Check here and skip this section if you do not want this coverage option
Coverage is contingent upon underwriting review and approval of the following questionnaire.
Does your organization currently have employees, volunteers or require the presence
of at least two adults when minors are present? Yes
No
Have any claims, allegations or charges of abuse, molestation or sexual misconduct been made against you
or your organization or anyone working on behalf of your organization?
Yes
No
Are you aware of any occurrences that could lead to a claim?
Yes
No
If you are aware of any occurrences please explain:
Do you, your organization or sanctioning/governing body have written procedures in
place regarding the prevention and mitigation of abuse, molestation or sexual misconduct?
Yes
No
Do the procedures require that known or suspected abuse incidents must be
be reported to law enforcement?
Yes
No
Are written procedures provided or available to each employee, volunteer or
sanctioning/governing body member?
Yes
No
Do the written procedures establish and require adherence to the “three person
rule”? (“Three person rule” prohibits one adult from being alone with one youth. A
second adult must be present, or there must be two or more youths with an adult.)
Yes
No
If no, do the procedures establish if and when exceptions to the “three person rule”
are permissible as part of your operations/activities?
Yes
No
Check here and skip the chart below if you have no employees or volunteers, but always require the presence
of at least two adults whenever minors are present
Please complete the following questions regarding employee and volunteer screening controls used by your
organization.
Are written applications required for employees?
Yes
No
Are written applications required for volunteers?
Yes
No
Employees : Does the application include questions about
whether the individual has ever been convicted for any
crime involving physical violence or sex related offenses?
Yes
No
Volunteers : Does the application include questions about
whether the individual has ever been convicted for any
crime involving physical violence or sex related offenses?
Yes
No
Employees : Are background checks provided by a third party
vendor/service?
Yes
No
Volunteers : Are background checks provided by a third party
vendor/service?
Yes
No
Please explain any “No” responses to employee and volunteer questions
Select an Option
Choose
Option 1 - $1 million limit
Option 2 - $100,000 limit
Annual Gross Receipts:
Rate:
Subtotal:
Molestation Premium :
Please make sure that you have completed everything to the best of your knowledge before going to the next page.