CULTURAL INSTITUTION RISK PURCHASING GROUP APPLICATION

Transcription

1 CULTURAL INSTITUTION RISK PURCHASING GROUP APPLICATION 1. Applicant name: 2. Mailing address: City: State: Zip code: 3. Do you own or lease the facility? Own Lease 4. Year business was established? Number of years under present management? FEIN: 5. List all Named Insureds and their interests: Note: The First Named Insured requires common/majority ownership of each Named Insured. If not, please explain. a. b. c. d. e. Explanation: 6. Please describe your scope of operations and types of productions: 7. What is the average number of productions? 8. What is the average length of a production? 9. Are all productions produced by you or do you bring in outside productions? 10. Do you rent your facility to others? (if yes, include a copy of the rental contract) Yes No 11. Please provide insurance requirements of any third party vendors/contractors (i.e. Janitorial, Security, Contractors) 12. Do you tour domestically or internationally? Domestically Internationally Neither 13. Do you teach any classes on premises? Yes No 14. Do you go into schools? Yes No DeWitt Stern Group 420 Lexington Ave Suite 2700 New York, NY T page 1/5

2 GENERAL LIABILITY 1. Annual number of attendees (all events): Total seating capacity: Sales/Receipts: a. Food/Restaurant: $ b. Liquor: $ c. Gift Shop: $ Describe: d. Parking: $ e. Tickets: $ f. Other: $ Describe: 2. Estimated total payroll for the upcoming 12 months: 3. Any performing arts camps? (if yes, attach a brochure) Yes No a. Number of dates the camp is open: b. Number of campers: c. Are waivers with parental/guardian consent required? (If yes, attach a copy) Yes No d. Day Camp Overnight Camp e. Age range: f. Do you have any field trips? (If yes, attach a schedule) Yes No g. What mode of transportation do you use for field trips? School Bus Public Transportation Other, please specify h. Who is responsible for transportation of the kids to and from the premises? Insured Parents Charter a Bus (If yes, please confirm that you do obtain a Certificate of Insurance from the Bus Company that includes your company as an Additional Insured) 4. Any school operations? Yes No a. Number of days the school is open: b. Number of students: c. Are waivers with parental/guardian consent required? (If yes, attach a copy) Yes No d. Age group of students: 5. Any childcare services provided? If yes, provide details: Yes No 6. Do you have Automated External Defibrillator(s) (AED)? Yes No a. If yes, are staff members trained to use it? Yes No b. Do you have a First Aid Kit on premises? Yes No c. If yes, are staff members trained to use it? Yes No 7. How many means of egress? a. Are doors locked during performances? Yes No b. Are all exits clearly marked? Yes No c. Are all doors equipped with panic hardware? Yes No 8. Do you have backup emergency lighting and/or emergency generators in the event of a power failure? Yes No 9. Do you have an emergency evacuation plan? (If yes, attach a copy) Yes No a. Evacuation procedures and floor plans posted? Yes No 10. Do you have a parking lot? Yes No 11. Any valet parking? Yes No a. Is the valet parking operation outsourced to a 3rd party? Yes No b. Do you obtain Certificate from the valet company? Yes No DeWitt Stern Group 420 Lexington Ave Suite 2700 New York, NY T page 2/5

3 c. If your employees provide the valet parking, do you run Motor Vehicle Reports on those employees? Yes No 12. Is parking lot well lit? Yes No 13. Is parking lot patrolled by security? Yes No ABUSE AND MOLESTATION (Please complete the following if there is any involvement with minors under the age of 18) 1. Does your employment process (for employees and volunteers) include verification of whether the individual has ever been convicted of any crime, including sex related or child abuse related offenses, before an offer of employment is made? Yes No 2. Do you verify employment references for employees and volunteers? Yes No 3. Do you conduct personal interviews? Yes No 4. Are formal written procedures in place for hiring? (If yes, attach a copy) Yes No 5. Is there a written supervision plan that monitors staff in day-to-day relationships with clients, both on and off premises? (If yes, attach a copy) Yes No 6. Is there a written crisis plan for dealing with employees, volunteers, victims, parents, authorities and the media if you have an incident of abuse? (If yes, attach a copy) Yes No 7. Have any incidents resulted in an allegation of sexual abuse? Yes No a. If yes, was the case settled? Yes No b. Was the case taken to trial? Yes No c. Amount paid for damages to the victim: $ 8. Does your state allow criminal background checks? Yes No a. If yes, do you run criminal background checks prior to hire for: Yes No Employees? Yes No Volunteers? Yes No 9. What, if any, is the child to employee/volunteer ratio? Yes No LIQUOR (Please complete the following if there is liquor sold at your location) 1. Is the liquor license in Applicant s name? Yes No a. If no, what is the name on the license and their relationship to the insured: b. Liquor license number: c. Class of license: 2. Is the liquor service sub-contracted to a third party? Yes No a. If yes, provide limits of liability maintained by the sub-contractor: b. Is Applicant listed as Additional Insured under sub-contractors liquor liability coverage? Yes No c. Is Contingent Liquor Liability coverage requested by the Insured? Yes No DeWitt Stern Group 420 Lexington Ave Suite 2700 New York, NY T page 3/5

4 3. Type of beverages sold: 4. Do the servers receive any type of alcohol awareness training? Yes No If yes, explain: EMPLOYEE BENEFITS 1. Proposed Retroactive Date: 2. Deductible: 3. Number of employees: 4. Limit of Insurance Each Employee/Aggregate 5. Losses and Known Acts, Errors or Omissions, which may result in claims being made under this insurance (Last 5 Years): (If none, state None ) 6. Employee Benefits provided. Mark with an I for Insured Plans and use an S for Self-Funded or Self-Insured Plans. Group Life Unemployment Insurance Group Accident Social Security Benefits Group Health Workers Compensation Group LTD Disability Benefits (required by states) Group Profit Sharing Plans Stock Subscription Plans* Pension Plans *EXPLAIN ELIGIBILITY FOR STOCK SUBSCRIPTION PLANS 7. Name and title of the person who has responsibility for the management of your employee benefit program: a. Number of years in this position: b. Number of years experience in the administration of benefits plans: 8. Are all Personnel who counsel employees about benefits familiar with the details of the pro-grams shown in Item #6 above? Yes No 9. Are all Personnel who counsel employees about benefits familiar with COBRA Requirements? Yes No 10. Are all programs in compliance with COBRA Requirements? Yes No Please explain any no responses: 11. Do you administer any benefits plans for others? Yes No If yes, please explain: 12. Have you rejected the Workers Compensation Acts in any states? Yes No If yes, what states? Do you offer alternative benefits packages in those states? Yes No If yes, please describe. 13. For optional Employee Benefits, are rejections, either signed or electronic, required and kept on file? Yes No DeWitt Stern Group 420 Lexington Ave Suite 2700 New York, NY T page 4/5

5 HIRED AND NON OWNED AUTO 1. Does the company own any vehicles? Yes No 2. Do your employees or volunteers routinely use their autos for company business: Yes No Total Number of Employees: Total Number of Volunteers: 3. Please provide the estimated Cost of Hire for all rental vehicles (cars, trucks, etc) during the next 12 months: UMBRELLA BENEFITS 1. Limit Requested: $ CONTACTS SIGNING THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE COMPANY TO COMPLETE THE INSUIRANCE, BUT IT IS AGREED THAT THE INFORMATION CONTAINED HEREIN SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE IS-SUED. IF ANY OF THE ABOVE QUESTIONS HAVE BEEN ANSWERED FRAUDULENTLY OR IN SUCH A WAY AS TO CONCEAL OR MISREPRESENT ANY MATERIAL FACT OR CIRCUMSTANCE CONCERNING THIS INSURANCE OR THE SUBJECT THEREOF, THE ENTIRE POLICY SHALL BE VOID. I/WE HAVE READ THE ABOVE AND AGREE THAT TO THE BEST OF MY/OUR KNOWLEDGE AND BELIEF SAME FULLY REPRE-SENT THE TRUE STATEMENT OF FACTS: APPLICANT: SIGNED BY: TITLE: DATE: AGENT/BROKER: SIGNED BY: TITLE: DATE: DeWitt Stern Group 420 Lexington Ave Suite 2700 New York, NY T page 5/5