PUBLIC ENTITY EXCESS LIABILITY INSURANCE QUESTIONNAIRE POLICY PERIOD: FROM:

Transcription

1 POLICY PERIOD: FROM: TO: Please answer all questions. Enter N/A if it does not apply. 1. NAME OF ENTITY: ATTACH LIST OF COMPLETE NAMED INSURED AS IT IS TO APPEAR ON POLICY. 2. MAILING ADDRESS: 3. STREET ADDRESS (NOT P.O. BOX) 4. CONTACT NAME/TITLE: 5. PHONE: 6. WEBSITE ADDRESS: LIMITS: REQUESTED: 2. RETENTION: REQUESTED: 3. EPL RETENTION: REQUESTED: EXPIRING: EXPIRING: EXPIRING: 1. POPULATION: AREA (SQ. MILES): A. INCORPORATED POPULATION: B. UNINCORPORATED POPULATION: 2. NUMBER OF EMPLOYEES: FULL TIME: PART-TIME: NUMBER OF OFFICIALS: ELECTED: APPOINTED: 3. TOTAL PROJECTED BUDGET: 4. LAW ENFORCEMENT: GROSS PAYROLL: NUMBER OF SWORN OFFICERS: NUMBER OF RESERVES: FULL TIME: PART-TIME: A. TOTAL CORRECTION FACILITY SQUARE FOOTAGE: Page 1 of 8

2 B. NUMBER OF JAILS: NUMBER OF CELLS: NUMBER OF HOLDING CELLS: C. NUMBER OF PRISONS: NUMBER OF CELLS: D. INMATE CAPACITY: MAXIMUM AVERAGE: E. LENGTH OF INMATE STAY: MAXIMUM AVERAGE: F. ADULT PRISONERS SEPARATED FROM JUVENILE PRISONERS: Yes No G. MALE AND FEMALE PRISONERS SEPARATED: Yes No H. STRIP SEARCH PROCEDURE: i. WHEN WAS IT IMPLEMENTED? ii. iii. IS IT A WRITTEN PROCEDURE? WHAT IS STAFF TRAINING? iv. ARE ALL DETAINEES SEARCHED? IF NO, WHAT IS THE POLICY AS RESPECTS DETERMINATION OF WHO IS SEARCHED? a. WHO HAS AUTHORITY TO MAKE THIS DETERMINATION? b. ARE DETAINEES SEGREGATED DURING THE SEARCH? IF YES, WHAT IS THE CRITERION FOR SEGREGATION? I. ARE THERE ANY SHARED JAIL SERVICES? Yes No IF YES, J. ARE THERE WRITTEN PROCEDURES ON THE FOLLOWING: ESCALATING USE OF FORCE: Yes No USE OF NON LETHAL WEAPONS: Yes No USE OF LETHAL WEAPONS: Yes No VEHICLE PURSUIT: Yes No RIDE ALONG: Yes No DATE LAST UPDATED? HOW OFTEN IS IT REVIEWED BY LEGAL COUNSEL? HOW OFTEN IS TRAINING REQUIRED? CALEA CERTIFIED? Yes No 5. FIRE DEPARTMENT: GROSS PAYROLL: PART TIME: FULL TIME: VOLUNTEERS: Page 2 of 8

3 NUMBER OF PARAMEDICS / EMTS: (INCLUDED IN ABOVE) 6. UTILITIES: A. WATER: Yes No i. PAYROLL: ii. BUDGET: iii. iv. ANNUAL GALLONS OF TOTAL (INDUSTRIAL / DOMESTIC) WATER DISTRIBUTION: DESCRIBE USES OF RECLAIMED WATER: v. CONTRACTUAL AGREEMENTS ASSUMING LIABILITY OF OTHER UTILITIES: vi. SOURCE(S) OF SUPPLY: B. GAS: Yes No i. PAYROLL: ii. BUDGET: iii. NUMBER OF CUSTOMERS: RESIDENTIAL: COMMERCIAL: INDUSTRIAL iv. AMOUNT PURCHASED ANNUALLY: v. DOES SYSTEM GENERATE: Yes No STORE: Yes No DISTRIBUTE: Yes No C. ELECTRIC Yes No i. PAYROLL: ii. BUDGET: iii. NUMBER OF CUSTOMERS: Page 3 of 8

4 RESIDENTIAL: COMMERCIAL: INDUSTRIAL: iv. AMOUNT PURCHASED ANNUALLY: v. DOES SYSTEM GENERATE: Yes No STORE: Yes No DISTRIBUTE: Yes No D. WATER SEWAGE TREATMENT: Yes No i. ANNUAL GALLONS: ii. NUMBER OF PLANTS: iii. MILES OF STORM SEWERS: 7. DAMS Yes No NUMBER: IF YES AND COVERAGE IS REQUESTED, PLEASE PROVIDE MOST CURRENT INSPECTION/ENGINEERING REPORT (ONE FOR EACH DAM). 8. BEACH OR WATER FRONT EXPOSURE: MILES OF: A. BEACHES OWNED OR OPERATED: i. NUMBER OF LIFEGAURDS: NUMBER OF: B. MARINAS: NUMBER OF SLIPS: RECEIPTS: C. PIERS: LENGTH: i. DESCRIPTION OF USE: D. WATERCRAFT: LENGTHS: i. DESCRIPTION OF USE: 9. NUMBER OF LAKES OR RESERVOIRS: RECREATIONAL USE: Yes No 10. SWIMMING POOLS: Yes No NUMBER OF POOLS: NUMBER OF LIFEGUARDS: NUMBER OF WATER SLIDES: NUMBER OF DIVING BOARDS: Page 4 of 8

5 11. SUMMER CAMPS: Yes No BACKGROUND CHECKS COMPLETED? : Yes No OVERNIGHT: Yes No SAFETY POLICIES / PROCEDURES? : Yes No SEXUAL ABUSE POLICY / TRAINING? : Yes No AVERAGE DAILY ATTENDANCE : 12. ZOOS: Yes No NUMBER: 13. AMUSEMENT PARKS: Yes No 14. SKATEBOARD PARKS: Yes No NUMBER: 15. WATER PARKS: Yes No NUMBER: 16. STADIUMS & GRANDSTANDS OR BLEACHERS (OVER 5,000 SEATING CAPACITY) Yes No NUMBER: CAPACITY: RECEIPTS: PROVIDE DESCRIPTION OF USE. IF CONTRACTED OUT, WHAT LIMITS ARE REQUIRED OF CONTRACTOR? IS HOLD HARMLESS REQUIRED? 17. PARKS: Yes No 18. FAIRGROUNDS: Yes No ANNUAL ADMISSIONS: ANNUAL RECEIPTS: 19. RACE TRACKS: Yes No 20. SPECIAL EVENTS SPONSORED BY INSURED (FESTIVALS, EXHIBITIONS, ETC.): Yes No IF CONTRACTED OUT, WHAT LIMITS ARE REQUIRED OF CONTRACTOR? IS HOLD HARMLESS REQUIRED? 21. EXHIBITION HALL/AUDITORIUM CONVENTION CENTER: Yes No SQUARE FEET: Page 5 of 8

6 RECEIPTS: 22. LANDFILLS OR DUMP SITES: Yes No NUMBER: HAVE THERE BEEN ANY VIOLATIONS IN THE PAST 10 YEARS? IF YES, 23. MILEAGE OF CITY STREETS OR ROADS: PAVED: UNPAVED: NUMBER OF BRIDGES OWNED, CONTROLLED, INSPECTED, MAINTAINED, AND OPERATED BY THE INSURED: HOW OFTEN ARE THEY INSPECTED? ARE ANY BRIDGES OVER 300 FT? Yes No 24. OWNED OR OPERATED DAY CARE CENTERS: Yes No NUMBER: AVERAGE DAILY ATTENDANCE: 25. MEDICAL CARE FACILITIES: Yes No TYPE: NUMBER LOCATIONS: SERVICES PROVIDED: NUMBER OF NURSES: 26. ANIMAL CONTROL DEPT.: Yes No 27. REDEVELOPMENT AGENCY: Yes No 28. HOUSING AUTHORITY: Yes No A. NUMBER OF BUILDINGS: B. NUMBER OF UNITS: C. NUMBER OF BUILDINGS MORE THAN (3) STORIES: 29. WELFARE/SOCIAL SERVICES DEPARTMENT: Yes No Page 6 of 8

7 30. CHEMICAL SPRAYING: Yes No 31. RADIO OR TELEVISION BROADCASTING: Yes No 32. GARBAGE COLLECTION: Yes No 33. AUTOMOBILE INFORMATION: A. LICENSED POLICE PRIVATE PASSENGER: B. LICENSED FIRE PRIVATE PASSENGER: C. LICENSED OTHER PRIVATE PASSENGERS: D. LICENSED LIGHT COMMERCIAL: E. LICENSED MEDIUM COMMERCIAL: F. LICENSED HEAVY COMMERCIAL: G. LICENSED EXTRA HEAVY: H. EXTRA HEAVY FIRE: I. AMBULANCE / RESCUE: J. MOTORCYCLES / SCOOTERS: K. BUSES NON-FIXED ROUTE: i. SEATING CAPACITY 1 8: ii. SEATING CAPACITY 9 20: iii. SEATING CAPACITY 21 60: iv. SEATING CAPACITY OVER 60: L. BUSES OTHER: i. DESCRIBE USE: M. BUSES FIXED ROUTE: SEPARATE TRANSIT APPLICATION REQUIRED N. REFUSE: O. TRUCKS: P. FIRE PUMPER: Q. FIRE OTHER: R. OTHER LICENSED VEHICLES: i. DESCRIBE USE: ARE THERE WRITTEN HIRING AND TRAINING PROCEDURES? Yes No ARE THERE WRITTEN MAINTENANCE PROCEDURES? Yes No ARE MVRs PULLED PRIOR TO ASSIGNING DRIVING DUTIES? Yes No 34. TRANSIT SYSTEM: BUSES: Yes No RAIL: Yes No IF COVERAGE REQUESTED, SEPARATE APPLICATION IS REQUIRED. IF CONTRACTED OUT, WHAT LIMITS OF INSURANCE ARE CARRIED BY CONTRACTOR? 35. AIRPORTS OWNED OR OPERATED BY CITY: Yes No Page 7 of 8

8 36. DOES THE APPLICANT HAVE A: A. FULL-TIME RISK MANAGER Yes No B. PART-TIME RISK MANAGER: Yes No C. FULL TIME SAFETY OFFICER: Yes No D. PART TIME SAFETY OFFICER: Yes No E. WRITTEN RISK MANAGERMENT OR SAFETY POLICY Yes No 37. NAME AND ADDRESS OF OUTSIDE CLAIMS SERVICING/HANDLING ORGANIZATION: CONTACT NAME & TITLE: PHONE: LOSS HISTORY INFORMATION: A. PLEASE PROVIDE CURRENTLY VALUED, FIRST DOLLAR LOSSES FOR THE PAST TEN (10) YEARS. B. PLEASE PROVIDE COMPLTE DESCRIPTION OF ANY CLAIM PAID OR RESERVED DURING THE LAST TEN (10) YEARS FOR $100,000 OR MORE. IF NONE PLEASE INDICATE: 39. EMPLOYMENT PRACTICES LIABILITY QUESTIONNAIRE ATTACHED PLEASE COMPLETE AND RETURN WITH APPLICATION. ****************************************************************************************************************************************************************************** CITY OR PUBLIC ENTITY OFFICIALS SIGNATURE: TITLE: DATE: PHONE: Page 8 of 8