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:

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

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

Yes No
4. Please provide the total annual expenditures/expenses.
5. Is the facility accredited?

Yes No
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?

Yes No
6a. If yes, please explain:
7. In the last three years, have any of your licenses been revoked, suspended or placed under probation?

Yes No
7a. If yes, please explain:
8. Has any staff member ever had their professional license revoked or suspended?

Yes No
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 Rehabilitation Developmentally Disabled Mentally Challenged Senior programs Counseling Head Start Physically Disabled Youth programs Day care Home Health Care Sheltered workshop
3. Does your facility provide treatment, care, or services for convicted sexual offenders? (If yes, facility is NOT eligible for program coverage.)

Yes No
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?

Yes No
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?

Yes No
9. Do any employees possess medical training or a medical degree?

Yes No
9a. If yes, do they provide services in the capacity of a physician or doctor? (If yes, coverage is not available.)

Yes No

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

Yes No
2. Does your present policy provide Abuse & Molestation Coverage?

Yes No
3. Have you had any lawsuits, mediations, arbitrations, or negotiated settlements in the past five (5) years?

Yes No
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?

Yes No
4a. If yes, please explain:
5. Does the applicant verify employment-related references?

Yes No
5a. If yes, how?

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

Yes

6a. On prospective employees and volunteers?

6b. On existing employees and volunteers?

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

Yes

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?

Yes No
8a. If yes, please explain:
9. Has there ever been an allegation of sexual abuse made against the insured?

Yes No
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)

Total

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

Yes No
3. Is any percentage ofthe facility owned or operated by a physician?

Yes No
4. Do you have written policies and procedures in place for storing/prescribing/administering all medications? (please attach)

Yes No
5. Do employees use their own vehicles for work purposes?

Yes No
5a. If yes, please explain:
5b. Are they required to provide proof of insurance with minimum limits?

Yes No
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?

Yes No
7a. If yes, explain how often and how far:
8. Do volunteers drive their own vehicles?

Yes No
8a. Are they required to provide proof of insurance with minimum limits?

Yes No
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)

Yes No
2. For in-patient only - Do you want coverage for employee theft of residents’ personal property ($2,500 per resident/$25,000 aggregate).

Yes No
3. For in-patient only - Do you need more than $25,000 crime aggregate? (Contact Kevin Morency)

Yes No
3a. If yes, requested amount?
4. Abuse & Molestation coverage (limits within the GL limits)

Yes No

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

Yes No
2. Number of annual clients
3. Daily Attendees
4. Please describe activities offered.
5. Do you want to include abduction coverage?

Yes No
AODA TREATMENT CENTERS
1. Do you offer alcohol and other drug abuse (AODA) treatment (out patient only)?

Yes No
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?

Yes No
CLOTHING CENTERS / THRIFT STORES
1. Do you offer clothing centers?

Yes No
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?

Yes No
2. Number of Acres
3. Number of Plots
4. Age range of participants
5. Number of participants
6. Is it fenced?

Yes No
COMPANION / SUPPORT SERVICES
1. Do you offer companion / support services?

Yes No
2. Number of Visits Per Year
4. Services Offered
3. Annual Expenditures
5. Do you use volunteers?

Yes No
5a. If yes, number of volunteers
5b. What training do volunteers receive?

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

Yes No
2. Is your food pantry operation

For Profit Non-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

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

Yes No
6a. If yes, percentage of building with sprinklers
6b. Is system annually inspected by sprinkler inspector?

Yes No
7. Describe methods of documenting goods.
8. Are expiration dates checked on all items?

Yes No
9. Does restocking occur during customer shopping hours?

Yes No
10. Is spoilage coverage needed?

Yes No
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?

Yes No
12. Are delivery areas separate from customer loading areas?

Yes No

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

Yes No

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?

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

Yes No

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?

Yes No
8. Dates of Operation
9. Hours of Operation
10. Are there separate male, female and family areas?

Yes No
INFORMATION & REFERRAL SERVICES
1. Do you offer information and referral services?

Yes No
2. Please describe the services you provide.
MEALS ON WHEELS PROGRAM
1. Do you offer a meals on wheels program?

Yes No
2. Number of annual meals

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

Yes No
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?

Yes No
2. Number of annual clients
NEIGHBORHOOD CENTERS / COMMUNITY CENTERS
1. Do you offer a neighborhood center?

Yes No
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?

Yes No
NUTRITION SITES
1. Do you offer nutrition programs?

Yes No
2. Who is eligible for your program?

Children Seniors
3. Number of annual clients
4. Services offered

OUTREACH MINISTRIES
1. Do you offer an outreach ministry?

Yes No
2. Annual Budget
3. Primary and Secondary Funding Sources
4. Do you lease dwellings on behalf of clients?

Yes No
4a. If yes, annual number
5. Do you have a staff training and development program? If yes, please provide.

Yes No
6. Please describe programs and services offered.
PREVENTION & INTERVENTION
1. Do you offer a prevention and intervention program?

Yes No
2. Please describe programs and services offered.
SENIOR CENTERS
1. Do you offer a senior center?

Yes No
2. Number of annual client contacts
3. Square Footage
4. Describe activities offered
5. Hours of operation
6. Do you offer transportation services?

Yes No
6a. Are the transportation services for clients only?

Yes No
6b. Is there a fee to ride

Yes No

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

Yes No
2. Is the sheltered workshop licensed? (If yes, please attach a copy of the license.)

Yes No
3. Please indicate the population served. Indicate based on census (Actual number, not full time equivalent)
3a. Developmentally Disabled

Mental Retardation Autistic Cerebral Palsy Down Syndrome
3b. Psychiatric Rehabilitation

Mental Disabilities Abused Adults Alcohol & Drug Methadone Maintenance
3c. Medical / Vocational Rehabilitation

Brain Injury Sports Injury Spinal Injury Disease Amputees
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?

Yes No
6a. If yes, please describe.
7. Are parts assembled for another company?

Yes No
7a. If yes, please describe.
8. Are parts manufactured for another company?

Yes No
8a. If yes, please describe.
9. Is a product manufactured?

Yes No
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?

Yes No
13. What controls are in place for painting, stripping, finishing, welding, metalworking, woodworking, etc?
14. Is there a quality control program in place?

Yes No
15. When was the last time OSHA inspected the workshop? (Please attach a copy of the inspection.)
16. Are fire drills conducted quarterly?

Yes No
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?

Yes No

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?

Yes No
20. Is transportation provided to the clients?

Yes No

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

Yes No
2. Types of problems treated by hotline.
3. Are volunteers used?

Yes No
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?

Yes No
2. Are you an alternative to incarceration for youths and adults. (Ineligible if court-ordered incarceration that involves detention.)

Yes No
3. Has any resident been accused of a criminal act involving physical harm or threats?

Yes No
4. Do you offer court ordered treatment or support?

Yes No
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?

Yes No
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?

Yes No

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?

Yes No
2a. If yes, total value to insure for?

Replacement Cost Actual Cost

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?

Yes No
2. Is insurance coverage needed for owned automobiles?

Yes No

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?

Yes No
3a. If yes, how many?
3b. Do you verify they have liability coverage?

Yes No
3c. Limits? ($)
COMMERCIAL CRIME
1. Do you desire coverage for Crime (Employee Dishonesty, Money, Forgery)?

Yes No
1a. If yes, requested amount?
COMMERCIAL UMBRELLA
1. Do you need a Commercial Umbrella?

Yes No
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.)

Yes No
WORKERS' COMPENSATION INSURANCE
1. Is there a written return to work program in place? If yes, please attach a copy.

Yes No
2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

Yes No
SPECIAL EVENTS / FUNDRAISERS
1. Do you host any special events?

Yes No
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
Date:
Questions? 877-244-9090
Kevin Morency | kmorency@morencyinsurance.com

Morency & Associates Inc.,
1194 Long Hollow Pike, Gallatin, TN 37066
Fax: 615-452-6580

https://insurancesocialservices.com/
Should be Empty: