1. Full description of all operation(s) and types of clients served:
   
   (Email or Mail brochure(s) if available)
2. Type of entity: For Profit Non-Profit Governmental Other
3. Number of years in operation*:
   Years under present management:
   Licensed by:
   *If new in operation, please email or mail a copy of the director's resume.
4. Was license ever suspended or revoked? Yes No
   If yes, provide details and explanation.
   
5. Primary funding source:
   
6. Professional organization memberships:
   
7. Have you ever discontinued any programs? Yes No
   If yes, explain:
   
8. What is your annual operating budget?
   
9. Are you accredited? Yes No
   If so, by whom?
   

Complete the chart even if requesting casualty lines of business only. Use additional sheet if necessary.

1. Do you provide 24 hour residential care? Yes No
   If yes, please contact us at (860) 844-8288 for additional supplemental application.
2. Do you provide childcare services? Yes No
   If yes, please contact us at (860) 844-8288 for additional supplemental application.
3. Do you provide Adult daycare? Yes No
   If yes, please contact us at (860) 844-8288 for additional supplemental application.
4. Do you operate a sheltered workshop? Yes No
   If yes, please contact us at (860) 844-8288 for additional supplemental application.
5. Do you operate a camp? Yes No
   If yes, please contact us at (860) 844-8288 for additional supplemental application.
6. Total Number of Staff:
   Ratio of Staff to Clients: (staff) to (clients)
   Annual Staff turnover rate %
   

   	Positions	# Full Time	# Part Time	# Contracted	# Licensed
   Administrators
   Counselors
   Psychologists
   Nurses, R.N.
   Nurses, L.P.N.
   Certified Nurse Assistants
   Home Health Aides
   Social Workers
   Clerical
   Teachers
   Physicians
   Psychiatrists
   Occupational Therapists
   Physical Therapists
   Others: (List)

7. Is the staff required to report to the administrator all incidences that may result in a claim? Yes No
8. Are written records of all incidences kept by the administrator? Yes No
9. Are all incidences reviewed? Yes No
10. Do you have a formal written safety program in place? Yes No
11. Does the facility have a written emergency evacuation plan? Yes No
    If yes, describe.
    
12. Are medications dispensed? Yes No
    If yes, where are they stored?
    
    1. Are they locked up whenever they're not being dispensed? Yes No
    2. Who has the authority to dispense medications?
    3. Can over-the-counter medicines be dispensed without written permission from a doctor?
       Yes No
    4. Are written records kept as to time, type of medication, amount of dosage and who dispensed the medications? Yes No
13. Is there a swimming pool on premises? Yes No
    If yes, please contact us at (860) 844-8288 for additional supplemental application.
14. Please describe the insured's fundraising activities including special events. List types of activities, numbers of participants, whether or not liquor is served or sold, where events are held, etc.
    
15. Does the insured have any physicians or R.N.'s as employed staff members? Yes No
    If yes, are they required to carry their own malpractice insurance? Yes No
    If they do, indicate carrier, limits and effective dates:
    
16. If contracted professionals are used, does the insured require them to sign a hold harmless or indemnification agreement? Yes No
    If yes, attach a copy of the standard agreement.
    Are certificates of insurance required and kept in file for those contracted professionals? Yes No
    If yes, what are the minimum limits of liability required?
    
17. Is a complete criminal background check required for all staff members? Yes No
    If yes, which of the following do you use?
    County criminal record search
    State criminal record search
    National criminal index search
    State prison search
    Federal prison search
    Sex offender search
    Criminal index search
    Nationwide U.S. Wants & Warrants search
    Teacher license
    Education verification
    FBI
18. Are formal written procedures in place for staff hiring? Yes No
19. Are prior employment and personal references verified prior to hiring? Yes No
20. Are licenses and other credentials verified prior to hiring? Yes No
21. Is there formal staff training? Yes No
22. Do you have volunteer workers? Yes No
    Is a complete background check required for all volunteers the same as for employees? Yes No
    If no, explain if background checks are done & if so, what method is used (see Question #17 above)
    
    Average number of volunteers daily:
    Describe the volunteers' duties:
    
    Are any volunteers working off court-mandated community service? Yes No
    If yes, explain:
    
23. Do you handle clients' money, bills or finances of any type? Yes No
    If yes, explain what is handled and what controls are in place:
    
24. Have there been any claims or suits, or do you know of any incidents that could result in a claim or suit of any type? Yes No
    If yes, explain:
    
25. Is the insured licensed to operate an adoption agency? Yes No
    If yes, how many children are placed annually?
    
    Where do the children being adopted come from?
    
26. Does the insured operate a foster care agency? Yes No
    If yes, how many children are placed annually?
27. Does the insured operate a crisis hotline? Yes No
    If yes, describe its purpose:
    
28. Are all staff members and volunteers formally trained and certified in the type of counseling they're doing?
    Yes No
    If yes, Describe training program:
    
    Are clients referred to specialists when appropriate? Yes No
29. Are files maintained to protect confidentiality of clients? Yes No
30. Do you currently carry professional liability insurance? Yes No
    If yes, indicate limits, carrier, occurrence or claims made & retro date (if any):
    
31. Do you do any consulting work? Yes No
    If yes, describe:
    
32. Do you do weatherization or building or renovation programs? Yes No
    If yes, please contact us at (860) 844-8288 for additional supplemental application.
33. Do you accept adjudicated youth in any of your programs? Yes No

1. Does your staff employment application include questions about whether the individual has ever been convicted for any crime, including sex-related or child-abuse related offenses? Yes No
2. Do you have a written procedure for dealing with sexual abuse? Yes No
   If yes, Provide details:
   
3. Do you have a plan of supervision that monitors staff in day-to-day relationships with clients, both on and off premises? Yes No
4. Have there been any claims or suits or do you have knowledge or information which might reasonably be expected to give rise to a claim of sexual or physical abuse or molestation? Yes No
   If yes, provide details:
   
5. Do you currently carry coverage for abuse or molestation? Yes No
   If yes, indicate limits, carrier, occurrence or claims made & retro date (if any):
   

1. Are keys locked and secured away from clients when not in use? Yes No
2. Have drivers attended a class or completed a self-study in defensive driving? Yes No
3. Are MVR's checked prior to hiring? Yes No
4. Is personal use of agency's automobiles permitted? Yes No
5. Are family members permitted to drive the agency's automobiles? Yes No
6. Do your employees or volunteers use their own vehicles on agency business? Yes No
   If yes, do they use their own vehicles to transport clients? Yes No
   Do you require your employees or volunteers to carry and provide evidence of personal auto insurance?
   Yes No
   If yes, what minimum liability limits do you require they have?
   
7. Are all vehicles insured on the schedule titled to the named insured? Yes No
   If no, explain:
   
8. Are vehicles equipped with safety belts for each passenger? Yes No
9. Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair & passenger?
   Yes No
10. Is a final check performed after unloading to be sure nobody is left inside when vacating the vehicle?
    Yes No
11. Do all large capacity vehicles (> 8 passengers) have an audible backup warning device?
    Yes No
12. Are any drivers under 21 or over 70 years of age? Yes No
13. Do drivers have the appropriate types of licenses for vehicles driven (i.e., buses, heavy trucks, etc.)
    Yes No
14. Are any vehicles leased or hired? Yes No
    If yes, describe what types, what uses and how often:
    
15. Are clients permitted to drive insured vehicles? Yes No
    If yes, explain in detail:
    
16. Do more than 50% of employees regularly use their own autos for business? Yes No

1. What is the level of support given to clients?
   Intermittent (episodic)
   Limited (for specified periods of time)
   Extensive (regular for extended periods of time)
   Pervasive (life-long, intense)
2. What percentage of clients are mentally challenged? %
   Is the mental retardation:
   Mild (IQ 70 to 55/50)
   Moderate (IQ 55/50 to 40/35)
   Severe (40/35 to 25/20)
   Profound (IQ below 25/20)
3. What percentage of clients are physically challenged? %
4. What percentage of clients are elderly? %
5. What percentage of clients have dementia or Alzheimer's? %
6. Does the insured offer any of the following?
   Hands-on assistance with activities of daily living Physical rehabilitation
   Skilled nursing care
   Other medical care (describe)
   
   Additional comments below:
   

Please make sure to submit the following attachments if applicable:

• Fully completed and signed ACORD applications
• Three-year currently valued company loss runs including details of losses over $5000
• Facility license (if required) for each location and/or operation
• Driver list
• MVR's if available
• Photographs of each location if available
• Brochure or information describing your operation
• Sample contracts and/or hold harmless agreements used for contracted staff
• Financial statement
• Supplemental questionnaires as required

Fraud Warning: 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 also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. I hereby certify that to the best of my knowledge and belief the information provided is true and correct and that no information which materially affects this insurance has been withheld:

Insured's Name Title Date

Agent's Signature Date