AVENUES EDUCATIONAL ADVANTAGE PROGRAM
HIGHER EDUCATION RISK SUPPLEMENTAL APPLICATION
Effective Date:
Named Insured:
Agency: Agency Code:
Please attach the following to submission:Company Loss Runs (minimum 3 years) School Handbooks, Brochures (if any)
ACORD Applications for all coverages desired Statement of Values
Schedule of Owned Vehicles Photos of all primary building structures
GENERAL INFORMATION
1.Type of accredited school:
Public college or university Private college or university
Trade or Vocational School Community college
Other (describe )
2.Date school founded or chartered:
3.Any policy or coverage declined, cancelled or non-renewed during the prior 3 years? Yes No
4.Prior Carrier Information:Carrier: Premium:
5.What are your annual receipts: from tuition? $
6.Please provide your total enrollment:
Undergraduate Graduate Adult Education
7.Please provide number of personnel employed:
AdministratorsTeaching Faculty Counselors/Psychologists
NursesAthletic Trainers Nonprofessional EmployeesVolunteer Workers Security Personnel All other
8.Total revenues (current fiscal): Total expenditures (current fiscal):
Total accumulative Deficit $ or Surplus $
9.Indicate any of the following Hiring Practices followed by the administration:
Signed employment applications are obtained for all potential employees
Employee referrals are used
Complete personal references are checked
Criminal background checks on all employees are required
Criminal background checks on volunteer workers are required
Documentation of employment applications and background/reference checks maintained
An employee orientations are conducted covering all Written Policies with documentation kept in file
Written employee handbook (provide copy)
SAFETY/SECURITY
1.Do you have a written safety policy in place? Yes No
2. Do you have an “all-hazards” emergency response plan in place? Yes No
Does your plan include response procedures to disease/pandemic outbreaks? Yes No
Does your plan require compliance with CDC and/or USDOE guidance? Yes No
3.Is there a Safety Committee with regular safety meetings conducted? Yes No
4.Please indicate any of the following building access and safety procedures that are in place:
visitor sign in procedures exterior doors locked during school day security cameras utilized
fire & emergency drills conducted metal detectors other security measures
5.Is there a security force on campus? Yes No
If yes, whose employees? the school Independent Contractor Auxiliary of local police
6.Do the local Police patrol regularly? Yes No If yes, what is the frequency?
7.Do Emergency Response Services (police, fire/rescue, and medical) participate in emergency planning? Yes No
8.Does the emergency plan include provisions identifying alternate facilities if part or all of a building
becomes unusable? Yes No
PROPERTY INFORMATION
(See Dormitory Supplemental Application for Residential Property Exposures)
- Indicate any of the following safety procedures currently in place to adequately control premises condition:
Written policy on reporting all property damage incidents to police(i.e. buildingentry, vandalism, etc.)
Preventive Maintenance Program of electrical & heating equipment, roofs, and plumbing.
Cooking equipment (NFPA 96 Fire Protection of commercial cooking operation:automatic fire suppression systems (UL300) and standard ventilation hood and ductwork)
Science Labs – chemical storage practices, ignition sources, and gas fuel shut-off devices
2. Indicate courses offered in vocational technology include Woodshop Auto repair Construction
Operation meets safety standards: flammable/combustible liquid storage, spray finishing processes
3.Does the school own any buildings that are vacant or unoccupied? Yes No
Please provide details for each building including future plans for structure:
4.Has the school secured a Professional Appraisal to establish the property values provided? Yes No
If appraisal completed, please provide copies with application.
If no appraisal, please advise the source utilized to determine values:
5.Is the emergency lighting installed in corridors and stairwells? Yes No
6.Are there any unusual building features or occupancies? Yes No
If yes, provide details:
7. Are there any buildings of historical value or listed on a historic register? Yes No
If yes, provide details:
GENERAL LIABILITY INFORMATION
1.Does the school have procedures in place for staff to conduct regular facility reviews to identify unsafe conditions and take corrective action to prevent accidents in the following areas:
Inspection of Interior/Exterior walking surfaces.
Please describe the frequency of inspections & how documented:
Written snow/ice removal procedures
Life Safety: adequate number of exits, emergency lighting, emergency procedures, and crowd controls
Food service: quality control measures in place for preparation/storage of food and housekeeping
2. Athletic Programs: please indicate any of the following procedures/activities that apply:
Student athletic permission slips and injury waiver signed by parent & obtained annually
Student Accident Policy offered to parents purchased by school district
Bleacher/Grandstand Inspections (NFPA 102 annually by staff/inspected by professional every 2 years).
3.Has asbestos, lead or toxic mold been detected in any school building or playground areas? Yes No
If yes, describe corrective actions:
4. Does the school own a student lounge or pub that serves liquor? Yes No
Please indicate if you have any of the following operations &/or activities
Foreign Travel Hall Rental Church or any Other House of Worship
Fund Raising Activities Before &/or After Care Dormitories / Housing
Radio Station Television Station Campus Newspaper
Work Study Programs Swimming Pool(s) Trampolines Events with liquor sales
Does your website comply with current state and federal privacy statues/regulations? Yes No
Please provide details of operations for each activity indicated above:
USE OF SCHOOL PROPERTY N/A
1.Do outside groups use the school property for activities? Yes No
If yes, describe:
2.Indicate if the school obtains any of the following:
Certificate of Insurance from group and $ Limits of Insurance required
Evidence that school is named as Additional Insured on groups’ liability insurance
A signed contract/agreement in which the school is held harmless (attach copy of the Building Use form).
SWIMMING POOLS N/A
1.Please indicate the number of pools:
2.Please indicate any of the below safety procedures in place:
Safety rules posted Lifeguard on duty at all times
Depth markings Pool locked after school hours
3.Are there any diving boards? Yes No
If yes, describe design (i.e. number/height)
4.Does the school allow use by outside groups? Yes No
5.If yes, do they require certificate of insurance? Yes No
CHILD CARE PROGRAM N/A
1.What are the hours of operation for the Child Care Programs?
2.How old are the children enrolled in these programs?
3.What is the teacher to child ratio for these programs?
4.What type of activities do they have in these programs?
5.Who operates the before/after care? school other
6.Who supervises the children? employed adults students volunteers
7.Does the school sponsor any special activities off-site? Yes No If yes, please explain:
What activities?
How transported?
Are permission slips obtained Yes No
SPORTS & ACTIVITIES (INDICATE ANY EXTRA CURRICULAR ACTIVITIES) N/A
Sports CampsGun ClubFireworks at sporting events
WatercraftHorseback RidingFestivals – parades
Rifle RangeSkateboard ParksAssociation with park departments
Ski Team/ClubRock climbingCanoeing Club
Challenge rope courseClimbing WallsOther
Please provide details of operations for each activity indicated above:
STUDENT FOREIGN STUDY PROGRAM or TRAVEL N/A
1.Are school-sponsored foreigntrips / study programs conducted? Yes No
If yes, describe:
If yes, is there Foreign Liability coverage in place? Yes No
SECTION V – CRIME N/A
Coverage / Limit / Deductible
Form A/O – Employee Dishonesty / $ / $
BLANKET SCHEDULE / $ / $
Form B – Forgery or Alteration / $ / $
Form C – Theft, Disappearance & DestructionInside / $ / $
Outside / $ / $
1.Number of Officers and Employees who handle or have custody of money, securities:______
2.Is there an audit by? CPA Public Accountant Staff Other ______
If yes, how frequent?______
3.Are bank accounts reconciled by someone not authorized to deposit or withdraw? Yes No
4.Will securities be subject to joint control of two or more responsible employees? Yes No
Note: Persons required by law to be individually bonded and treasurers are automatically excluded from coverage Form O.
AUTO / BUS
1.Provide complete driver information (i.e. name, DOB, License #) for all employees including
teachers and coaches: attached
2.Do you allow anyone to operate an owned vehicle without first obtaining his or her MVR? Yes No
3.Are students allowed to drive school owned vehicles? Yes No
Describe criteria used to qualify student drivers:
4.Does the school have a routine maintenance program for all vehicles? Yes No
5.Are maintenance records kept for each vehicle? Yes No
6.DRIVER QUALIFICATIONS (including approved substitute drivers):
Please indicate if you have any of the following driver selection procedures in place:
Prescreening the drivers’ MVRs, verify CDL and physicals, past qualifications and training
prior to job offer.
Orders and reviews all employed drivers MVR’s annually.
Has an established performance review process that includes a “Driver Discipline Policy”
that outlines the number of moving violations and “at fault” accidents that are acceptable
before employment actions are taken.
Has written guidelines defining an acceptable Motor Vehicle Report?
What actions are taken if an employee’s driving record is considered unacceptable?
SEXUAL MISCONDUCT LIABILITY N/A
Desired Limits: $100,000/$100,000 $300,000/$300,000
$500,000/$500,000 $1,000,000/$1,000,000
Requested Innocent Party Defense Coverage Limit $100,000 $300,000
POLICIES/PROCEDURES
1.Does the Insured have a written policy(including training) addressing abuse, molestation, and sexual harassment in all of its forms (i.e. anti-abuse, anti-molestation, anti-harassment)? Yes No
2.If “Yes”, are the policies communicated annually to:
a. Staff? Yes No
b. Students? Yes No
c. Volunteers? Yes No
3.Is documentation of the communication of the policies prohibiting abuse, molestation, and sexual harassment maintained? Yes No
4.Has a Title IX or equivalent officer/coordinator been appointed by the Insured to receive and investigate complaints of abuse, molestation, and/or harassment? Yes No
- Has this person been adequately trained in these duties? Yes No
- Has the Insured developed and publicized the reporting and investigation procedures to employees, students, and volunteers? Yes No
- If “Yes” are these guidelines communicated to all employees and volunteers? Yes No
7.Does the Insured operate a child care program? Yes No
If answer to 7 is “Yes”, please complete the following:
- Total number of children in program:
- Staff to child ratio
- Is facility open to parental visits/inspection? Yes No
e.Is there an employee orientation program designed to explain the goals of the program as well as emergency health & safety procedures? Yes No
f.Is the program operated solely by the Insured or is any portion of the program contracted out?
INSURED LOSS HISTORY
1.Has the Insured ever had a claim involving abuse (physical or sexual), sexual misconduct, or sexual molestation (staff to student, student to student, or other type)? Yes No If “Yes”, please provide details, including final resolution.
2.Is there any record or knowledge of any previous incident(s) that might have resulted in a claim of abuse (physical or sexual), sexual misconduct, or sexual molestation (staff to student, student to student, or other type) had they been pursued? Yes No If “Yes”, please provide details.
EDUCATORS ERRORS & OMISSIONS LIABILITY N/A
POLICY INFORMATION
- Current Retroactive Date
- Current E&O Carrier
- Requested Policy Limits
$500,000/$500,000 $1,000,000/$1,000,000
4. Desired Deductible: minimum $1,000 $2,500 $5,000
5. Requested Non-Monetary Party Defense Coverage Limit $100,000 None
GENERAL APPLICANT INFORMATION
- Board Members are Elected Appointed Both If appointed, by whom?
- Number of Board Members Term of Office
- Are Terms Staggered? Yes No
- Current student enrollment Enrollment (a) Expected for next year (b) Prior year
- Does the Education Institution anticipate any reduction in force of professional or non-professional staff during the next twelve (12) months? Yes No
- Budget
Deficit (-)
Current year
Prior year
Previous Year
- If deficit exists, indicate cause of deficit and how it will be eliminated:
- What is entity’s bond rating: Current Previous:
1.Does the entity participate with other entities in providing special education services or vocational training? Yes No If yes, please describe and list other participating entities:
2.Has the entity had any on-site monitoring by State or Federal Agencies? Yes No
If yes, describe:
3.Have any of the following taken place during the last three (3) years? Explain all “yes” answers below.
a.Strike, slowdown or other workforce disruptions? Yes No
b.Charges or complaints involving integration, discrimination
EEOC violations, or other violations of civil rights? Yes No
c.Employee suspension, demotion, dismissal, involuntary transfer, or tenure contract nonrenewal or cancellation? Yes No
If “Yes”, describe:
POLICIES AND PROCEDURES INFORMATION
- Has entity established policies/procedures for handling employees in the areas of:
Dismissal Yes No In writingDemotion Yes No In writing
Promotion Yes No In writingHiring Yes No In writing
InvoluntaryBackground
Transfer Yes No In writingChecks Yes No In writing
ProgressiveAnnual
Discipline Yes No In writingEvaluations Yes No In writing
EmploymentEmployee
Applications Yes No In writingOrientation Yes No In writing
2.Do policies/procedures provide for administrative appeals?
If yes, how many administrative appeals have occurred during the past twelve (12) months?
3.Have your policies been reviewed by counsel? Yes No
4.Do you conduct drug testing on employees or students? Yes No
If “Yes”, describe who is tested and the purpose and frequency of such testing.
5.Has entity established policies/procedures for students in the areas of:
Suspension Yes No In writingHarassment Yes No In writing
Expulsion Yes No In writingEnrollment Yes No In writing
Locker/student
Hazing Yes No In writingSearches Yes No In writing
Parking Yes No In writing
6.Do you have a written procedure for the prompt reporting of claims and incidents that can reasonably expected to result in claims? Yes No
7.List the name of the individual designated to handle the reporting of claims, complaints, charges, lawsuits and incidents that may reasonably expected to result in a claim.
Name Title Phone #
8.Please attach a copy the following documents:
(a)Student Handbook Attached to application Yes No
(b)Employee Handbook(s) Attached to application Yes No
LOSS & INCIDENT INFORMATION
1.List all incidents within the past five (5) years involving the entity, employees, student teachers or volunteers that have not yet resulted in a charge, complaint or claim, but may be reasonably expected to result in a claim. (Please attach a separate sheet if necessary).
DateCurrent StatusDescription
2.List all claims within the past five (5) years including complaints, charges, administrative proceedings, due process hearings, and lawsuits involving the entity, employees, student teachers or volunteers. (Please attach a separate sheet if necessary).
DateDamagesExpensesCurrent StatusDescription
LAW ENFORCEMENT / SECURITY PROFESSIONAL LIABILITY N/A
POLICY INFORMATION
1.Requested Retroactive Date Current Retroactive Date
2.Current Carrier
3.Requested Policy Limits $100,000/$100,000 $300,000/$300,000 $500,000/$500,000 $1,000,000/$1,000,000
4.Deductible $1,000 $2,500 $5,000 $7,500 $10,000
5.Non-Monetary Relief Defense Coverage $100,000 None
EXPOSURE INFORMATION
1.Total number of law enforcement/security personnel
2.Total annual payroll/expense for law enforcement/security personnel
3.Number of personnel in following categories:
a.School Resource Officer b.Full-time Employees
c. Part-time Employees d.Volunteers
e. Independent Contractors f.Employees with firearms
g. Employees with h.Personnel employed by
arrest authorityoutside security firm or
police department
If personnel from outside security firm or police department are used, please indicate name of firm or department:
a. Does school obtain “Certificate of Insurance” from security firm? Yes No
Describe minimum requirements and training for security personnel:
POLICIES AND PROCEDURES INFORMATION
1.Has entity established policies/procedures for handling security/law enforcement employees in the areas of:
Use of Force Yes No In writingUse of Deadly Force Yes No In writing
ProgressiveAnnual
Discipline Yes No In writingEvaluations Yes No In writing
EmploymentEmployee
Applications Yes No In writingOrientation Yes No In writing
2.Do policies/procedures provide for administrative appeals? Yes No
If yes, how many administrative appeals have occurred during the past twelve (12) months?
3.Have your policies been reviewed by counsel? Yes No
4.Does Insured conduct drug testing on security/law enforcement employees? Yes No
If “Yes”, describe the method and frequency of such testing.
5. Do security/law enforcement personnel receive training in the administration of:
CPR Yes NoFirst Aid Yes No
Crowd Control Yes NoPassive Restraint Yes No
Use of Force Continuum Yes No
6.Do you have a written procedure for the prompt reporting of claims and incidents that can reasonably expected to result in claims? Yes No
7.List the name of the individual designated to handle the reporting of claims, complaints, charges, lawsuits and incidents that may reasonably expected to result in a claim.
Name Title phone #
LOSS & INCIDENT INFORMATION
List all claims within the past five (5) years including complaints, charges, administrative proceedings, due process hearings, and lawsuits involving the entity, security/law enforcement employees, outside security/law enforcement personnel or volunteers. (Please attach a separate sheet if necessary).
DateDamagesExpensesCurrent StatusDescription
DORMITORY GENERAL INFORMATION
1. How many dormitory buildings are owned and/or operated by the institution? Please specify the number of stories and total occupancy capacity for each building. For buildings over 25 years, please provide latest updates to roof, electrical, heating and plumbing.
BUILDING / # OF STORIES / TOTAL OCCUPANCY / SPRINKLERED? / YEAR BUILT
2. How many fraternity/sorority houses or facilities are owned and/or operated by the institution? Please specify the number of stories and total occupancy capacity for each building. For buildings over 25 years, please provide latest updates to roof, electrical, heating and plumbing.
BUILDING / # OF STORIES / TOTAL OCCUPANCY / SPRINKLERED? / YEAR BUILT
3. How many student houses/apartment buildings are owned and/or operated by the institution? Please specify the number of stories and total occupancy capacity for each building. For buildings over 25 years, please provide latest updates to roof, electrical, heating and plumbing.
BUILDING / # OF STORIES / TOTAL OCCUPANCY / SPRINKLERED? / YEAR BUILT
DORMITORY LIFE SAFETY & SECURITY
1. Is there more than one means of ingress/egress on each floor? Yes No
2. Do all rooms have metal doors with deadbolt locks? Yes No
If No, what types of doors are provided?
3. Is each building equipped with a hard-wired smoke/heat detection system? Yes No
4. Is each building equipped with central station fire alarms? Yes No
If No, what types of fire alarms are provided?
5. Is each floor equipped with fire extinguishers? Yes No
6. Is each room equipped with a smoke detector? Yes No
7. Are portable heaters, hot plates, and cooking equipment prohibited? Yes No
If No, please explain.
8. Are there emergency/evacuation procedures in place? Yes No
9. Are there scheduled fire drills and testing of fire alarms? Yes No
If Yes, how often?
10. Is emergency lighting provided in the stairwells and hallways? Yes No
11. Are the entrances/exits to each dormitory locked at all times with access limited
by a security system? Yes No
If No, please describe how access to dormitories by non-residents is controlled.
12. Is there a Resident Assistant or other supervisor on each floor? Yes No
13. Is there a schedule security patrol for all buildings? Yes No
14. Are parking lots well lit? Yes No
15. Does the institution have a written policy that prohibits hazing? Yes No
16. Are fraternities/sororities required to carry their own liability insurance, including liquor liability? Yes No
WORKERS COMPENSATION N/A
1.Provide details of the employee orientation:
2.Are detailed job description provided including physical requirements to perform specific tasks? YesNo
3.Does the school have a stable workforce-reflecting turnover less than 25% annually? YesNo
4.EMPLOYEE TRAINING & PERSONNEL PROTECTION
a.Does the school provide skills training in each specific job categories involved? YesNo
b.Does the school provide safety training for identifying/reporting hazards that may exists? YesNo
c.Is protective equipment provided and maintained? YesNo
d.Insured has preventive maintenance program for tools and equipment. YesNo
e.Are all personnel trained in First Aid and Emergency Plan? YesNo
- SAFETY PROGRAM – describe administration involvement in the formation, participation, and
enforcement of the school’s safety program:
Established “Safety and Health Mission Statement”.
Written safety rules distributed and all employees are instructed on their purpose and
consequences if not followed.
“Safety Committee” formed to create a positive interest in safety among employees.
Development of light duty, return to work procedures for employees returning from injuries
Accident Review procedures – to collect facts, analyze underlying cause of accident,
report findings, recommend corrective measures to reduce the possibility of recurrence.
Conduct regular safety training on various topics (proper lifting, slip/trip prevention)
- Does the district have procedures in place to ensure prompt reporting of claims? YesNo
A designated person who knows the proper procedure is responsible for claims.
School historically reports accidents/injuries in seven days or less.
7.Does the school have OSHA Programs in place and documented? (i.e. Hazard Communication,
Lockout/Tag out, Blood-Borne Pathogens, etc.) YesNo
8.What is the level of housekeeping on the premises?
Check those applicable: routine facility inspections conducted walking surfaces inspected ………………………………… ice/snow removal procedures
DECLARATION AND SIGNATURE