Community Service Insurance Program

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1 Community Service Insurance Program Patriot Insurance Agency, Inc. DBA: Arizona Patriot Insurance Agency, Inc. in CA, NC, ND P.O. Box 1298 Sonoita, AZ Phone: Fax: Toll Free Number: They depend upon you, and you can depend upon us.

2 Patriot Insurance Agency, Inc. DBA: Arizona Patriot Insurance Agency, Inc. in CA, NC, ND P.O. Box 1298 Sonoita, AZ Phone: Fax: Toll Free Number: This Pro-Life insurance program was the first ever specifically developed for Crisis Pregnancy Centers, Pregnancy Care Clinics, and Maternity Homes. All organizations regardless of national affiliation may apply. When purchasing insurance please be sure to compare our Counselor's Professional Liability policy to any others you may be considering. Over 1200 centers throughout the United States have chosen this program because of its superior coverage and savings. Again this year we are offering substantial distinctions, which surpass other policies. If at anytime you are in need of insurance, loss prevention advice or assistance please feel free to call. May God bless the lineage of love you give each day. Sincerely, Patriot Insurance Agency, Inc

3 Program Coverage The following pages offer a general explanation of Insurance, Bonds, and Financial Products offered at group rates through the Community Service Insurance Program. This summary in no way changes or affects the insurance afforded under such policy as actually issued. All coverages are subject to the actual Policy conditions and exclusions. Each organization participating in the program will receive a certificate of insurance describing the exact coverage and benefits provided within the program master policy. After you have read this booklet, if you have any questions, please feel free to call us at "Master Policy" Under this special program your Professional Liability, General Liability, and Hired and Non-Owned Automobile Liability policies are written through a master policy program. This means: 1. Each organization still retains its own Individual Limits. 2. Major cost savings to the Insurance Company because they only have to print one master policy. This greatly reduces their processing costs. The savings are passed on to you. 3. Individual Certificates (proof) of Insurance will be issued to you upon approval of your application. Payments included with an application DOES NOT constitute underwriting acceptance. 4. You may have a copy of your own Policy Wording upon request. Please call for copies. 5. Program effective dates run from July 1, 2012 to July 1, 2013 of each year. You may join at any time. If you purchase optional policies such as Director's and Officers' Coverage, Medical Clinics or Pregnancy Diagnostic Services, Property Coverage for Buildings or Increased Limits on Contents, Group Medical Insurance, Life Insurance, Fidelity Bond/Employee Dishonesty Coverage, Umbrella/Excess Coverage, Tax Deferred Annuities or Adoption Liability, these will be issued individually to each organization/center. 2

4 Three-Part Program with Optional Products Available Standard Program includes of 1. Comprehensive General Liability. Limit: $1,000,000 Per Occurrence $3,000,000 General Aggregate. There will be a $2,500 Deductible. On a Claims Made Basis. 2. Counselor Professional Liability. 3. Hired and Non-Owned Automobile Liability. Optional Insurance and Financial Products: 1. Directors and Officers Coverage 2. Medical Clinics or Pregnancy Diagnostic Services 3. Property Coverage for Buildings or Coverage on Contents 4. Adoption Liability Coverage 5. Sexual Abuse/Molestation Coverage 6. Group Medical Insurance 7. Life Insurance 8. Fidelity Bond/Employee Dishonesty Coverage 9. Umbrella/Excess Coverage 10. Tax Deferred Annuities (T.D.A.'s) 11. Workers Compensation 12. Volunteer Accident 3

5 PART ONE Comprehensive General Liability Individual Policy Limits Each primary Organization has their own individual limit of $ 1,000,000 Per Occurrence and $ 3,000,000 Aggregate Major Benefits 1. Special program rate greatly reduces cost 2. Claims Made Basis 3. Deductible of $2500 per occurrence Claims made covers only those losses that are reported during the policy term. What is Covered? For example: 1. Bodily Injury to a third party for slip and fall claims ON or OFF your "premises" including meetings, fund-raising events and walk-a-thons. 2. Property Damage to a third party's property e.g. should the insured damage property during a meeting, fund-raiser or event. Fund Raising Activities You are covered for normal fund raising activities such as; Walk-A-Thons & Banquet Dinners. Please call if you have additional activities. We will supply you with a Certificate of Insurance Request Form/Special Event Questionnaire which will need to be completed and returned for review. Who is liable when I rent equipment or services from vendors? If an outside group, company, or vendor is used to run an event or supply equipment or products, it is necessary to obtain proof of coverage from that supplier or company, usually in the form of a Certificate of Insurance. Be careful not to sign a Hold Harmless Agreement releasing a supplier against defective equipment. 4

6 PART TWO Professional Liability Who is Covered? Board Members, Directors, Officers, Employees and Volunteers for all counseling activities relating to the duties and responsibilities of providing pregnancy related counseling and related support services. This program was specifically designed for the counseling activities surrounding the operation of a Crisis Pregnancy Center, to include Maternity Homes and Post Abortion Counseling. If you are a Medical Clinic or are involved in pregnancy diagnostic and confirmation services using sonograms or physical examinations please call us for details on a separate policy which will cover this additional exposure. What is Covered? Coverage applies to claims arising out of misinformation, improper counseling, guilt syndrome, mental anguish or misrepresentation. Limits: $1,000,000 Per Occurrence $3,000,000 Per Named Organization Aggregate Limit What is NOT Covered? If your Organization has an extensive social service mission involving counseling of rape victims, sex abuse, suicide, spouse abuse, adoption, sexual molestation or other counseling services, please call us so we can provide you with an explanation of this endorsement. 5

7 PART THREE Hired and Non-Owned Auto Liability Coverage Hired includes an automobile the organization hires, rents or borrows, but not automobiles owned by the insured, employee, volunteer, or staff. Non Owned is an automobile owned by an employee, volunteer or staff while being used in the business of the organization. Limits available are: $300,000, $500,000 or $1,000,000. Deductible of $2,500. Provides automobile liability coverage over and above a driver's personal insurance, when using it for business purposes. This is Third Party Liability Insurance, e.g., it will pay Bodily Injury and Property Damage claims on behalf of the person's auto you hit. This is not physical damage coverage for your employee s, volunteer's, or staff's automobile. Their own individual policies should apply. 6

8 Optional Coverages These options are available on an individually underwritten basis at special program rates. Please call for an application. 1. Directors & Officers Coverage Who is Covered? Your organization, directors, officers, trustees, employees, volunteers, members of the staff, faculty or any duly constituted committee of your organization. Examples of What is Covered Claims or allegations of: 1. Errors in Management 2. Waste of Assets 3. Discrimination, Wrongful Termination or other Employment Related Claims 2. Professional Medical Clinics or Sonogram Diagnostic Services Pregnancy confirmation services such as the use of a sonogram or physical examinations require a greater form of Professional Liability Coverage. Patriot Insurance Agency, Inc. has developed a special program for this additional coverage. Please call for an application. 3. Property Coverage For Buildings or Coverage on Contents For those organizations that own their own buildings, or for the business personal property/contents coverage at their location, a separate quote can be provided. Please see the attached property application for required information. 4. Adoption Liability Professional Liability for organizations that specialize in Adoption Services to their clients. Please call for an application. 7

9 5. Sexual Abuse/Molestation Coverage Coverage for claims or allegations of Sexual Misconduct. Please call for an explanation of this endorsement. 6. Group Medical Insurance Major Medical coverage for groups of two or more. Please call for a census form and information. 7. Life Insurance Individual Life Insurance coverage and benefits provided on a case by case basis. Please call for application. 8. Fidelity Bond/Employee Dishonesty Coverage Protects the organization against theft of money and securities by dishonest employees. Limits of $10,000 - $25,000 - $50,000 or higher are available at special program rates. Please call for application. 9. Umbrella / Excess Coverage Additional coverage above and beyond that of your primary coverage limit can be quoted up to $50,000,000. Please call for application. 10. Tax Deferred Annuities (T.D.A.'s) Employees of 501c3 nonprofit organizations are eligible for these retirement and investment opportunities. Please call for an informational brochure. 11. Workers Compensation Please call for an application. 10. Volunteer Accident Please call for an informational brochure and application.

10 8 Directors & Officers Liability $1,000,000 Annual Aggregate Limit on a Claims Made Basis Who is Covered? All Directors, officers, trustees, and employees, including staff, volunteers, and committee members. Policy Highlights Each organization has its own individual limit of coverage. Various Limits will be quoted, Such as: $500,000 and $1,000,000 up to $3,000,000 Major benefits could include: Duty to defend Entity Coverage Defense coverage is outside the limit of liability Prior Acts coverage Provides coverage for claims brought by insured persons Coverage for wrongful termination and employment related practices (Optional) To apply for a quotation, please contact our agency to request the insurance application. Once you have received please complete the application and return to our agency so we may begin the quotation process.

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12 What To Do Next Please forward the completed application to our agency to receive a proposal of insurance. You may either mail or fax to our agency. The proposal will indicate how to request the policy to be bound. 2. Upon underwriting acceptance your check will be deposited and a Certificate (proof) of Insurance will be sent to you. Your mailed check or payment does not constitute underwriting acceptance or approval, only a Certificate of Coverage is deemed as proof of coverage. 3. Retain the program booklet for future reference. 4. If at any time you require additional Certificates of Insurance, please feel free to call. Additionally, once you become aware of any claim, please notify us within five (5) business days. 10

13 Patriot Insurance Agency, Inc. DBA: Arizona Patriot Insurance Agency, Inc. in CA, NC, ND P.O. Box 1298 Sonoita, AZ Phone: Fax: Toll Free Number: DIRECTIONS FOR OBTAINING A QUOTATION Please find enclosed the application regarding Package Liability coverage to be completed. Please follow these easy steps to expedite your request for a quotation: 1. Make sure that all questions are answered completely and as accurately as possible. Missing information will delay your quotation. 2. Make certain you sign the application. (Signing does NOT obligate you to purchase the coverage.) 3. Copies of Advertisements: a. Yellow Pages, Newspapers, Church Bulletins, Brochures, TV/Radio 4. A copy of the membership of an affiliation with a National Organization. 5. Should you have prior coverage, please provide current loss runs (claims history report from carrier). a. If no prior insurance, forward the Executive Director s resume. 6. Board of Director Guidelines 7. Client Referral Guidelines 8. Personnel Procedures 9. Hired and Non Owned a. Motor vehicle reports (MVRs) b. Copies of personal auto policy declaration pages. Upon receipt of the above information, a quotation is generally available within fifteen (15) business days. Should we be of further assistance, please contact our Underwriting Department at Thank you. Please forward all the above information to our agency via mail, fax or . Thank you for allowing us to service your insurance needs and we look forward to working with you in the near future.

14 Patriot Insurance Agency, Inc. DBA: Arizona Patriot Insurance Agency, Inc. in CA, NC, ND P.O. Box 1298 Sonoita, AZ Phone: Fax: Toll Free Number: COMMUNITY SERVICE INSURANCE PROGRAM APPLICATION 2012 to 07/01/2013 Term Organization s Legal Name: APPLICANT INFORMATION SECTION Name of Director/Contact: Mailing Address: (Including City, State and Zip) Physical Location Address: (Including City, State and Zip) Telephone Number: Fax Number: Address: Web Page Address: Federal Identification Number: WARRANTY Please understand that your answers and responses throughout this application serves as a warranty. Your completed application will become part of the wording and conditions of your organization s policy. Therefore, any misrepresentation or omissions made on this application may void any or all coverage benefits under these policies. Your signature below acknowledges that you understand this warranty and certifies your responses to be true and correct. Applicant s Signature Applicant s Name (printed) Date: Title: LOSS EXPERIENCE SECTION Over the last four years have any claims, incidents or lawsuits been brought against your organization or affiliated organization? YES* NO *If yes, please attach detailed claim information with the date of loss or occurrence, the status, the amount reserved or paid and a description of the claim or allegation. This application form duly completed, together with any supplementary information must be signed in ink by the Executive Director or Board President. ALL QUESTIONS MUST BE COMPLETED, SIGNED AND ANY APPLICABLE INFORMATION PRESENTED BEFORE A QUOTE CAN BE OFFERED.

15 COMMUNITY SERVICE INSURANCE PROGRAM APPLICATION 2012 to 07/01/2013 Term Page 2 of 6 DESCRIPTIONS OF OPERATIONS SECTION Please describe your organization s operation, purpose, and daily functions. (Please use a separate sheet of paper if more space is required.) 1. Are you affiliated with a National Organization? If yes, please indicate 2. Do you have a maternity home or operate an overnight facility? YES NO a. ** If yes, Are you licensed by the state(s) in which you operate? YES NO (Please attach copy of license and latest inspection.) b. Is it renewed: Annually Semi-Annually Other: 3. Are you a multi-location organization? YES* NO *If Yes, please attach (on a separate sheet of paper) a schedule which will contain the following information for each location: (1) the physical location address, (2) the hours of operation per week including weekends if applicable (3) a description of the services provided to your clients. 4. Average number of hours per week the main location is open: 5. Average number of Employees: Average number of Volunteers: 6. Average number of those providing counseling (Counselors) 7. How many new personnel were added + or left - your staff last year. 8. Are you organized as a 501(c)(3) nonprofit organization? YES NO 9. Name of present insurance carrier for General Liability and Professional Liability: Expiration Date: Premium: Effective Date Organization Began Service: Date of Incorporation of your Organization:

16 COMMUNITY SERVICE INSURANCE PROGRAM APPLICATION 2012 to 07/01/2013 Term Page 3 of 6 PROFESSIONAL LIABILITY SECTION 1. Is there an established training and continuing education program provided for all counselors? YES NO If Yes, does the training and education provided to your counselors teach counseling with a loving/factual approach to your clients? Specifically, are the harsh techniques of employing the pressures of guilt or mental anguish rejected as an appropriate counseling procedure? YES NO 2. How often does the Director conduct a performance review with the individual counselors? Is this review done in writing? YES NO 3. Do you make referrals to an adoption agency? YES NO If Yes, do you have a Hold Harmless Agreement signed by your client? YES NO 4. Do you have a licensed physician practicing at your location? YES NO 5. Do the physicians you refer your clients to carry their own Professional Liability Insurance? YES NO If Yes, do you require proof of coverage? YES NO 6. Do you provide rape, sex abuse, suicide, spouse abuse, substance abuse, or other extensive social service counseling? YES** NO **If so, this Insurance Program does not cover the exposures associated with operating these extensive social service operations as described above. We have a separate program available to cover these exposures. (Please call for information.) 7. Are you a Pregnancy Care Medical Clinic? YES** NO **A Pregnancy Care Medical Clinic provides sonograms, physical examinations, and other select medical services. **If Yes, this Insurance Program does NOT cover these exposures. A separate policy may be added to cover these additional exposures. (Please call for information.) 8. Please provide the annual number of client contacts (visits, call-in etc.) for the following services: Pregnancy counseling: Individual Pregnancy counseling: Group Family/Independent Living Skills Training Adoption / Foster care counseling* (*Other than Options Counseling) Adoption / Foster Care Referrals Other types of counseling (describe below) # of Visits

17 COMMUNITY SERVICE INSURANCE PROGRAM APPLICATION 2012 to 07/01/2013 Term Page 4 of 6 GENERAL LIABILITY SECTION 1. Does your location maintain dry floors, unobstructed walkways and halls during operating hours in order to reduce the exposure to accidental slip and fall claims? YES NO 2. Many landlords require General Liability limits of $1,000,000 per location. Does this amount adequately meet the requirements of your lease? YES NO* *If not, what Liability Limit is required? **Program automatically includes $1,000,000 General Liability Limit. Additional excess Umbrella limits may be purchased. Please call for an application. 3. YOUR ADDITIONAL INSUREDS: Insurable Interest check the box that applies: Name: Funding/Placement Landlord Contract/Service Address: Other: Please Describe: Name: Funding/Placement Landlord Contract/Service Address: Other: Please Describe: 4. Do you lease or sub-lease to others any portion of the locations scheduled on the application? YES NO a. If yes, do you require that your tenant carry liability insurance for the Occupancy? YES NO b. If yes, how do you make sure the coverage is maintained? 5. Is care taken in planning and coordinating your fund raising activities? Specifically, do you require all vendors or equipment suppliers to provide a Certificate (proof) of Insurance, prior to remitting payment for their services? YES NO 6. In the past have you safely planned and managed crowd control, movement, and overflow parking during your events? YES NO 7. When you hold a meeting or event is care taken when using property of a Third Party (such as: church, school, etc?) Yes No 8. Are volunteers, employees, or those working at your center covered by Workers Compensation Insurance or Personal Health Insurance or Group Medical Insurance? YES NO

18 COMMUNITY SERVICE INSURANCE PROGRAM APPLICATION 2012 to 07/01/2013 Term Page 5 of 6 ADVERTISING LIABILITY SECTION 1. Please indicate if you advertise in the newspapers, yellow pages, church bulletins or other print media? YES* NO *If Yes, what classified heading(s) are used for your ads? 1. Abortion 2. Abortion Services 3. Clinics 4. Family Planning/Birth Control 5. Social Services 6. Abortion Alternatives 7. Pregnancy Counseling 8. Other please describe: 2. Do you advertise on the radio or television? ** YES NO If either media is utilized, does the script include any ambiguous terminology while describing exactly what services you provide? YES NO **PLEASE INCLUDE A COPY OR SCRIPT OF YOUR RADIO OR TELEVISION ADVERTISEMENT. HIRED AND NON-OWNED AUTO LIABILITY SECTION (Subject to Underwriting Approval) 1. Do you provide transportation for your clients? YES NO 2. Do employees, workers, or volunteers use their vehicles on behalf of the organization? YES NO It is management s responsibility to establish and enforce drive selection criteria 3. Do you order Motor Vehicle Reports (MVR) annually for all employees and volunteers driving their vehicles on your behalf? YES NO 4. Do you have a procedure for evaluating MVR s to identify unacceptable/marginal drivers? YES NO 5. Does the Organization verify that the employees or volunteers have their own vehicles properly insured? YES NO PLEASE NOTE: Evidence of adequate insurance must be updated annually.

19 COMMUNITY SERVICE INSURANCE PROGRAM APPLICATION 2012 to 07/01/2013 Term Page 6 of 6 OPTIONAL: PHYSICAL & SEXUAL ABUSE SECTION (Subject to Underwriting Approval & Additional Premium) 1. Does your state permit you to do criminal background investigations on prospective employees/volunteers? YES NO a. If yes, do you routinely request and receive such background investigations? YES NO b. If yes, how often? 2. Do you verify employment related references? YES NO 3. Do you verify educational requirements? YES NO 4. Do you conduct a personal interview? YES NO 5. Are professional licenses checked for employees/volunteers? YES NO 6. Do you provide new employee orientation? YES NO 7. Do you discuss at staff orientations, physical and sexual abuse issues, how to recognize the signs and what to do if a client reports someone molested him/her? YES NO 8. Do you have a plan of supervision that monitors staff in day-to-day relationships with clients? YES NO 9. Do you have a crisis management plan for dealing with staff, victim, parents, authorities and media if you have an incident of abuse? YES NO 10. Have you ever had an incident which resulted in an allegation of sexual abuse? YES NO 11. Was a claim ever made against you? YES NO

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