Social Services Insurance Questionnaire

Social Services Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationOther (specify)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
GENERAL INFORMATION
1. Number of years under current ownership:
2. Is this operation:

Non-profitFor Profit
3. Is this facility licensed? (If yes, please provide copy of all licenses.)

YesNo
4. Please provide the total annual expenditures/expenses.
5. Is the facility accredited?

YesNo
5a. If accredited, who granted the accreditation?
5b. If accredited, what date was the accreditation given?
6. In the past 12 months have any complaints been filed with a Licensing Board against your facility?

YesNo
6a. If yes, please explain:
7. In the last three years, have any of your licenses been revoked, suspended or placed under probation?

YesNo
7a. If yes, please explain:
8. Has any staff member ever had their professional license revoked or suspended?

YesNo
8a. If yes, please provide the name of the staff member(s), reason for and the date of revocation/suspension and the length of time the employee(s) has been with your facility.
9. Who is the contact person for inspections:
9a. Phone number of inspection contact:

DESCRIPTION OF OPERATIONS

1. What is the age range of clients that you work with (give number for each):

	Under 18 years	18 - 45 years	16 - 65 years	Over 65 years
Number in each age range

2. Please indicate if any of these programs are present:

Alcohol/Drug Abuse RehabilitationDevelopmentally DisabledMentally ChallengedSenior programsCounselingHead StartPhysically DisabledYouth programsDay careHome Health CareSheltered workshop
3. Does your facility provide treatment, care, or services for convicted sexual offenders? (If yes, facility is NOT eligible for program coverage.)

YesNo
4. If any operations are In-patient, please advise the number of beds licensed for:
5. If any professional services are Out-patient (no overnight stays), please list the annual number of client contacts: (Client contacts is defined as the total number of client meetings annually.)
6. Do you sell or rent medical equipment to others?

YesNo
6a. If yes, please explain:
6b. Provide gross receipts from sale or rental of medical equipment to others:
7. Describe other Operations that are present (please attach all brochures or any other advertising literature):
8. Do you employ a Medical Director?

YesNo
9. Do any employees possess medical training or a medical degree?

YesNo
9a. If yes, do they provide services in the capacity of a physician or doctor? (If yes, coverage is not available.)

YesNo

LIABILITY INFORMATION
1. Does your present policy include Professional Liability?

YesNo
2. Does your present policy provide Abuse & Molestation Coverage?

YesNo
3. Have you had any lawsuits, mediations, arbitrations, or negotiated settlements in the past five (5) years?

YesNo
3a. If yes, please explain:
4. Are you aware of any circumstances which may give rise to a general liability and/or professional liability claim?

YesNo
4a. If yes, please explain:
5. Does the applicant verify employment-related references?

YesNo
5a. If yes, how?

6. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse related offenses:

	Yes	No
6a. On prospective employees and volunteers?
6b. On existing employees and volunteers?

7. Does the applicant discuss the following items at staff orientation?

	Yes	No
3a. Child/Sexual Abuse
3b. How to recognize the signs of abuse
3c. What to do if a client/child reports someone molested him/her

8. Does the applicant have knowledge of any incident which could give rise to, or result in, an allegation of sexual abuse?

YesNo
8a. If yes, please explain:
9. Has there ever been an allegation of sexual abuse made against the insured?

YesNo
9a. If yes, please explain:

STAFF

1. Please indicate the number of personnel per classification:

	Full -Time Employees	Part-Time Employees	Full -Time Contractors	Part-Time Contractors	Full -Time Volunteers	Part-Time Volunters
Aides
Attorneys
Chiropractors
Counselors
Dental Hygienists
Dentists
Emergency Medical Technicians
Financial Advisors
LPN
Nurse Practitioners
Occupational Therapists
Pharmacists
Physical Therapists
Physicians
Psychiatrists
Psychologists
R.N.
Social Workers
Technicians
Other (describe below)
Other (describe below)
Total

1a. Please describe "Other" Staff:
2. Do you maintain certificates of insurance from all providers who carry their own insurance

YesNo
3. Is any percentage ofthe facility owned or operated by a physician?

YesNo
4. Do you have written policies and procedures in place for storing/prescribing/administering all medications? (please attach)

YesNo
5. Do employees use their own vehicles for work purposes?

YesNo
5a. If yes, please explain:
5b. Are they required to provide proof of insurance with minimum limits?

YesNo
5c. What limit?
6. What is the average distance that an employee will drive his/her vehicle for work purposes per week?
7. Do employees transport clients in employee vehicles?

YesNo
7a. If yes, explain how often and how far:
8. Do volunteers drive their own vehicles?

YesNo
8a. Are they required to provide proof of insurance with minimum limits?

YesNo
8b. What limit?
OPTIONAL COVERAGE
1. For in-patient only - Do you want coverage for property of residents ($2,500 per resident/$25,000 aggregate)

YesNo
2. For in-patient only - Do you want coverage for employee theft of residents’ personal property ($2,500 per resident/$25,000 aggregate).

YesNo
3. For in-patient only - Do you need more than $25,000 crime aggregate? (Contact Kevin Morency)

YesNo
3a. If yes, requested amount?
4. Abuse & Molestation coverage (limits within the GL limits)

YesNo

ADULT DAY CARE CENTERS
1. Do you offer adult day care?

YesNo
2. Number of annual clients
3. Daily Attendees
4. Please describe activities offered.
5. Do you want to include abduction coverage?

YesNo
AODA TREATMENT CENTERS
1. Do you offer alcohol and other drug abuse (AODA) treatment (out patient only)?

YesNo
2. Number of Annual Out Patient Clients
3. Average Length of Stay
4. Please describe all methods of detox, including medications
5. Are you a psychiatric hospital?

YesNo
CLOTHING CENTERS / THRIFT STORES
1. Do you offer clothing centers?

YesNo
2. Square Footage of Facility
2a. Please provide address if different than applicant address.
Street Address, City, State, Zip
3. Estimated Annual Receipts
4. Description of Goods Sold
COMMUNITY GARDEN
1. Do you offer a community garden?

YesNo
2. Number of Acres
3. Number of Plots
4. Age range of participants
5. Number of participants
6. Is it fenced?

YesNo
COMPANION / SUPPORT SERVICES
1. Do you offer companion / support services?

YesNo
2. Number of Visits Per Year
4. Services Offered
3. Annual Expenditures
5. Do you use volunteers?

YesNo
5a. If yes, number of volunteers
5b. What training do volunteers receive?

FOOD PANTRY
1. Do you offer a food pantry operation?

YesNo
2. Is your food pantry operation

For ProfitNon-Profit

3. Please provide number of employees and volunteers on part-time and full-time basis:

	Part-Time	Full-Time
Employees
Volunteers

4. Square footage of facility. Please provide signage (off-limit areas, no smoking, no eating, rules, etc.)
4a. Please provide address of property if different than applicant address.
Street Address, City, State, Zip
4b. Are you

OwnerTenant
5. Describe layout of facility (grocery store, warehouse, full-service, self-service, etc.).
6. Does building have fire sprinklers?

YesNo
6a. If yes, percentage of building with sprinklers
6b. Is system annually inspected by sprinkler inspector?

YesNo
7. Describe methods of documenting goods.
8. Are expiration dates checked on all items?

YesNo
9. Does restocking occur during customer shopping hours?

YesNo
10. Is spoilage coverage needed?

YesNo
10a. If yes, spoilage limit requested
11. What type of equipment do you have for use by employees and volunteers? (Examples: ladders, carts, rolling ladders, lifts)
11a. Are employees and volunteers trained on all kinds of equipment?

YesNo
12. Are delivery areas separate from customer loading areas?

YesNo

HOMELESS SHELTERS
1. Do you offer a homeless shelter? (No run-away shelters.)

YesNo

2. Please provide number of employees and volunteers on part-time and full-time basis:

	Part-Time	Full-Time
Employees
Volunteers

3. Number of beds.
4. Number of clients annually.
5. Square footage of facility.
6. What fire protection is available?

AlarmExtinguishersSprinkler System
6a. If yes, last date serviced:
7. Are meals provided?

YesNo

7a. If yes, indicate which of the following apply and the number of each:

	Enter Number Below
Ranges
Ovens
Deep Fryers
Grills
Broilers
Griddles

7b. Is there a 40 BC fire extinguisher in the kitchen?

YesNo
8. Dates of Operation
9. Hours of Operation
10. Are there separate male, female and family areas?

YesNo
INFORMATION & REFERRAL SERVICES
1. Do you offer information and referral services?

YesNo
2. Please describe the services you provide.
MEALS ON WHEELS PROGRAM
1. Do you offer a meals on wheels program?

YesNo
2. Number of annual meals

METHADONE MAINTENANCE PROGRAM
1. Do you offer a methadone maintenance program?

YesNo
2. Number of annual clients
3. Average length of treatment
4. Describe all methods of detox, including medications
NEEDLE EXCHANGE PROGRAM
1. Do you offer a needle exchange program?

YesNo
2. Number of annual clients
NEIGHBORHOOD CENTERS / COMMUNITY CENTERS
1. Do you offer a neighborhood center?

YesNo
2. Number of annual client contacts
3. Square Footage
4. Please describe activities offered.
5. Hours of Operation
6. Any one-on-one tutoring offered?

YesNo
NUTRITION SITES
1. Do you offer nutrition programs?

YesNo
2. Who is eligible for your program?

ChildrenSeniorsOther
3. Number of annual clients
4. Services offered

OUTREACH MINISTRIES
1. Do you offer an outreach ministry?

YesNo
2. Annual Budget
3. Primary and Secondary Funding Sources
4. Do you lease dwellings on behalf of clients?

YesNo
4a. If yes, annual number
5. Do you have a staff training and development program? If yes, please provide.

YesNo
6. Please describe programs and services offered.
PREVENTION & INTERVENTION
1. Do you offer a prevention and intervention program?

YesNo
2. Please describe programs and services offered.
SENIOR CENTERS
1. Do you offer a senior center?

YesNo
2. Number of annual client contacts
3. Square Footage
4. Describe activities offered
5. Hours of operation
6. Do you offer transportation services?

YesNo
6a. Are the transportation services for clients only?

YesNo
6b. Is there a fee to ride

YesNoFee amount

SHELTERED WORKSHOP PROGRAM
1. Do you offer a sheltered workshop program?

YesNo
2. Is the sheltered workshop licensed? (If yes, please attach a copy of the license.)

YesNo
3. Please indicate the population served. Indicate based on census (Actual number, not full time equivalent)
3a. Developmentally Disabled

Mental RetardationAutisticCerebral PalsyDown SyndromeOther
3b. Psychiatric Rehabilitation

Mental DisabilitiesAbused AdultsAlcohol & DrugMethadone MaintenanceOther
3c. Medical / Vocational Rehabilitation

Brain InjurySports InjurySpinal InjuryDiseaseAmputeesOther
4. Please describe the work the clients perform on site.
5. What machinery and/or equipment is on the premise?
6. Is any machinery/equipment used by the clients?

YesNo
6a. If yes, please describe.
7. Are parts assembled for another company?

YesNo
7a. If yes, please describe.
8. Are parts manufactured for another company?

YesNo
8a. If yes, please describe.
9. Is a product manufactured?

YesNo
9a. If yes, please describe the product that is manufactured.
9b. Gross Sales of Product Manufactured
10. Whose label goes on the product? (Please provide a copy of the label.)
11. Who is the end user of the product?
12. Are flammables stored in the proper receptacles?

YesNo
13. What controls are in place for painting, stripping, finishing, welding, metalworking, woodworking, etc?
14. Is there a quality control program in place?

YesNo
15. When was the last time OSHA inspected the workshop? (Please attach a copy of the inspection.)
16. Are fire drills conducted quarterly?

YesNo
17. Indicate the type of work performed by off site contracts.
17a. If they are hired with their job coach, how long does the coach usually stay paired with the client?
18. Do you provide workers' compensation for workshop employees?

YesNo

18a. If yes, please indicate gross dollar amounts for the following:

	Work Comp Limit	Gross Dollar Amount ($)
Off-site Janitorial (Gross Payroll for ($))
Off-site Landscaping (Gross Payroll for ($))
Restaurants and/or Cafe (Gross Receipts for ($))
Stores (Gross Sales for ($))
Camps (Annual Seasonal for ($))

19. If a client and/or employee is injured on the job, is there a return to work program?

YesNo
20. Is transportation provided to the clients?

YesNo

TELEPHONE CRISIS CENTERS
1. Do you offer a telephone crisis center?

YesNo
2. Types of problems treated by hotline.
3. Are volunteers used?

YesNo
3a. If volunteers, please describe counseling training they receive.
4. Hours of Operation
5. Please provide procedures for handling a crisis hotline call.
TRANSITIONAL LIVING CENTERS
1. Do you offer transitional living centers?

YesNo
2. Are you an alternative to incarceration for youths and adults. (Ineligible if court-ordered incarceration that involves detention.)

YesNo
3. Has any resident been accused of a criminal act involving physical harm or threats?

YesNo
4. Do you offer court ordered treatment or support?

YesNo
5. Please describe the type of services you offer.
6. Number of annual client contacts
7. Capacity of transitional housing
8. Square footage
9. Average length of stay
WOMEN'S SHELTERS
1. Do you offer women shelters?

YesNo
2. Square Footage
3. Please describe the type of services you offer.
4. Average length of stay

PROPERTY INSURANCE
1. Do you need Building and/or Content Coverage?

YesNo

1a. If yes, please complete chart below or provide a separate property schedule with the following information:

	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2

2. Do you need Equipment Coverage?

YesNo
2a. If yes, total value to insure for?

Replacement CostActual CostTotal Value ($)

2b. If yes, please complete equipment schedule below or provide a separate equipment schedule with the following information:

	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

COMMERCIAL AUTOMOBILE INSURANCE
1. Does the business title any automobiles or other operating vehicles in the business name?

YesNo
2. Is insurance coverage needed for owned automobiles?

YesNo

2a. (If yes, complete chart below or provide a separate vehicle/fleet schedule with following info.)

	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

2b. If yes, limits desired:

	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible

3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?

YesNo
3a. If yes, how many?
3b. Do you verify they have liability coverage?

YesNo
3c. Limits? ($)
COMMERCIAL CRIME
1. Do you desire coverage for Crime (Employee Dishonesty, Money, Forgery)?

YesNo
1a. If yes, requested amount?
COMMERCIAL UMBRELLA
1. Do you need a Commercial Umbrella?

YesNo
1a. If yes, limit of liability needed? ($)
DIRECTORS AND OFFICERS INSURANCE
1. Do you need Directors and Officers Liability Coverage? (If yes, please contact Kevin Morency.)

YesNo
WORKERS' COMPENSATION INSURANCE
1. Is there a written return to work program in place? If yes, please attach a copy.

YesNo
2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

YesNo
SPECIAL EVENTS / FUNDRAISERS
1. Do you host any special events?

YesNo
1a. Please describe each special event and fundraiser and include the number of expected attendees for each.
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.
Signature

Clear
Or Enter Your Full Name as Signature:
Date:
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://insurancesocialservices.com/
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