MINNESOTA PUBLIC SCHOOL PROGRAM QUESTIONNAIRE COMMERCIAL PROPERTY COVERAGE PART

Transcription

1 QUESTIONNAIRE Insured, ISD # & Name: Insured s Mailing Address: School Representative s Name: Agency s Name & Address: Agent s Name: Agent s Phone Number: Agent s Address: Title: COMMERCIAL PROPERTY COVERAGE PART Property Underwriting Information Complete the Following and Include any Remarks in the Remarks Section Below Does the school district have a wind turbine anywhere on its property? Are there plans to build a wind turbine in the near future? Do the school buildings limit access to a single, monitored entry during the school day? Are visitors required to sign in and wear visitor badges? Are surveillance cameras utilized? If yes, How long are the recordings kept? Where are the recordings kept? Does adequate lighting exist outside the premises? How is building access controlled? Yes No Are there any historic buildings or buildings with unique construction features such as ornate facades, columns, etc? If yes, is/are the building(s) listed on the MN Historical Register? Please describe: Are procedures in place when an employee or student takes equipment off premises? Are any buildings currently vacant or does the school district plan on vacating any structures in the near future? If so, please list below the structures and describe the security measures in place. Remarks:

2 COMMERCIAL GENERAL LIABILITY Exposure Base Information The following will need to be completed unless the information is otherwise provided on an ACORD Application. Classification Class Description Rating Basis # of or $ales Schools Public - Elementary, Kindergarten or Junior High Students Schools Public High Students Faculty Liability for Corporal Punishment of Students Teachers Stadiums Operated By Insured Gross Sales Nurses Nurses Swimming Pools Each Pool Swimming Pools Commercially Operated Gross Sales Skating Rinks Ice Gross Sales Health Or Exercise Clubs Gross Sales Day Care Centers Persons (average daily attendance) Clubs Members General Liability Underwriting Information Complete the Following and Include any Remarks in the Remarks Section Below Does the school district have a formal disaster control program including periodic drills for the protection of students? With regards to the school district s Emergency Response Plan (ERP): A. Does your ERP apply to all school locations, including temporary locations? B. Is the ERP distributed to all employees? C. Are all school employees trained to access and use the ERP? D. Do you have a Crisis Response Team? If yes, how often do they meet? E. Do you work with or retain any professional crisis management companies? If yes, please list the names of all the companies: Yes No Are formal safety procedures in place with the special hazards associated with shop, garage, and laboratory premises exposures? If yes, Are Protective guards on shop equipment present? Do vehicle repairs occur on non-district vehicles? Please complete this section if the school district has a pool: Is there a diving board? Are the drain covers in compliance? Ratio of swimmers to staff if used by Community Education or Recreation Center. Please complete this section if the school district has a Community/Fitness Center: Is there an agreement between the school district and the center? (If yes, please provide a copy) The center is open: hours per day; days per week Is the center supervised during all hours of operation? Describe below any exposures / programs not typical to school districts including, but not limited to, such activities as riding stables, flight training or other aircraft exposures, student trips to foreign counties, etc.

3 Complete the Following and Include any Remarks in the Remarks Section Below Please complete this section if the school district has a Child/Day Care Center: The center is open: hours per day; days per week Number of staff members:. Are staff district employees? Are all children of school age? Is a formal plan in place for the snow removal of sidewalks and parking lots? Yes No Is a formal plan in place to inspect and repair playground equipment? Please complete this section if the school district s facilities are used or leased by outside organizations: Are outside organizations required to provide Certificates of Insurance showing their Limits of Insurance? Is the school district requesting they be listed as an Additional Insured on the policy of the outside organization? Does the school district have a trampoline exposure? Does the school district have climbing walls? If subcontractors are used for such things as snow removal, are Certificates of Insurance obtained and kept on record? Does the school district include in their hiring practices: A. Criminal background checks? B. Education verification? C. Reference checks? Is the school district created through a Joint Power Agreement? (If yes, please provide a copy) Does the school district have an anti-bullying policy in place? Does the school district have a written policy clearly expressing management commitment to child abuse prevention Zero Tolerance? Are there written procedures, rules, codes of conduct and disciplinary measures established for all staff and volunteers to clearly define how the child abuse prevention policy is to be implemented, and consequences for non-adherence? Have all of the teachers been trained to recognize the signs or symptomatic behaviors of a child who has been molested? Describe below how allegations of sexual abuse are dealt with by school administrators.

4 Complete the Following and Include any Remarks in the Remarks Section Below Is the school district currently party to any AIA Documents? If so, does the document waive the school s rights to subrogate against the contractor? Is the school district planning construction in the near future? Who is responsible for dispensing medication? Yes No Describe their duties and qualifications: Is a medication log maintained? Are parents required to complete medical emergency cards annually? School District s Athletic Program Policies Does the School District require: Signed Parent or Legal Guardian consent form allowing students to participate in School Varsity or Organized Sports while knowing there are inherent risks associated with playing these sports? Does the School District have formalized Concussion policies and procedures per Minnesota State High School League guidelines? Does the School District have a formalized Heat Stress Prevention policy and prevention program? Does the School District have a formalized Lightning/Threatening Weather Policy per Minnesota State High School League guidelines? Remarks:

5 BUSINESS AUTO COVERAGE Underwriting Information Complete the Following and Include any Remarks in the Remarks Section Below Yes No Does the school district employ a sub-contractor to bus students? If Yes, 1) Does the school district require the sub-contractor to provide Certificates of Insurance showing liability insurance limits equal to their own automobile liability insurance? 2) Does the school district require they be listed as an additional insured on the sub-contractor s policy? 3) Is the school district s subcontractor checking MVRs on their drivers? A copy of the Certificates of Insurance must be attached to this questionnaire. Do employees/volunteers use their personal vehicles on behalf of the school? Never? Occasionally? Frequently? If used, 1) For what purpose? 2) Does the Insured obtain copies of the individual or personal insurance policies from employees/volunteers? 3) Limits Required? 4) How frequently is this information updated? Is there a seat belt cutter available in each transporting vehicle (ex: car, van, suburban, bus) that is equipped with seat belts? Does the school district have a scheduled maintenance program for owned vehicles that includes written maintenance logs? Does the school district have an active safety program in place that includes, but is not limited to, scheduled safety meetings with drivers, review of accidents for future preventability and a safe driver awards program? Is the safety program monitored? Do drivers conduct a daily inspection of vehicles and complete a checklist? Are vehicles kept inside a garage when not in use? Does the school district have formal hiring procedures in place which includes, but is not limited to, preemployment physicals, reference checks, criminal background checks, MVR review? Does the school district have a driver-training program in place that includes classroom as well as road tests? Does the school district have pre-determined intervals for ordering MVRs? (Please describe below) Does the school district have criteria in place for evaluating MVRs? (Please describe below) Does the school own or lease Passenger Vans? If Yes, 1) Is training provided drivers to regarding the safe handling of these vehicles? 2) Do only specially-trained drivers operate these vehicles? 3) Is a plan in place to replace these vehicles with other types of vehicles?

6 Complete the Following and Include any Remarks in the Remarks Section Below Yes No Are any owned vehicles equipped with specialized equipment such as wheelchair lifts? If Yes, 1) Is special training in the use of this equipment provided? 2) Does the school allow only designated, adequately trained individuals to operate vehicles with lifts? 3) Are these vehicles equipped with tie-down belts to secure wheelchairs? Are any owned vehicles allowed to be used for personal use by school personnel or their family members? (Indicate which vehicles are used). Are any vehicles leased/rented to others? Please describe: Are any vehicles rented on a temporary basis from others? If yes, provide the annual rental expense $. Are any vehicles used for Driver Training Vehicles? If so, please identify in the automobile schedule. Is the school district in compliance with Federal, State, and local regulations affecting their operations? Remarks: Date Organized: Number of Board Members: Elected Appointed Number of Students: Current Year Prior Year Next Yr. Est. Number of Employees: Administration SCHOOL LEADERS LEGAL LIABILITY COVERAGE (Claims Made Coverage) Teachers / Teaching Assistants / Tutors (Full-Time) Teachers / Teaching Assistants / Tutors (Part-Time) Counselors (Masters Degree) Counselors (all other) Child Care Nurse LPN Nurse RN Nurse Practitioners Psychologists (Masters or PhD s) Psychologists (all other)

7 Therapists Occupational Therapists Physical Therapists Speech / Hearing Other Professionals All Others School Leaders Underwriting Information MINNESOTA PUBLIC SCHOOL PROGRAM Did any of the following take place in the last three years? Yes No School Closing School Opening Staff Reduction Strike Lay-off Does the school contract with individuals to perform professional services on behalf of the school? If yes, does the school district obtain a Certificate of Insurance for the contracted individual? Does the school obtain Certificates of Insurance, as evidence of medical malpractice coverage or any other professional coverage carried, for employed/contracted/volunteer professionals? If Yes, 1) Does the school district require employed/contracted/volunteer professionals to provide Certificates of Insurance showing adequate liability limits? A copy of the Certificates of Insurance must be attached to this questionnaire. Does the school s pre-employment background check include: Yes No 1) Professional references? 2) Fingerprint / FBI check? 3) State-level criminal background check? 4) Education verification? Are written performance evaluations performed on all employees at least annually?

8 Confidentiality Where are student information and records maintained? Who has access to this information? Are there security measures in place? What is policy regarding release of information? Does the school district have a prescribed curriculum for each grade level? Yes No Has any employee been suspended, dismissed, demoted, transferred, or have had their tenured contract non-renewed? If yes, please describe (offer no names): Have there been formal allegations involving integration, segregation, discrimination, or violation of civil rights in the last three years? Has any person, former employee, or job applicant made a claim alleging unfair or improper treatment regarding hiring, salary, advancement, demotion, suspension, or termination? Has any claim been made or is now pending against any person in his or her official capacity as an official, employee, or volunteer? Does any board member, employee, or volunteer have any knowledge of any negligent act, error, omission, or breach of duty that may reasonably be expected to give rise to a claim? While in your employment or under contract, has any person performing professional services ever been reprimanded, suspended or disciplined by any agency or governmental entity?

9 Remarks: Provide 5-year claims or losses (regardless of fault and whether or not insured) or occurrences that may give rise to claims. Please include the date of occurrence, coverage line, description, date of claim, amount paid, amount reserved and open/closed. Authorized District Signature / Title: Date: