. Footage
Services Provided at this location
0 /
Location 2 Name
Sq. Footage
Services Provided at this location
0 /
Location 3 Name
Sq. Footage
Services Provided at this location
0 /
Location 4 Name
Sq. Footage
Services Provided at this location
0 /
Location 5 Name
Sq. Footage
Services Provided at this location
0 /

(on the comments section, list additional locations)

LIST ANY LANDLORDS THAT REQUIRE TO BE ADDED AS ADDITIONAL INSURED AND PROVIDE INSURANCE REQUIREMENTS IN LEASE:
0 /
Describe supervision and security at residential shelter:
0 /
Your staff to client ratio
Type of clients i.e. seniors, disabled, shelter for homeless
Do you prohibit acceptance of residents who have been convicted of a violent or sexual crime
Do you own or operate a pool?
Is pool gated?
Property

(Please complete ONLY if you would like a quote for property)

Would you like fire/theft coverage for your property (building, personal property, computers)?If yes, please provide the following info for each location:
Location #1 / Address:
# of stories
Age of building
If building is over 25 years old, indicate types of upgrades
Construction (frame/stucco, concrete, etc):
Security (dead bolts, central alarm?):
Building (if you own building) $
Loss Payee:
Location #2 / Address:
# of stories
Age of building
If building is over 25 years old, indicate types of upgrades
Construction (frame/stucco, concrete, etc):
Security (dead bolts, central alarm?):
Building (if you own building) $
Loss Payee:
Location #3 / Address:
# of stories
Age of building
If building is over 25 years old, indicate types of upgrades
Construction (frame/stucco, concrete, etc):
Security (dead bolts, central alarm?):
Building (if you own building) $
Loss Payee:
Location #4 / Address:
# of stories
Age of building
If building is over 25 years old, indicate types of upgrades
Construction (frame/stucco, concrete, etc):
Security (dead bolts, central alarm?):
Building (if you own building) $
Loss Payee:
Location #5 / Address:
# of stories
Age of building
If building is over 25 years old, indicate types of upgrades
Construction (frame/stucco, concrete, etc):
Security (dead bolts, central alarm?):
Building (if you own building) $
Loss Payee:
Amount of Business Income/Extra Expense: $
0 /
Rental Income and location: $
0 /
Tenants and Improvements Coverage: List location and amount of property coverage needed for tenants Improvements
0 /
Do you have any renovation projects or construction projects in this coming year?
If yes, please provide details and cost of renovations or construction
0 /
Would you like a quote for Earthquake or Flood?
Have you filed any property or crime claims in the past five years
If yes, provide details
0 /
Does organization own any fine art or collectables? If so, list value of artwork and location:
0 /
Supplemental Questionare

Professional Liability: Please list the number of employees, volunteers contractors:

Heart Care Professionals

Employees
Volunteers
Contractors

Teachers, Day Care Workers

Employees
Volunteers
Contractors

Special Education Teachers, Guidance Counselors, Vocational

Employees
Volunteers
Contractors

Mental Health Professionals: Psychologists, Social Workers,Counselors

Employees
Volunteers
Contractors

Student Interns under your supervision

Employees
Volunteers
Contractors

Student Interns under your supervision

Psychiatrist
Other
Employees
Volunteers
Contractors

Other Professionals

Title
Employees
Volunteers
Contractors
List all accreditations
Does your organization provide medical services
Describe
Does your organization provide services to clients that are suicidal or violent
Abuse & Molestation
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?
Do you verify employment related references?
Do you have written procedures for dealing with sexual abuse?
Do you have a plan of supervision that monitors staff in day-to-day relationships with clients both on and off premises
Has your organization ever had an incident which resulted in an allegation of sexual abuse
If yes, please describe
Please indicate age range of clients
Annual # of clients
Special Events
Event #1
Name of Event
Date & Time
Total Estimated Attendance
Gross Sales for Admissions
Gross Sales from Alcohol Sales
Annual Event?
Has any claim ever arisen out of event?
Emergency medical personnel present?
Security personnel present?
Event #2
Name of Event
Date & Time
Total Estimated Attendance
Gross Sales for Admissions
Gross Sales from Alcohol Sales
Annual Event?
Has any claim ever arisen out of event?
Emergency medical personnel present?
Security personnel present?
Event #3
Name of Event
Date & Time
Total Estimated Attendance
Gross Sales for Admissions
Gross Sales from Alcohol Sales
Annual Event?
Has any claim ever arisen out of event?
Emergency medical personnel present?
Security personnel present?
Workers Compensation Insurance

Complete this form is you are interested in a workers compensation quote. Please provide five years ofworkers’ comp claims history with this form and a copy of your current policy.

Address #1
WC Class Code
No of Full Time Employees
No of Part Time Employees
Estimated Annual Payroll
Address #2
WC Class Code
No of Full Time Employees
No of Part Time Employees
Estimated Annual Payroll
Address #3
WC Class Code
No of Full Time Employees
No of Part Time Employees
Estimated Annual Payroll
Address #4
No of FullTime Employees
No of Part Time Employees
Estimated Annual Payroll
Address #5
WC Class Code
No of Part Time Employees
Estimated Annual Payroll
Address #6
WC Class Code
No of FullTime Employees
No of Part Time Employees
Estimated Annual Payroll
Are the board of directors or owners of the corporation to be excluded
If yes, list board members or owners of corporation with title (and /or ownership %)
0 /
Health Insurance Company
% of employees covered

Total Payrolls for the past five years: chronologically with the most current year first

$
$
$
$
$
Percentage of employees with company longer than one year
Name of present Workers Comp Carrier
Expiration Date
Are volunteers covered under workers compensation?
If no, what is the name of your Volunteer Accident Insurance
Do any employees work out of state
If yes, describe services
Are volunteers covered under workers compensation?
If yes, describe
Are new employees provided training
Do you provide drug screening for any employees
Are written applications used for all employees
Do any employees transport clients
Do employees use their personal vehicle for company business
Do you participate in the California Pull Notice Program
Who is responsible for safety meetings and loss control
List the name , policy period and premium of your workers compensation insurance carriers for past five years
0 /
Automobile Insurance

Provide information regarding owned vehicles

Auto 1

Year
Make
Model
Vin #
Cost New
Wheelchair Lift
City Garaged

Auto 2

Year
Make
Model
Vin #
Cost New
Wheelchair Lift
City Garaged

Auto 3

Year
Make
Model
Vin #
Cost New
Wheelchair Lift
City Garaged
What are vehicles used for?
Mileage
Daily Radius
Name of current Automobile Insurance Company
Name of current Automobile Insurance Company
Premium
Expiration Date
Does the organization run annual MVRs on all drivers?
If no, how are drivers screened
Loss Payee
Do any employees or volunteers drive their own vehicle on behalf of the organization
If yes, how many employees
how many volunteers
Have there been any automobile claims in past five years
If yes, please provide claims history and details of each claim
0 /
Claim History: Please describe ANY claims or lawsuits in the past five years
0 /
Comments
0 /

I declare that all statements I have made are true and I have fully disclosed allrequested information

Your Nameyour full name
Date
Email
Favorite Fruitspick one!
Previous
Next