• Boys & Girls Club Insurance Questionnaire

  • Applicant is:

  • GENERAL LIABILITY

  • 5. Are independent contractors required to provide certification of insurance? (If yes, please provide copy of COI.)
  • 7. Is the facility open 24 hours?
  • 8. Do you have AEDs and Emergency O2 available on premises?
  • 9. Are Waivers obtained from all members, guests; and for high risk activities and rental groups? (Please provide copies of waivers.)
  • 10. Does the facility have an Internet Use Policy that is actively enforced?
  • 11. Is cell phone use restricted to the lobby or public gathering areas?

  • SERVICES PROVIDED

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  • 4. Do you have an obstacle course?
  • 4b. Is the course inspected?
  • 4e. Is there a maintenance program for the course?
  • 4f. Is a written record of maintenance kept?
  • 5. Does the facility conduct licensed childcare services?
  • 5a. Is the center:
  • Note: Center MUST be licensed or certified to be considered for coverage (or "Registered" for Iowa only. (Attach copy of state license)
  • 5c. In the past 12 months, have any complaints been filed with the Licensing Board against applicant’s facility?
  • 5d. In the past 3 years has any of the applicant’s licenses been revoked, suspended or placed under probation?
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  • 5f. Is applicant licensed/certified for: (Grades 1–12 & home schools are not eligible)
  • 5h. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective employees? (If no, Abuse and Molestation coverage is not available.)
  • 5i. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective volunteers? (If no, Abuse and Molestation coverage is not available.)
  • 5j. Does applicant have a Student Accident Insurance Policy in effect?
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  • 5ki. Has there ever been an allegation of sexual abuse made against the employee or volunteer?
  • 5l. If located in a commercial building, are there any other occupants in this building?
  • 5m. Does the applicant own the building?
  • 5mi. Does the insured lease any space to other tenants?
  • 5miii. Are any residential apartments located within this building? (Attach copy of tenant's HO4 & Lease Agreement.)
  • 6. Does the facility conduct massage therapy?
  • 7. Does the facility contain swimming pools?
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  • 8. Does the facility contain tanning beds/booths?
  • 9. Does the facility have a restaurant or snack bar?
  • 9a. If yes, is there an Automatic Fire Extinguishing System over all cooking surfaces?
  • 10. Does the facility conduct one-on-one unsupervised mentoring with minors? (i.e. Reach and Rise)
  • 11. Does the facility provide counseling, shelters, or other social services?
  • 11b. Is this operation:
  • 11c. Is this facility licensed? (If yes, please provide copy of all licenses.)
  • 11e. Is the facility accredited?
  • 11f. In the past 12 months have any complaints been filed with a Licensing Board against your facility?
  • 11g. In the last three years, have any of your licenses been revoked, suspended or placed under probation?
  • 11h. Has any staff member ever had their professional license revoked or suspended?
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  • 11k. Please indicate if any of these programs are present:
  • 11l. Does your facility provide treatment, care, or services for convicted sexual offenders? (If yes, facility is NOT eligible for program coverage.)
  • 11o. Do you sell or rent medical equipment to others?
  • 11q. Do you employ a Medical Director?
  • 11r. Do any employees possess medical training or a medical degree?
  • 11ri. If yes, do they provide services in the capacity of a physician or doctor? (If yes, coverage is not available.)
  • 11s. Does your present policy include Professional Liability?
  • 11t. Does your present policy provide Abuse & Molestation Coverage?
  • 11u. Have you had any lawsuits, mediations, arbitrations, or negotiated settlements in the past five (5) years?
  • 11v. Are you aware of any circumstances which may give rise to a general liability and/or professional liability claim?
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  • 11x. Do employees use their own vehicles for work purposes?
  • 11z. Do employees transport clients in employee vehicles?
  • 11aa. For in-patient only - Do you want coverage for property of residents ($2,500 per resident/$25,000 aggregate)
  • 11bb. For in-patient only - Do you want coverage for employee theft of residents’ personal property ($2,500 per resident/$25,000 aggregate).
  • 11bbi. For in-patient only - Do you need more than $25,000 crime aggregate?
  • 11cc. Abuse & Molestation coverage (limits within the GL limits)

  • ABUSE & MOLESTATION

  • 1. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective employees and volunteers?
  • 2. Does the applicant verify employment-related references?
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  • 4. Does the applicant have knowledge of any incident which could give rise to, or result in, an allegation of sexual abuse?
  • 5. Has there ever been an allegation of sexual abuse made against the insured?

  • PROPERTY INSURANCE

  • 1. Do you need Building and/or Content Coverage?
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  • 2. Do you need Equipment Coverage?
  • 2a. If yes, total value to insure for?
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  • COMMERCIAL AUTOMOBILE INSURANCE

  • 1. Does the business title any automobiles or other operating vehicles in the business name?
  • 2. Is insurance coverage needed for owned automobiles?
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  • 3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?
  • 3b. Do you verify they have liability coverage?

  • COMMERCIAL CRIME

  • 1. Do you desire coverage for Crime (Employee Dishonesty, Money, Forgery)?

  • COMMERCIAL UMBRELLA

  • 1. Do you need a Commercial Umbrella?

  • DIRECTORS AND OFFICERS INSURANCE

  • 1. Do you need Directors and Officers Liability Coverage? (If yes, please contact Kevin Morency.)

  • WORKERS' COMPENSATION INSURANCE

  • 1. Is there a written return to work program in place? If yes, please attach a copy.
  • 2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

  • SIGNATURE

  • The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.

  • Questions? 877-244-9090
    Kevin Morency |  kmorency@morencyinsurance.com 

    Morency & Associates Inc.
    141 New Shackle Island Rd, Hendersonville, TN 37075
    Fax: 615-452-6580

    https://clubassociationinsurance.com/

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