Houses of Worship SuppApp - USLI

1 Page 1 of 4 HWP Sup_App 1/15 CARRIER: Houses of Worship supplemental ApplicationSUBMIT supplemental APPLICATION ALONG WITH A COMPLETED ACORD APPLICATION. PLEASE FILL OUT THE GENERAL INFORMATION SECTION, ALONG WITH THE SECTION(S) YOU ARE REQUESTING of coverage being requested: q General liability q Property q Non profit D&OGENERAL INFORMATION:1. Name of organization: _____2. Location address: _____3. Mailing address: _____4. Web site address: _____5. Does this organization have a tax exempt status as defined by the q Yes q No6. Does the organization have functioning and operational smoke and/or heat detectors in all public areas and units?

2 Q Yes q No7. Has the organization been cancelled or non-renewed for of insurance in the past three years? q Yes q No (If Yes , please provide details separately)RATING INFORMATION:8. Total # of buildings: _____ Total sq. ft. per building: Building 1: _____Building 2: _____Building 3: _____ Total sq. ft. being used for church operations per building: Building 1: _____Building 2: _____Building 3: _____9. Building Interest: q Owner q Tenant 10. For property coverage, provide limits: Building 1: _____ Building 2: _____ Building 3: _____ Contents 1: _____ Contents 2: _____ Contents 3: _____11.

3 Does the organization have any residential facilities for clergy only? q Yes q No If Yes , please provide square footage: _____(sq ft)12. Does the organization lease space to others? q Yes q No If Yes , apartments _____(# of units), Mercantile _____(sq ft), Other _____ Description of mercantile operations _____13. Total number of members : _____14. Total number of employees: Full Time: _____ Part Time: _____ Volunteers: _____ Seasonal: _____15. Annual revenue: _____ Fund balance (Total assets minus total liabilities): _____GENERAL LIABILITY:16. Check all services that apply and provide details for each: q School q Youth/Recreation center q Overnight camp q Missionary trips q Adult daycare q Soup kitchen q Pool q Medical ministry q Job training q Shelter operation q Fair q Rooming house q Cemetery q Other: _____ Details of checked items: _____17.

4 Are all exit signs illuminated on premises? q Yes q No18. Are there two or more means of egress? q Yes q No19. Any anticipated construction of new buildings or alterations to existing structures? (If Yes , please provide details separately) q Yes q No20. Does organization require commercial tenants to carry general liability insurance with organization named as an additional insured? q Yes q No21. Has the organization or any of its past or present directors, officers, trustees, committee members, employees, volunteers or others acting on behalf of the organization ever been accused of or been involved in a lawsuit, claim or criminal charge involving sexual abuse, sexual misconduct or sexual molestation?

5 Q Yes q Nopage 2 of 4 HWP Sup_App 1/1522. Are there child-sitting/nursery operations during the services? q Yes q No a. If Yes , is there a sign in and sign out procedure for the children? q Yes q No23. Does the organization have a childcare, after school program or day camp operations? q Yes q No (If Yes , please complete our Child Care Addendum to Storefront/Community Church)24. Is the organization involved with any missions or activities involved disaster recovery relief (physical aid), q Yes q No construction/renovations, home building, school (k-12), gym, adult daycare or prison ministry services?

6 25. Does the organization participate in, organize, or sponsor any events that include fireworks, firearms, hunting, q Yes q No water hazards, overnight camps, bon fires, haunted attractions, hayrides, or air shows?26. Does the organization operate a soup kitchen, food bank, thrift store, shelter, or cemetery? q Yes q NoABUSE AND MOLESTATION LIABILITY:27. Does your hiring process for employees and volunteer workers include questions about whether the individual has ever been convicted of any crime and involved in any lawsuit, claim or criminal charge involving sexual abuse, sexual molestation or sexual misconduct?

7 Q Yes q No28. Do you require and verify prior employment and personal references on every prospective employee? q Yes q No29. Except for bona fide counseling sessions, are minors ever left alone with only one adult in any program, service, event or other church-sponsored activity? q Yes q No30. Do you follow policies or procedures for the proper supervision of employees and volunteers who are in direct contact with minors and other individuals in all on-site or off-site programs, services, events or other activities of applicant? q Yes q NoPASTORAL PROFESSIONAL LIABILITY: Check limit option that applies (can not exceed GL Limit): q 100,000 q 300,000 q 500,000 q 1,000,00031.

8 Does the organization have more than five pastors/clergy on staff? q Yes q No32. Does the organization offer counseling services for a fee? q Yes q No33. Does the organization utilize contracted counseling providers? q Yes q No34. Are members referred to specialists when appropriate? q Yes q No35 Are procedures in place to protect the confidentiality of members? q Yes q No36. Have there been any prior allegations, claims or suits as a result of counseling services? q Yes q No37. HIRED AND NONOWNED AUTO: q Check if coverage is desired and answer questions a-c Note: If hired/nonowned is checked, limit will equal general liability occurrence limit.

9 A. Does the organization have a business (or commercial) automobile insurance policy in force or own or lease autos on a long term basis? q Yes q No b. Does the organization regularly transport people or deliver goods or products? q Yes q No c. Does the organization require its employees to use their personal automobile to conduct the organization s business on a regular basis? q Yes q NoPROPERTY:38. Does the organization s buidings have aluminum wiring (including partial) or knob and tube wiring? q Yes q No39. Is 100% of the electrical wiring on functioning and operational circuit breakers?

10 Q Yes q No40. Are any buildings currently damaged by fire or otherwise? q Yes q No41. Are any buildings partially constructed? q Yes q No42. Is this property a seasonal operation? q Yes q No43. Has the organization had any bankruptcies, tax or credit liens against them in the past five years? q Yes q No44. Has any officer or board member of organization been previously convicted of the felony of arson? q Yes q No45. Are functioning and operational fire extinguishers readily available? q Yes q No46. Are there any wood-burning stoves, space heaters or temporary heating devices? q Yes q No47. Are any locations mobile homes?