4-H Insurance Questionnaire

4-H Insurance Questionnaire
Applicant's Name:*
Name of 4-H organization:*
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. Please describe the activities or objectives of your organization. (Please attach brochure if you have one.)
2. How many registered members in your organization?
3. Check all that apply to your operation:

For ProfitNot-For-ProfitOpen to PublicPrivate Membership
4. How many years have you been in operation?
5. In what state(s) do you conduct operations?
6. Any medical services or medical advice of any kind provided to members or to the public?

YesNo
7. Are any kinds of personal care or medical care services provided in any capacity?

YesNo
6/7 a. If yes to 6 or 7, please explain below.
EVENT INFORMATION

1. List all events of 100 attendees or more: include whether conducted on your premises or away from premises:

	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

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

	Name	Position	Qualifications/Experience/Certification
1
2
3