Big Brothers BIg Sisters Supplemental Application

Big Brothers Big Sisters Supplemental Application

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Agency Name*

Address*

Address 2

City*

State*

Zip*

Contact Person*

Email*

FEIN*

Number of years in operation

Years under present management

Annual operating budget

Annual Payroll

Your Current Insurance Company

Expiration Date of your Insurance

Date

Your Current premium

Limit of Insurance

Claims made retro date

Has your agency changed it's name anytime after your retro date?

YesNo

Please indicate name changes

Has your agency discontinued any programs after your retro date

YesNo

Please describe

Please indicate the number of matches:

Total Site or School Based Matches*

Community Based Matches:

Community Male:*

Community Female*

Community Couples*

Hispanic Mentoring:

Does the affiliate agency adhere to the Big Brothers Big Sisters Standards of Practice for:

One-To-One Service in its completeness

yesno

If no, please explain:*

Does the affiliate agency utilize the following screening practices with every volunteer prior to being matched with a child?

In person interview?

yesno

Professional staff conducts an assessment in the volunteer"s home environment by in-home-visits?

yesno

Conducts a 50-State criminal and sex registry background check?

yesno

Completes three or more personal references?

yesno

Is at least one of the personal references from a relative of a volunteer?

yesno

Complete at least one professional reference?

yesno

Does the affiliate agency’s casework manual contain policies and procedures on how to recognize, prevent, and train volunteers on child sexual abuse, misconduct, or child endangerment issues?

yesno

Please explain any no answer.*

Please describe any additional safety, training or oversight measures you have established that exceed the standards set forth by the National Office. Please describe alternate standards adopted by this affiliate agency:

Please describe how volunteers are trained to provide mentorship to their matches:

How many estimated case closures did your agency experience last year?

Does the closure process include a questionnaire or interview with the child’s guardian that includes inquiry about concerns related to possible inappropriate conduct?

Please indicate

yesno

How does your affiliate agency manage inquiries or confidential information about children or the volunteers?

AGENCY STAFFIndicate the number of staff, contracted professionals, and volunteers:

Any Medical Professionals?

YesNo

Please indicate number of people:

Full-Time

Part time

Volunteer

Contracted

Any Social Workers?

YesNo

Please indicate number of people:

Full-Time

Part time

Volunteer

Contracted

Any Clerical / Administrative?

YesNo

Please indicate number of people:

Full-Time

Part time

Volunteer

Contracted

Any Other?

YesNo

Please describe

Please indicate number of people:

Full-Time

Part time

Volunteer

Contracted

If contracted professionals are used, does the affiliate agency require them to sign a hold harmless or indemnification agreement?

YesNo

Are Certificates of Insurance required and kept on file for those contracted professionals?

YesNo

Potential Claim Acknowlegdement

Has any employee, volunteer, officer/director or independent contractor been reprimanded, suspended or dismissed as a result of alleged, suspected or actual physical abuse, sexual abuse or acts/errors/omissions related to professional services?

Incidents reported, allegations or claims made, investigations made, or criminal/civil actions brought against your organization or its employees, volunteers, officers/directors or independent contractors for alleged, suspected or actual physical abuse, sexual abuse or acts/errors/omissions related to professional services that are not described on loss runs?

Do you have knowledge or information of any facts, circumstances or situations that might reasonably be expected to give rise to a claim of physical abuse, sexual abuse or acts/errors/omissions related to professional services?

Potential Claim Acknowlegdement

Has any employee, volunteer, officer/director or independent contractor been reprimanded, suspended or dismissed as a result of alleged, suspected or actual physical abuse, sexual abuse or acts/errors/omissions related to professional services?

Incidents reported, allegations or claims made, investigations made, or criminal/civil actions brought against your organization or its employees, volunteers, officers/directors or independent contractors for alleged, suspected or actual physical abuse, sexual abuse or acts/errors/omissions related to professional services that are not described on loss runs?

Do you have knowledge or information of any facts, circumstances or situations that might reasonably be expected to give rise to a claim of physical abuse, sexual abuse or acts/errors/omissions related to professional services?

Please indicate yes or no*

YesNo

If yes, please describe.*

Site Based Programs

Program Name

Where does the program take place?

Will there always be an adult, other than the volunteer, present while each program is taking place?

yesno

If no please explain*

Will volunteers use their personal auto to transport children in connection with the program?

YesNo

If yes please explain*

Does any aspect of this program involve any unsupervised one-to-one contact between a volunteer and a child, including transportation?

YesNo

If yes please explain*

Are release forms, stating that there is to be no contact between the child and volunteer outside the agency-arranged program, signed by the parents or legal guardians and the volunteers?

YesNo

If no please explain*

Hired and Non-Owned Auto Liability

Do you want coverage for these non-owned/hired autos?

YesNo

Does this agency have a procedure in place to verify that all employees and volunteers transporting children, using their personal vehicles for agency business, maintain personal auto insurance.

YesNo

Indicate how evidence of adequate limits are verified for each employee and volunteer:

Certificates of Insurance

true

Declarations page of Auto Policy

true

Other

true

Please describe

Does the agency verify auto coverage for each employee and volunteer at least annually?

YesNo

Does the affiliate agency hire any vehicle for transporting affiliate agency employees, volunteers, or children?

YesNo

Fund Raising and Special Events

Please list name of event/s

Will any of the following activities be part of any event?

Events where liquor is provided by the BB/BS agency and a license is required

true

Parades sponsored by the Insured

true

Automobile Rallies

true

Firearms

true

Animals (other than household pets)

true

Carnivals / Fairs with mechanical rides sponsored by the Insured

true

Rodeos

true

Events lasting more than 5 days

true

Aircraft or Air Shows

true

Motorcycle Rallies or Runs

true

Fireworks

true

Contact Sports

true

Events with admission of over 500 people at any one time

true

Political Rallies

true

Please explain any/all checked.*

DECLARATION AND SIGNATURE

The person named herein is authorized and designated to give and receive all notices on behalf of the entity and all Insured"s from the entity or their authorized representative(s) concerning insurance.

The person named herein is authorized and designated to give and receive all notices on behalf of the entity and all Insured"s from the entity or their authorized representative(s) concerning insurance.

First Name

Last Name

Title / Position:

The authorized signer of this application represents to the best of his/her knowledge and belief that the statements and information set forth herein are true and include all material information. The authorized signer also represents that any fact, circumstance or situation indicating the probability of a claim or legal action now known to any entity official or employee has been declared, and is agreed by all concerned that the omission of such information shall exclude any such claim or action from coverage under the insurance being applied for. Signing of this application does not bind or offer any insurance, nor commit the authorized signer to accept insurance, but it is agreed that this application and any attachments hereto shall be the basis of the insurance and will be incorporated by reference and made part of the policy should the policy be issued.

The authorized signer of this application represents to the best of his/her knowledge and belief that the statements and information set forth herein are true and include all material information. The authorized signer also represents that any fact, circumstance or situation indicating the probability of a claim or legal action now known to any entity official or employee has been declared, and is agreed by all concerned that the omission of such information shall exclude any such claim or action from coverage under the insurance being applied for. Signing of this application does not bind or offer any insurance, nor commit the authorized signer to accept insurance, but it is agreed that this application and any attachments hereto shall be the basis of the insurance and will be incorporated by reference and made part of the policy should the policy be issued.

Signature of Authorized Entity Representative:

Date Signed

Date