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General Insurance Application
Request a Quote
Our Address
750 Terrado Plaza, Suite 238 Covina, CA 91723
lillian@bakerromero.com
(626) 332-2258
Everyday 9:00am - 5:00pm
General Insurance Application
Please complete and return this general application so that we can assist you with your insurance needs. Please also provide a brochure and five years of claim history (if applicable).
Requesting quotes for the following coverage
Professional Liability
Abuse
Property
Crime
Automobile
Umbrella
Workers Compensation
Other
IRS 501 3c
Max. file size: 8 MB.
Please submit a copy of your IRS 501(c)3 letter
Name of Organization
Tax ID Number
Street Address
Street Address
Phone Number
Business Phone
Phone Number
Mail Address
Fax
Number of Years in Business
Website
Contact Person & Title
Is Your Organization A Non-Profit?
Yes
No
Provide details
Brochure
Max. file size: 8 MB.
What Type of Organization
Corporation
Joint Venture
Subchapter "S" Corporation
Individual
Trust
Other
Description of ALL Services in Detail
Brochure
Max. file size: 8 MB.
Number of Employees
Number of Volunteers
Number of Interns
Are Interns Compensated
No
Yes
Annual Payroll
Number of Contractors
Annual Payroll
Annual Budget
Do you have Services provided by independent contractors?
No
Yes
Explain the Services provided:
Do you require independent contractors (1099’s) to provide proof of General Liability Insurance?
No
Yes
Do you offer Youth Service or after school program?
No
Yes
Do guardians or parents sign a hold harmless waiver agreement?
Yes
No
Number of Students
Age Range of Students
Number of teachers
Do you provide in-home services?
No
Yes
Number of Employees
Describe in-home Services
Do you provide counseling services?
No
Yes
Number of annual counseling visits
Do you prescribe medications?
No
Yes
Do you provide crisis intervention (hotline, inpatient, etc.)
No
Yes
Do any professional counselors carry their own professional liability coverage?
No
Yes
Do you provide any mentoring programs:
No
Yes
Is contact required in a group setting
No
Yes
List Additional Insureds ( ie. Funders, Mortgage, etc.) and provide copy of lease or agreement:
Describe any services you provide “off site” i.e. home visits, meals on wheels, community centers, school sites, etc.:
Payroll for staff that work off-site: $
Number of staff
Do employees or volunteers drive their own vehicles on behalf of the organization?
No
Yes
Number of Staff with personal autos
Indicate type of usage
Errands
Delivery of meals or property
Transportation of other people
Other
Please explain
Average number of people transported per week?
Does your organization run or require an annual MVR for drivers that drive their personal autos?
No
Yes
Does your organization require proof of personal auto insurance on vehicles driven for your organization, at each policy renewal?
No
Yes
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:
CPA
Public Accountant
Other
Are bank accounts reconciled by someone not authorized to deposit or withdraw?
No
Yes
Please explain
Is countersignature of check required?
No
Yes
Who signs controls?
List All Locations (street address) & Square Footage:
Location 1
Name
Sq. Footage
Services Provided at this location
Location 2
Name
Sq. Footage
Services Provided at this location
Location 3
Name
Sq. Footage
Services Provided at this location
Location 4
Name
Sq. Footage
Services Provided at this location
Location 5
Name
Sq. Footage
Services Provided at this location
List additional locations if you have:
LIST ANY LANDLORDS THAT REQUIRE TO BE ADDED AS ADDITIONAL INSURED AND PROVIDE INSURANCE REQUIREMENTS IN LEASE:
Describe supervision and security at residential shelter:
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?
Yes
No
Do you own or operate a pool?
No
Yes
Is pool gated?
No
Yes
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)?
No
Yes
Location 1
Location Address
Number of stories
Age of building
Location 2
Location Address
Number of stories
Age of building
Location 3
Location Address
Number of stories
Age of building
Location 4
Location Address
Age of building
Number of stories
Location 5
Location Address
Number of stories
Age of building
If building is over 25 years old, indicate types of upgrades
Plumbing
Electrical
Roof
Construction (frame/stucco, concrete, etc):
Security (dead bolts, central alarm?):
Building (if you own building) $
Loss Payee:
Rental Income and location: $
Tenants and Improvements Coverage: List location and amount of property coverage needed for tenants Improvements
Do you have any renovation projects or construction projects in this coming year?
No
Yes
Please provide details and cost of renovations or construction
Would you like a quote for Earthquake or Flood?
No
Yes
Have you filed any property or crime claims in the past five years?
No
Yes
Provide details:
Does organization own any fine art or collectables?
No
Yes
List value of artwork and location:
Supplemental Questionare
Professional Liability: Please list the number of employees, volunteers contractors:
Health 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
Psychiatrist
Other
Employees
Volunteers
Contractors
Other Professionals
Employees
Volunteers
Contractors
List all accreditations
Does your organization provide medical services?
No
Yes
Describe
Does your organization provide services to clients that are suicidal or violent?
No
Yes
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?
Yes
No
Do you verify employment related references?
Yes
No
Do you have written procedures for dealing with sexual abuse?
Yes
No
Do you have a plan of supervision that monitors staff in day-to-day relationships with clients both on and off premises?
Yes
No
Has your organization ever had an incident which resulted in an allegation of sexual abuse?
No
Yes
Please describe:
Please indicate age range of clients
Annual Number of clients
Special Events
Event #1
Name of Event
Total Estimated Attendance
Date & Time
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
WC Class Code
No of Full Time Employees
No of Part Time Employees
Estimated Annual Payroll
Address #5
WC Class Code
No of FullTime Employees
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
No
Yes
List board members or owners of corporation with title (and /or ownership %)
Health Insurance Company
% of employees covered
Total Payrolls for the past five years: chronologically with the most current year first
Add
Remove
Percentage of employees with company longer than one year
Name of present Workers Comp Carrier
Expiration Date
MM slash DD slash YYYY
Are volunteers covered under workers compensation?
Yes
No
What is the name of your Volunteer Accident Insurance?
Do any employees work out of state?
No
Yes
Describe services:
Are volunteers covered under workers compensation?
No
Yes
Describe
Are new employees provided training?
Yes
No
Do you provide drug screening for any employees?
Yes
No
Are written applications used for all employees?
Yes
No
Do any employees transport clients?
Yes
No
Do employees use their personal vehicle for company business?
Yes
No
Do you participate in the California Pull Notice Program?
Yes
No
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
Automobile Insurance
Provide information regarding owned vehicles
Auto #1
Year
Make
Model
Vin Number
Cost New
Wheelchair Lift
City Garaged
Auto #2
Year
Make
Model
Vin Number
Cost New
Wheelchair Lift
City Garaged
Auto #3
Year
Make
Model
Vin Number
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
MM slash DD slash YYYY
Does the organization run annual MVRs on all drivers?
Yes
No
How are drivers screened?
Loss Payee
Do any employees or volunteers drive their own vehicle on behalf of the organization?
No
Yes
How many employees?
How many volunteers?
Have there been any automobile claims in past five years?
No
Yes
Please provide claims history and details of each claim
Claim History: Please describe ANY claims or lawsuits in the past five years
Comments
I declare that all statements I have made are true and I have fully disclosed allrequested information
Name
First
Date
MM slash DD slash YYYY
Email
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