Great American Specialty Human Services Quick App

Property Questions

* How many locations? If more than 5 locations you may choose to enter up to 5 here and submit the remaining locations by attachment of a SOV. 1 2 3 4 5

Location 1

If you choose, you can upload a separate SOV document. The document must contain ‘Complete Address, Construction Type, Year Built, Valuation (including Building Limit, Contents Limit, BI/EE Limit, and any Ancillary Coverage Limits), Square Footage, Occupancy, Protection, Exposures.)’. Submitting attachments to the inbox as a submission or as additional information related to a submission may slow the quote delivery timeline, depending upon the completeness of the information submitted. For guaranteed expedited quote delivery, be sure to complete the QuickApp in full without any attachments.

* Property Address

* City

* State

* Zip

Building Limit:

Contents Limit:

Fine Arts or Inland Marine Floater Limit:

* Year Built (Best estimate if unknown):

* Construction Class:

* Square Footage:

*Approximate Percent Sprinklered:

* Number of Stories:

Select those items updated within previous 30 years (multi-select)

Location 2

* Property Address

* City

* State

* Zip

Building Limit:

Contents Limit:

Fine Arts or Inland Marine Floater Limit:

* Year Built (Best estimate if unknown):

* Construction Class:

* Square Footage:

* Approximate Percent Sprinklered:

* Number of Stories:

Select those items updated within previous 30 years (multi-select)

Location 3

* Property Address

* City

* State

* Zip

Building Limit:

Contents Limit:

Fine Arts or Inland Marine Floater Limit:

* Year Built (Best estimate if unknown):

* Construction Class:

* Square Footage:

* Approximate Percent Sprinklered:

* Number of Stories:

Select those items updated within previous 30 years (multi-select)

Location 4

* Property Address

* City

* State

* Zip

Building Limit:

Contents Limit:

Fine Arts or Inland Marine Floater Limit:

* Year Built (Best estimate if unknown):

* Construction Class:

* Square Footage:

* Approximate Percent Sprinklered:

* Number of Stories:

Select those items updated within previous 30 years (multi-select)

Location 5

* Property Address

* City

* State

* Zip

Building Limit:

Contents Limit:

Fine Arts or Inland Marine Floater Limit:

* Year Built (Best estimate if unknown):

Construction Class:

* Square Footage:

* Approximate Percent Sprinklered:

* Number of Stories:

Select those items updated within previous 30 years (multi-select)

* Do any locations have other occupants or surrounding neighbors that present an elevated fire risk? Yes No

General Liability

* Occurrence or Claims-Made form? Occurrence Claims-Made

Retro Date (if claims-made)

Does the organization:

* Provide alternative sentencing, lock-down, or incarceration programs? Yes No

* Sponsor rallies, civil demonstrations, protests, or participate in lobbying? Yes No

* Own or operate tanning beds? Yes No

* Provide commercial lending services or handle client’s money? Yes No

* Accept donated vehicles? Yes No

* Provide any services in private homes? Yes No

If yes, please provide details.

* Employ armed security officers? Yes No

* Sponsor any athletic activities or leagues for members or the general public? Yes No

If yes, please provide details.

* If pre-owned items are held for sale, are they sold "as is"? Yes No N/A

* Own or operate any swimming pools? Yes No

Number of drains:

Are lifeguards on duty at all times or is pool clearly marked to swim At Your Own Risk? Yes No

Are there any diving boards or water slides? Yes No

Are pool chemicals always properly stored? Yes No

* Create its own print or electronic media: Yes No

Do you request waivers before including images of people, or are you willing to? Yes No

* Host large public meetings or performances in any venue? Yes No

Provide ushers to assist with seating? Yes No

Have lighted aisles and exits? Yes No

Have emergency lighting? Yes No

Utilize pyrotechnics? Yes No

* If the organization is subject to licensing/accreditation inspecting are there any uncorrected life safety violations? Yes No N/A

Special Event

* Does the organization host any special events? Yes No

Abuse and Molestation

* Does the organization provide services to the elderly, developmentally disabled adults, children under age 18, or overnight services? Yes No

* Occurrence or Claims-Made form? Occurrence Claims-Made

Retro Date (if claims-made)

* Does the organization have written policies requiring reporting of known or suspected abuse? Yes No N/A

* Does the organization allow any one-on-one contact with clients away from premises or outside of supervised, group area? Yes No N/A

Which of the following controls are required for employees/volunteers before they may come into contact with at-risk populations? (Check all that apply)

Written application including picture ID.

Personal interview.

Personal reference checks.

Name/SSN check

FBI fingerprint check.

How long are controls listed above retained?

Professional Liability

* Occurrence or Claims-Made form? Occurrence Claims-Made

Retro Date (if claims-made)

* Adoption or foster placement? Yes No

* Medical services including prescription of medication, methadone, or detox? Yes No

* Services to Alzheimer’s, dementia, bi-polar, schizophrenic, paranoid, psychotic, or severely mentally ill clients? Yes No

* Services to medically fragile individuals? Yes No

* Ever use chemical or physical restraints? Yes No

* Respite care, hospice care, or other care for the elderly? Yes No

* Services typically provided by a doctor, RN, alternative medicine, OBGYN, dentist, or other licensed medical professional? Yes No

* Crisis intervention, suicide prevention hotlines, or eating disorder counseling? Yes No

* Advocacy or legal services? Yes No

* Services in private homes without the legal guardian present? Yes No

In this next section, please enter the number of professionals employed in each category listed. If none, leave blank.

Medical student, nurse practitioner, physician assistant, or psychiatrist:

CNA, LPN, RN:

Behavioral, Occupational, Respiratory, Speech, Physical therapists:

Aides:

Counselors, Social Workers, Psychologists:

Teacher, Daycare Workers, Special Education Teachers:

Art, Dance, Music Therapist:

Other professionals:

* Do you maintain copies of Licenses for all employed, volunteer, and contracted professionals who are required to be licensed? Yes No

* Are procedures in place to verify current licenses are maintained? Yes No

* Has the organization’s license or any employee/volunteer’s license been revoked, suspended, or made conditional by any regulatory agency? Yes No

Owned Auto

Auto #1

If you choose, you can upload a separate Vehicle List document. The document must contain ‘Year, Make, Model, and correct VIN”. Submitting attachments to the inbox as a submission or as additional information related to a submission may slow the quote delivery timeline, depending upon the completeness of the information submitted. For guaranteed expedited quote delivery, be sure to complete the QuickApp in full without any attachments.

* Year

* Make

* Model

* VIN

Use of vehicle (multi-select)

Auto #2

Year

Make

Model

VIN

Use of vehicle (multi-select)

Auto #3

Year

Make

Model

VIN

Use of vehicle (multi-select)

Auto #4

Year

Make

Model

VIN

Use of vehicle

Auto #5

Year

Make

Model

VIN

Use of vehicle (multi-select)

Hired and Non-Owned Auto

* Hired or Non-Owned Autos are used for: "If Any"- incidental exposure only
Transport Clients

Times per week

Run errands

Times per week

Deliver meals or property:

Times per week

* Do you maintain proof of personal auto insurance for anyone driving on your organization’s behalf? Yes No

* Do you maintain proof of an MVR record with no more than two accidents or moving violations in the previous 3 years and zero DUIs in the previous five years for anyone driving on your organization’s behalf? Yes No

Umbrella

* Umbrella Limit

Underwriting

Profile

General (if unknown, leave blank):

Property Questions

Location 1

Location 2

Location 3

Location 4

Location 5

General Liability

Does the organization:

Special Event

Abuse and Molestation

Which of the following controls are required for employees/volunteers before they may come into contact with at-risk populations? (Check all that apply)

Professional Liability

Owned Auto

Auto #1

Auto #2

Auto #3

Auto #4

Auto #5

Hired and Non-Owned Auto

Umbrella