Supplemental Application - Hanover InsuranceCentral Station Yes No • Central Station Yes No • Smoke Detectors Yes No Are smoke detectors: hard wired battery operated 5. Are evacuation

H U M A N S E R V I C E S A D V A N TA G E

Supplemental Application

Include the following with this completed & signed supplemental application:

• ACORD applications, completed & signed • Statements of value

• Photographs of residential locations • Descriptive brochures, publications &/or newsletters

• Loss runs for current year and 3 years prior which • If autos, ACORD should include full schedule of vehicles

are currently dated and drivers list with full license numbers and dates of birth

• Current Financial Information

In addition to completing the primary Human Services Supplemental Application, you must complete a separate questionnaire for

each of the following services your organization provides:

• Daycare & Educational Programs

• Special Events

• Adoption/Foster Care

A. GENERAL APPLICANT INFORMATION

Applicant Name: _______________________________________________________________________________________________________________

Website: _______________________________________________________________________________________________________________________

Contact Person for Inspection: ___________________________________________________________________________________________________

Email: ________________________________________________________ FEIN: _________________________________________________________

1. Full description of all operation(s) and types of clients served:

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

(Attach brochure(s) if available)

2. Type of entity: Non-Profit For Profit

3. Number of years in operation*: ___________ Years under present management: ___________

* If operating for 3 years or less, please send a copy of the director’s resume, a list of your Board of Directors,

and your pro-forma financials.

4. Are you a licensed facility? Yes No

5. Has your license ever been suspended or revoked? Yes No

If Yes, attach copy of Authority’s report.

6. Have there been any claims that allege negligence or failure to comply with any

regulatory/licensing guidelines? Yes No

If Yes, provide details and explanation: _______________________________________________________________________________________

__________________________________________________________________________________________________________________________

7. Primary funding source: Federal State County Other

Annual operating budget: ___________________________ Annual payroll: _________________________________________________________

8. Professional organization memberships or affiliations: ___________________________________________________________________________

9. Have you ever discontinued any programs? Yes No

If Yes, provide details, explanation including dates:

10. Are you currently accredited? JCAHO CARF COA Other ______________________________________________________

11. Prior Carrier Information

NO PRIOR

COVER AGE

COMPANY LIMITS COVER AGE

FORM

RETROACTIVE

DATE

ANNUAL

PREMIUM

Professional Liability

Occurrence

Claims-Made____/____/____

$

General Liability

Occurrence


$

Abuse & Molestation

Occurrence


$

Or, provide Annual Policy Premium

$

Professional Liability Deductibles – Optional

(Check one, if no option is selected, no deductibles will apply)

1,000 2,500 5,000 10,000 25,000

12. Indicate number of staff: Total number of Employees _____ Total number of Volunteers _____

POSITIONEMPLOYEE VOLUNTEERS CONTR ACTORS INTERNS

F/ T P/ T F/ T P/ T F/ T P/ T F/ T P/ T

Child Case Worker

Counselor (other)

Home Health Aide

Nurse Practitioner

Nurse — LPN

Nurse — RN

Nutritionist

Physician

Physician Assistant

Psychiatrist

Psychologist

Resident Manager

Social Worker — Bachelors (BSW)

Social Worker — Masters (MSW)

Teacher/Tutor/Aide

Therapist — Physical/ Occupational

Therapist — Speech/Hearing

Other Positions (specify)

Other Positions (specify)

B. MANAGEMENT PRACTICES

1. Is the staff required to report to the administrator all incidences that may result in a claim? Yes No

2. Are written records of all incidences kept by the administrator & reviewed? Yes No

3. Do you have a formal written safety program in place? Yes No

4. Do you have a plan in place for medical emergencies? Yes No

5. Is there always someone trained in CPR and first aid on the premises? Yes No

6. Do you have AED(s)? Yes No

Are staff members trained to use? Yes No

7. Do you have a written and enforced Smoking Policy? Yes No

Are “no smoking” signs posted in areas not designated for smoking? Yes No

8. What type of method do you use for de-escalation? ____________________________________________________________________________

How often is the staff recertified? _____________________________________________________________________________________________

9. Do you have any security provided for protection of your clients/residents? (Check all that apply)

Guards Video Cameras Other: __________________________________________________________________________________

10. Do you have sign in/sign out procedures for: Staff Clients/Residents Visitors/Public

11. Do you have a preventative maintenance plan in place for all owned property? Yes No

12. Were your buildings originally constructed for current occupancy? Yes No

13. Do you have a formal incident review committee? Yes No

14. Do you have formal client intake and discharge protocol? Yes No

If Yes, please describe: ______________________________________________________________________________________________________

1. Hiring Practices:

a. Are formal written procedures in place for staff hiring? Yes No

b. Do you require your staff to complete an employment application? Yes No

c. Do you conduct a personal interview for each prospective staff member? Yes No

d. Do you verify employment related references? Yes No

e. Do you verify licenses and other credentials? Yes No

2. Name of executive director/manager: _________________________________________________________________________________________

Number of years in this field: __________ Number of years at this facility: __________

3. Is there formal staff training? Yes No

4. Are files maintained to protect the confidentiality of clients? Yes No

C. PROFESSIONAL LIABILITY

1. Do you have a medical clinic? Yes No

The facilities are for: Staff Clients/Residents General Public

Do you provide more than immediate care/first aid? Yes No

If Yes, please explain: _______________________________________________________________________________________________________

Do you perform any consulting work? Yes No


2. Are medications dispensed? Yes No

If Yes, answer the following questions:

a. Where are the medications stored? ________________________________________________________________________________________

b. Who has the authority to dispense medications? ____________________________________________________________________________

c. Can over-the-counter medicines be dispensed without written permission from a doctor? Yes No

d. Are written records kept as to the time, type of medication, amount of dosage and who dispensed the medications? Yes No

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3. Do you practice cyber counseling? Yes No

If Yes, please answer the following:

a. List states you where currently and plan to practice: _________________________________________________________________________

b. Do you follow the ACA Code of Ethics? Yes No

c. Do you utilize specialized software to monitor sessions? Yes No

If Yes, please provide name: ______________________________________________________________________________________________

d. Please provide total number of Cyber Counselors: Full time: _____ Part time: _____

Are all licensed? Yes No

If not, how many are not licensed in Cyber Counseling? Full time: _____ Part time: _____

e. Please provide Cyber Counseling client count: Current year: _____ Expected next year: _____

4. What is the staff turnover percentage for professional staff? _____________________________________________________________________

5. Do you have any employed or contracted Psychiatrists or Physicians (other MD’s)? Yes No

6. Do you have any employed, contracted or volunteer Nurse Practitioners? Yes No

If Yes, how many? ______

a. Do Nurse Practitioners Prescribe medication? Yes No

If Yes, how many Nurse Practitioners prescribe medication? ______

Work in non-medical positions within the scope of the Human Services organization such as managers,

educators, directors, nursing duties? Yes No

b. Do your Nurse Practitioners provide services to individuals other than your clients? Yes No

If Yes, please explain: ____________________________________________________________________________________________________

7. Does the Insured use employed, contracted, or volunteer Medical Professionals? Yes No

If Yes, answer the following questions:

a. Are any Psychiatrists/Nurse Practitioners a member of American Academy of Child & Adolescent Psychiatry (AACAP) Yes No

b. Does any Psychiatrist/MD or Nurse Practitioner perform any clinical or pharmaceutical research on clients? Yes No

If Yes, please explain:

_______________________________________________________________________________________________________________________

c. Does the MD/Nurse Practitioner get informed consent prior to prescribing medications? Yes No

d. Please complete the table below for any psychiatrists, MDs, Nurse Practitioners, Dentists or Optometrists

NAME Dr. _________________________ Dr. _________________________ Dr. _________________________

Specialty

Board Certified or Eligible

Years in Practice

License Number

Hours p/wk for Insured

Employed or Contracted?

Does physician/Nurse Practitioner carry own Malpractice insurance?****

If Yes, does coverage include acts while working for this agency?

If Yes, does coverage include Contingent Coverage for this agency?

Any claims in past 5 years?

****Provide Certificate of Medical Malpractice for each Psychiatrist, Physician and Nurse Practitioner

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D. ABUSE AND MOLESTATION:

1. Does your staff employment application include questions about whether the individual has ever been

convicted for any crime, including sex-related or child-abuse related offenses? Yes No

2. Does Insured run criminal background checks for employees? Yes No

3. Do you have volunteer workers? Yes No

Is a complete background check required for all volunteers, the same as for employees? Yes No

If No, please explain: _______________________________________________________________________________________________________

Are any volunteers working off court-mandated community service? Yes No


Do you complete background checks on contracted staff? Yes No

4. Do you have written procedure for dealing with physical and sexual abuse? Yes No

If Yes, attach a copy.

5. Are you aware of any abuse or molestation claims, allegations, or incidences made against your organization,

or against anyone working on your behalf that may give rise? Yes No

Was the claim filed? Yes No

Is the claim: Open Closed

If a claim was filed, please provide details including dates, amount paid/incurred and resulting organizational/policy

changes as a result (attach additional page if necessary).

__________________________________________________________________________________________________________________________

6. Do you have a plan of supervision that monitors staff in day-to-day relationships with clients both on and off-premises? Yes No

7. Are procedures in place to avoid one-on-one situations so that more than one employee/volunteer is present

at all times when a child is in your care? Yes No

8. Is there documented formal staff training on child/sexual abuse, including how to recognize the signs and how to

report a known or suspected incident? Yes No

9. Total number of unduplicated clients served annually: __________

10. Average number of clients served at any one time:__________

11. Indicate annual number of clients in each age range for all programs/services:

0–8 years: ______ 9–18 years: ______ over 18 years: ______

E. RISK MANAGEMENT:

1. Have all buildings constructed prior to 1971 been inspected for lead paint? Yes No

If No, what is the plan for abatement? ________________________________________________________________________________________

2. Are any non-ambulatory clients above the first floor? Yes No

3. How many means of egress are there? ____________

Are all Exits clearly marked & illuminated? Yes No

4. Are the following in place?

• Fire Alarms Yes No • Security Alarm Yes No

• Central Station Yes No • Central Station Yes No

• Smoke Detectors Yes No

Are smoke detectors: hard wired battery operated

5. Are evacuation procedures & floor plans posted & evacuation plan practiced at least monthly? Yes No

6. Are there fire extinguishers on each floor? Yes No

How often and by whom are they serviced? ___________________________________________________________________________________

7. Are fire drills conducted? Yes No

How often? ________________________________________________________________________________________________________________

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8. Does the facility have a written emergency evacuation plan? If Yes, attach a copy. Yes No

9. If you contract for services, do you require the contractors to sign a hold harmless or indemnification agreement?

If Yes, attach a copy of the standard agreement. Yes No

Are certificates of Insurance required and kept in file for those contractors? Yes No

If Yes, what are the minimum limits of liability required? _________________________________________________________________________

10. Do you use security personnel at any of your locations? Yes No

If Yes, are they Subcontracted? Employed? # Full Time: _______ # Part Time: _______

Please list all locations where security personnel are used: ______________________________________________________________________

If Subcontracted, please provide the name of the security firm or police department used:

__________________________________________________________________________________________________________________________

Do you obtain certificates of insurance granting you additional insured status from your subcontractors?

If Yes, attach a copy. Yes No

Are security personnel armed? Yes No

Describe minimum requirements and training for security personnel:

__________________________________________________________________________________________________________________________

F. AUTOMOBILE: N/A

1. Are all vehicles listed on the ACORD application titled to the applicant? Yes No

If No, please explain: _______________________________________________________________________________________________________

2. Are keys locked and secured away from clients when not in use? Yes No

3. Do vehicles with 8 or more seating capacity have an audible backup warning device? Yes No

4. Do you require seat belts to be worn by all occupants? Yes No

5. Do vehicles equipped for wheelchairs have tie-down belts to stabilize the wheelchair and passengers? Yes No

6. Do you require both a vehicle operator and a passenger monitor on your multiple passenger vehicles

while transporting clients? Yes No

7. Are vehicles checked after passengers disembark to make sure nobody is left behind? Yes No

8. Do you transport clients for other human service agencies? Yes No


9. Do you lend your vehicles to other agencies or organizations? Yes No


10. Is there a formal accident analysis program in place? Yes No

11. Do you obtain MVR’s upon hire? Yes No

If Yes, please describe your protocol for monitoring MVRs: ______________________________________________________________________

12. Do you require drug tests on all drivers? Yes No

If Yes: Before Hiring After Hiring Random

13. Are clients permitted to drive insured vehicles? Yes No


14. Do you allow personal use of your owned vehicles? Yes No

If Yes, by whom and for what reasons?

__________________________________________________________________________________________________________________________

15. Is training provided for new employees/volunteers prior to their transporting clients? Yes No

16. Do you have a vehicle maintenance program in place that complies with OEM standards? Yes No

17. Do you have rules governing the use of cell phones while driving? Yes No

If Yes, please describe: ______________________________________________________________________________________________________

PAGE 6

18. Are your 15 passenger vans equipped with Electronic Stability Control (ESC)? Yes No

If No, do you: (Check all that apply)

Limit passengers to 10 or less Remove rear seat Do not allow cargo loaded on roof

19. Is there a pre-trip inspection of the vehicle which includes tire pressure check? Yes No

HIRED AND NON-OWNED AUTO N/A

1. Are any vehicles leased or hired? Yes No

If Yes, describe what types, what uses and how often:

__________________________________________________________________________________________________________________________

2. Do you hire from a transportation company? Yes No

If Yes, with drivers? Yes No

3. Total number of hired vehicles: ________ Annual cost of hire: _______

4. How many drive personal vehicles for business use regularly? F/T:______ P/T:______ Volunteers: _____________________

How many drive personal vehicles for business use occasionally? F/T:_____ P/T:_____ Volunteers: ___________________

How many drive personal vehicles to transport clients? F/T:_____ P/T:_____ Volunteers: ____________________________

5. Do you require your employees/volunteers that use their own autos to carry and provide evidence

of personal auto insurance? Yes No

Please indicate mimimum limits of personal auto limits required: _________________________________________________________________

Is proof of personal auto insurance required on a renewal basis? Yes No

Explain what purpose Employees or Volunteers use their own autos on behalf of the organization?

__________________________________________________________________________________________________________________________

DONATED VEHICLES OR OTHER MOTORIZED CRAFT N/A

1. Do you accept donations of: Vehicles Boats Aircraft Other: _______________________________ NA

2. Do you repair or refurbish any of these donated items? Yes No

If Yes, please indicate who performs the work for you: Staff Clients Other: _________________________________________

G. RESIDENTIAL FACILITIES: N/A

(Note: Substance Abuse Facilities require separate supplemental application)

1. What was the date of the last inspection by the licensing agency? _______________________________________________________________

Were there any violations or deficiencies noted? Yes No


2. Types of Residential Facilities and Total # of Beds (Check all that apply):

FACIL IT Y T YPE: # OF BEDS/ CLIENTS:



Acute Skilled Care ____________ Transitional Housing ____________ Vocational ____________

Aged ____________ Outpatient Counseling ____________ Other

Group Home ____________ Schools ____________ ____________________ ____________

Hospice ____________ Daycare: Adult ____________ Other

Independent Living ____________ Child ____________ ____________________ ____________

Inpatient Crisis Care ____________ Youth Recreation ____________

Low Income Housing ____________ Sexual Offenders ____________

Respite Care ____________ Ex-Offender Reentry ____________

Detoxification ____________ Crisis Hotline

Shelter (describe) Suicide: Annual Calls ____________

____________________ ____________ Other: Annual Calls ____________

PAGE 7

3. Annual number of residents by age group: Less than 18: _____ 18-65: _____ Over 65: _____

4. Are males segregated from females (other than family members)? Yes No

If Yes, describe how they are separated: _______________________________________________________________________________________

5. Does a physician screen clients prior to admission? Yes No

6. Do you require signed release forms for the release of records to other individuals or entities? Yes No

7. Are residents primarily responsible for their own basic personal care including bathing, dressing, eating and

restroom functions? Yes No

8. Is 24-hour “awake” staff supervision provided? Yes No

9. What is the ratio of resident to staff: Day_________________ Night_________________

10. How often are rooms inspected?__________________ Who inspects rooms? _______________________________________________________

Do you have written inspection procedures for staff to follow? Yes No

Do you have a checklist to follow and retain documentation of inspection? Yes No

11. How often are bed checks done? ____________________________________________________________________________________________

And are they: Random Scheduled NA

12. Are there security cameras monitoring operation? Yes No

13. Are residents rooms ever locked from the outside? Yes No

14. Is there a formal elopement/run away policy? Yes No

15. Do any of the residents have prior involvement with acts of property damage? (e.g. Arson, Vandalism) Yes No

16. Are residents required to notify the facility when leaving and returning? Yes No

17. If this is an abuse shelter, describe controls to maintain secrecy of location:

__________________________________________________________________________________________________________________________

18. Describe types of recreational activities on and off-premises:

__________________________________________________________________________________________________________________________

H. COOKING FACILITIES: N/A

1. The cooking equipment type is: Residential Commercial

If commercial type, complete the following section:

a. Describe Equipment: (Grills, broilers, fryers, etc) and number of each:

_______________________________________________________________________________________________________________________

b. Cooking Equipment is equipped with: Hoods Ducts Exhaust Fans Automatic fuel shutoff controls

Automatic fire suppression systems No protection Other: ___________________________________________________

c. Is there a cleaning maintenance contract for the fire extinguishing system? Yes No

If Yes, what is the frequency of the cleaning?________________________________________________________________________________

And, what is the name of the maintenance company? ________________________________________________________________________

Is the system UL 300/NFPA compliant? Yes No

2. Are there fire extinguishers in the cooking area(s)? Yes No

I. IN-HOME SERVICES: N/A

1. Please indicate type of services provided: Medical Care Nonmedical Home Companion Care

2. Do you sell and/or rent medical equipment? Yes No

If Yes, what are annual sales? $_______________________ Annual rental receipts? $_______________________

3. Is each visit documented? Yes No

PAGE 8

J. CAMPS AND RECREATION: N/A

1. Type of program: YMCA YWCA Boys’ & Girls’ Club JCC Other _____________________________________

2. Services offered (check all that apply):

Babysitting Day Camp Mentoring Snack Bar/Restaurant Youth Recreation

Child Daycare Fitness Center Other Social Services Swimming Pool(s) Other

Counseling Service Fitness Classes Overnight Camp Team Sports

3. Are all entrances attended? Yes No

4. Are all visitors to the facility required to sign in and sign out? Yes No

5. Do participants sign a hold harmless/waiver at registration? If Yes, attach copy. Yes No

6. Is there a policy relating to supervision of minors? Yes No

If Yes, describe:

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

7. Does your organization provide accident insurance for members? Yes No

8. Do you have any mentoring programs that match youth with adult mentors? Yes No

If Yes, do you have a written policy that prohibits “one-on-one” between mentor & mentee? Yes No

ATHLETIC ACTIVITIES:

1. Do you organize any or offer league or team sports? Yes No

If Yes, how many registrants do you have in all sports (total)? ____________________________________________________________________

2. Do you require all participants in organized sporting activities to carry Accident Medical Insurance? Yes No

3. Indicate all of the following activities that you offer at any location:

Babysitting Skating—Ice

Baseball Soccer

Basketball Softball

Boxing Swimming—Lake

Cheerleading Swimming—Pool

Child Daycare Swimming Pool(s)

Climbing Wall—Indoor Trampoline

Climbing Wall—Outdoor Wrestling

Diving Other________________

Football—Flag, Touch Other________________

Football—Tackle

Gymnastics — Tumbling only

Hiking/Backpacking

Hockey—Field

Lacrosse/Rugby

Martial Arts

Motorized Vehicles, Including Dirt Bikes, Go Carts, etc.

Mountain Biking or BMX

Obstacle Course

Outdoor Rock Climbing, Rappelling

Riflery

Rope Course—High Elements

Scuba Classes or Training

Skateboarding

For all activities indicated above, provide description of each activity, including number of participants, location and safety con-

trols, in comments section.

CAMPS:

1. What are the number of days the camp operates each year? ____________________________________________________________________

2. What is the average number of campers per day? ______________________________________________________________________________

3. Number of campers in each age range: Under 12_________ Age 13-16_________ Over 16_________

4. Total number of: Adult Counselors _________ Youth Counselors _________

5. Is written permission/waiver of liability obtained from every camper’s parent or guardian? Yes No

PAGE 9

6. Do you operate a seasonal camp facility, which provides overnight camping? Yes No

If Yes: a. What is the average length of stay? ________________________________________________________________________________

b. Are sleeping quarters and bathrooms divided by gender? Yes No

c. What lifesaving skills are required of counselors? CPR First Aid Other ________________________________

d. Do you keep a medical history on file of each camper? Yes No

e. Are medications locked up? Yes No

f. If well water, how often is this tested? ______________________________________________________________________________

g. Does a caretaker live at the camp during the off-season? Yes No

FACILITIES RENTAL:

1. Is a written lease required for every rental? Yes No

2. What are your gross receipts from all rental operations? $ _______________________________________________________________________

3. What activities are offered to rental groups?

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

Do you provide supervision of any of these activities? Yes No

If Yes, which activities? ______________________________________________________________________________________________________

4. Are all safety requirements spelled out in writing in the lease agreement? Yes No

5. When leasing to a business entity or group do you obtain Certificates of Insurance with liability limits

of at least $1 million? Yes No

If Yes, are you named as an additional Insured on the lessee’s liability insurance policy? Yes No

TRIPS/FIELD TRIPS/TRAVEL:

1. How many trips are sponsored each year? _____________________________________________________________________________________

2. Are all trips within the United States, U.S. Territories, or Canada? Yes No

If No, explain:

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

3. Do any trips last more than one day? Yes No

If Yes, describe length of time, destination(s) and purpose:

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________

4. Are signed permission and waiver agreements obtained from the parent of each participant for each trip? Yes No

5. Do all participants wear identification tags or identifiable clothing on all trips? Yes No

PAGE 10

6. Is there a policy regarding emergencies and trained personnel on all trips? Yes No

Do you have concussion protocols? Yes No

If Yes, provide details: _______________________________________________________________________________________________________

Do you provide trampolines or other bouncing devices? Yes No

If Yes, describe type: ________________________________________________________________________________________________________

Describe how access is controlled:____________________________________________________________________________________________

Describe controls to monitor and supervise activity: ____________________________________________________________________________

Do you provide therapeutic horseback riding? Yes No

Must attach a copy of the rider’s registration form and any/all medical and/or liability release forms.

Are liability waivers signed by all parents and guardians? Yes No

If you own a riding facility, do you allow public access or provide boarding services for other’s horses? Yes No

SWIMMING POOL: N/A

1. Is there a trained/certified lifeguard on duty? Yes No

If Yes, how many?_____________ During what hours: ___________________________________________________________________________

2. The pool area includes: Diving Board Kiddie pool Waters Blobs Water Trampoline

Hot Tub/Whirlpool Sauna Waterslide

If diving board is present, what is height? ________________

If waterslide is present, what is height ?__________________ Length? __________________

3. Who uses the area: Staff Clients/Residents Visitors/Public

4. Pool location: Indoors Outdoors

If outdoors, is the pool completely fenced with a self-locking gate? Yes No

If Yes, what is the type of the fence?___________________________________________ Height? _______________________________________

5. Are depths clearly marked? Yes No

6. Is the pool/hot tub equipped with lifesaving equipment including shepherd’s hook, rings & buoys? Yes No

7. Is the staff trained in water safety? Yes No

8. Does signage include: Pool Rules ”No Diving” ”Swim at your own risk”

If pool rules are posted, do they meet your state and local regulations? Yes No

9. Are swimming lessons given? Yes No

If Yes, by whom? ___________________________________________________________________________________________________________

10. Is there any swim team participation? Yes No


11. Is the storage of pool chemicals secured? Yes No

12. How often is the water tested in the swimming pool?____________________ Hot tub? ____________________

Are these chemical readings/test results recorded each time and logs maintained? Yes No

13. How often is the pool cleaned? ______________________________________________________________________________________________

14. Do you have specific guidelines regarding closing the pool due to water contamination? Yes No

15. Is the facility leased to others for parties, etc? Yes No

16. Are all swimming pools and spas compliant with the Virginia Graeme Baker Pool & Spa Safety Act? Yes No

PAGE 11

MISCELLANEOUS: N/A

1. Do you have a climbing wall or tower? Yes No

If present, please indicate: Total Number ______ Height ______

2. Do you have zip lines? Yes No

If present, please indicate: Total Number ______ Height ______ Length ______

Who has access? Clients Staff Public/Visitors

How is access contolled? ____________________________________________________________________________________________________

Is safety equipment required for each participant? Yes No

3. How often do you perform inspections? _______________________________________________________________________________________

Are inspections performed by certified specialists? Yes No

Is staff certified? Yes No

If Yes, please describe the certification process and through whom the certification is received:

__________________________________________________________________________________________________________________________

COMMENTS

_______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________

PANDEMIC AND COMMUNICABLE DISEASE

1. Do you have formal procedures in place to handle pandemic or other communicable diseases? Yes No

a. Do your procedures address:

i. Staffing Yes No

ii. Training Yes No

iii. Personal protective equipment Yes No

iv. Client care Yes No

v. Vendors/visitors Yes No

vi. Internal & external communication Yes No

vii. Maintenance of premises and vehicles Yes No

viii. CDC guidelines and recommendations Yes No

b. Please provide a copy of your written procedures

2. Have you ever had to implement those procedures? Yes No

a. If yes, please provide details. _____________________________________________________________________________________________

_______________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________

PAGE 12

All products are underwritten by The Hanover Insurance Company or one of its insurance company subsidiaries or affiliates (“The Hanover”). Coverage may not be available in all jurisdictions and is subject to the company underwriting guidelines and the issued policy. This material is provided for informational purposes only and does not provide any coverage. For more information about The Hanover visit our website at www.hanover.com

©2020 The Hanover Insurance Group. All Rights Reserved.

The Hanover Insurance Company440 Lincoln Street, Worcester, MA 01653

h a n o v e r . c o m The Agency Place (TAP) — https://tap.hanover.com

115-1047 (5/20)

PAGE 13

DECLARATION AND SIGNATURE

Authorized Entity Representative Designation

The person named herein is authorized and designated to give and receive any and all notices on behalf of the entity and all Insureds from

the entity or their authorized representative(s) concerning this insurance.

Named Individual: _____________________________________________________________________________________________________________

Title/Position: _________________________________________________________ Date: _____________________________________________

Attestation

The authorized signer of this application represents to the best of his/her knowledge and belief that the statements and information set forth

herein are true and include all material information. The authorized signer also represents that any fact, circumstance or situation indicating

the probability of a claim or legal action now known to any entity official or employee has been declared, and it is agreed by all concerned

that the omission of such information shall exclude any such claim or action from coverage under the insurance being applied for. Signing of

this application does not bind The Hanover Insurance Group, Inc. to offer, nor the authorized signer to accept insurance, but it is agreed this

application and any attachments hereto shall be the basis of the insurance and will be incorporated by reference and made part of the policy

should a policy be issued.

Signature of Authorized Entity Representative

______________________________________________________________________ Date ____________________________________________

http://www.hanover.comhttps://tap.hanover.com

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Title: Date: Named individual: Signature of rep: Date sig: Pandemic 1: OffPandemic a i: OffPandemic a ii: OffPandemic a iii: OffPandemic a iv: OffPandemic a v: OffPandemic a vi: OffPandemic a vii: OffPandemic a viii: OffPandemic 2: OffPandemic 2a1: Pandemic 2a2: Pandemic 2a3: Button1: Save: Print: Applicant Name: Website: Contact person: GenAppInfo4: OffGenAppInfo5: OffGenAppInfo6: OffGenAppInfo2 FP: OffApplicant email: GenAppInfo3 YrsOp: GenAppInfo3 YrsMgmt: GenAppInfo2 NP: OffGenAppInfo6Y1: GenAppInfo6Y2: GenAppInfo7 AYBudget: GenAppInfo7 AYPayroll: GenAppInfo8: CCW Emp FT: CCW Vol PT: CCW Vol FT: CCW Int PT: CCW Int FT: CCW Cont PT: CCW Cont FT: Counselor Emp FT: Counselor Vol PT: Counselor Vol FT: Counselor Int PT: Counselor Int FT: Counselor Cont PT: Counselor Cont FT: Home Health Emp FT: Home Health Vol PT: Home Health Vol FT: Home Health Int PT: Home Health Int FT: Home Health Cont PT: Home Health Cont FT: Nurse Emp FT: Nurse Vol PT: Nurse Vol FT: Nurse Int PT: Nurse Int FT: Nurse Cont PT: Nurse Cont FT: NurseLPN Emp FT: NurseLPN Vol PT: NurseLPN Vol FT: NurseLPN Int PT: NurseLPN Int FT: NurseLPN Cont PT: NurseLPN Cont FT: NurseRN Emp FT: NurseRN Vol PT: NurseRN Vol FT: NurseRN Int PT: NurseRN Int FT: NurseRN Cont PT: NurseRN Cont FT: Nutrition Emp FT: Nutrition Vol PT: Nutrition Vol FT: Nutrition Int PT: Nutrition Int FT: Nutrition Cont PT: Nutrition Cont FT: Physician Emp FT: Psych Emp FT: Psych Vol PT: Psych Vol FT: Psych Int PT: Psych Int FT: Psych Cont PT: Psych Cont FT: Psychol Emp FT: Psychol Vol PT: Psychol Vol FT: Psychol Int PT: Psychol Int FT: Psychol Cont PT: Psychol Cont FT: ResMgr Emp FT: ResMgr Vol PT: ResMgr Vol FT: ResMgr Int PT: ResMgr Int FT: ResMgr Cont PT: ResMgr Cont FT: SocWrkBSW Emp FT: SocWrkBSW Vol PT: SocWrkBSW Vol FT: SocWrkBSW Int PT: SocWrkBSW Int FT: SocWrkBSW Cont PT: SocWrkBSW Cont FT: SocWrkMSW Emp FT: SocWrkMSW Vol PT: SocWrkMSW Vol FT: SocWrkMSW Int PT: SocWrkMSW Int FT: SocWrkMSW Cont PT: SocWrkMSW Cont FT: Teacher Emp FT: Teacher Vol PT: Teacher Vol FT: Teacher Int PT: Teacher Int FT: Teacher Cont PT: Teacher Cont FT: TherOcc Emp FT: TherSpeech Emp FT: TherSpeech Vol PT: TherSpeech Vol FT: TherSpeech Int PT: TherSpeech Int FT: TherSpeech Cont PT: TherSpeech Cont FT: OtherPos1 Emp FT: OtherPos1 Vol PT: OtherPos1 Vol FT: OtherPos1 Int PT: OtherPos1 Int FT: OtherPos1 Cont PT: OtherPos1 Cont FT: OtherPos2 Emp FT: OtherPos2 Vol PT: OtherPos2 Vol FT: OtherPos2 Int PT: OtherPos2 Int FT: OtherPos2 Cont PT: OtherPos2 Cont FT: TherOcc Vol PT: TherOcc Vol FT: TherOcc Int PT: TherOcc Int FT: TherOcc Cont PT: TherOcc Cont FT: Physician Vol PT: Physician Vol FT: Physician Int PT: Physician Int FT: Physician Cont PT: Physician Cont FT: PhysicianAsst Emp FT: PhysicianAsst Vol FT: PhysicianAsst Vol PT: PhysicianAsst Cont FT: PhysicianAsst Cont PT: PhysicianAsst Int FT: PhysicianAsst Int PT: GenAppInfo11e: OffGenAppInfo11d: OffGenAppInfo11c: OffGenAppInfo11b: OffGenAppInfo11a: OffGenAppInfo12 Emp#: GenAppInfo12 Vol#: GenAppInfo6 Fed: OffGenAppInfo6 State: OffGenAppInfo10 CARF: OffGenAppInfo6 County: OffGenAppInfo10 COA: OffGenAppInfo10 Other: OffGenAppInfo10 JCAHO: OffGenAppInfo11 AM NoPrior: OffGenAppInfo10 Othertxt: GenAppInfo11 PL NoPrior: OffGenAppInfo11 PL Company: GenAppInfo11 PL Limits: GenAppInfo11 PL AnnPrem: GenAppInfo11 PL CovForm Occ: OffGenAppInfo11 PL RetDate MM: GenAppInfo11 PL RetDate DD: GenAppInfo11 PL RetDate YY: GenAppInfo11 GL Company: GenAppInfo11 GL Limits: GenAppInfo11 GL CovForm Occ: OffGenAppInfo11 GL NoPrior: OffGenAppInfo11 PL CovForm CM: OffGenAppInfo11 GL CovForm CM: OffGenAppInfo11 AM CovForm Occ: OffGenAppInfo11 AM CovForm CM: OffGenAppInfo11 GL RetDate MM: GenAppInfo11 GL RetDate DD: GenAppInfo11 GL RetDate YY: GenAppInfo11 GL AnnPrem: GenAppInfo11 AM RetDate YY: GenAppInfo11 AM RetDate DD: GenAppInfo11 AM RetDate MM: GenAppInfo11 AM Limits: GenAppInfo11 AM Company: GenAppInfo11 AM AnnPrem: GenAppInfo11 Provide AnnPrem: DocName1: DocName2: DocName3: Specialty1: Specialty2: Specialty3: BoardCert1: BoardCert2: BoardCert3: Yr in Prac1: Yr in Prac2: Yr in Prac3: LicNo1: LicNo2: LicNo3: Hrs p/wk1: Hrs p/wk2: Hrs p/wk3: Emp or Cont1: Emp or Cont2: Emp or Cont3: Carry Mal Ins1: Carry Mal Ins2: Carry Mal Ins3: Cov Incl Acts1: Cov Incl Acts2: Cov Incl Acts3: Contingent1: Contingent2: Contingent3: 5Yr1: 5Yr2: 5Yr3: MgmtPractices1: OffMgmtPractices7b: OffMgmtPractices7a: OffMgmtPractices6b: OffMgmtPractices6a: OffMgmtPractices5: OffMgmtPractices4: OffMgmtPractices3: OffMgmtPractices2: OffFEIN: MgmtPractices8b: MgmtPractices8a: MgmtPractices9 Guard: OffMgmtPractices9 VidCam: OffMgmtPractices9 Other: OffMgmtPractices11: OffMgmtPractices12: OffMgmtPractices13: OffMgmtPractices14: OffMgmtPractices9 Other Exp: HiringPractices1a: OffHiringPractices1b: OffHiringPractices1c: OffHiringPractices1d: OffHiringPractices1e: OffMgmtPractices14Y: HiringPractices2a: HiringPractices2b: HiringPractices3: OffHiringPractices4: OffProLiab1: OffProLiab1 Staff: OffProLiab1 Client: OffProLiab1 Gen Pub: OffProLiab1 First Aid: OffHiringPractices2: ProLiab1 First AidY: ProLiab1 Consult: OffProLiab1 Consult: OffProLiab2: OffProLiab2c: OffProLiab2d: OffProLiab1 ConsultY: ProLiab2a: GenAppInfo1: Comments: ProLiab2b: ProLiab3: OffProLiab3b: OffProLiab3c: OffProLiab3cY: ProLiab3d: OffProLiab3d FT: OffProLiab3d PT: OffProLiab3d No FT: OffProLiab3d No PT: OffProLiab3e NY: OffProLiab5: OffProLiab6: OffProLiab3e CY: OffProLiab6a: OffProLiab6 Y: OffProLiab6a NonMed: OffProLiab6a Prescribe: OffProLiab6b: OffProLiab4: ProLiab7: OffProLiab7a: OffProLiab7b: OffProLiab6b Y: ProLiab7b Y: ProLiab7c: OffProLiab3a: AbuseMol1: OffAbuseMol2: OffAbuseMol3: OffAbuseMol3 BackChk: OffAbuseMol3 BackChkY: AbuseMol3 ComSvc: OffAbuseMol3 ContrBkChk: OffAbuseMol4: OffAbuseMol5: OffAbuseMol5 Claim: OffAbuseMol5 ClaimOpen: OffAbuseMol5 ClaimClose: OffAbuseMol6: OffAbuseMol7: OffAbuseMol8: OffAbuseMol9: AbuseMol10: RiskMgmt1: OffAbuseMol5 ClaimDet: RiskMgmt2: OffRiskMgmt3: OffRiskMgmt3 NumExits: RiskMgmt4 Fire: OffRiskMgmt4 CentSta: OffRiskMgmt4 SmokDet: OffRiskMgmt4 SmokDetWired: OffRiskMgmt4 SmokDetBatt: OffRiskMgmt4 SecAlarm: OffRiskMgmt4 CentSta2: OffRiskMgmt5: OffRiskMgmt6: OffRiskMgmt7: OffRiskMgmt1 N: RiskMgmt7 Often: RiskMgmt6 Often: AbuseMol3 BackChkN: RiskMgmt8: OffRiskMgmt10: OffRiskMgmt10 Emp: OffRiskMgmt10 Sub: OffRiskMgmt10 PT: RiskMgmt9 Y: RiskMgmt10 SecLoc: RiskMgmt10 CoI: OffRiskMgmt10 Arm: OffRiskMgmt10 SecFirm: Automobile1: OffAutomobile2: OffAutomobile3: OffAutomobile4: OffAutomobile5: OffAutomobile6: OffAutomobile7: OffAutomobile8: OffAutomobile9: OffRiskMgmt10 Training: Automobile1 N: Automobile8 Y: Automobile9 Y: Automobile10: OffAutomobile11: OffAutomobile12: OffAutomobile13: OffAutomobile14: OffAutomobile11 Y: Automobile12 After: OffAutomobile12 Before: OffAutomobile12 Random: OffAutomobile13 Y: Automobile15: OffAutomobile16: OffAutomobile17: OffAutomobile14 Y: Automobile17 Y: HiredAuto1: OffHiredAuto1 Y: Automobile18: OffAutomobile19: OffAutomobile18 Limit: OffAutomobile18 NoRear: OffAutomobile18 NoRoof: OffHiredAuto2: OffHiredAuto2 Y: OffHiredAuto5: OffHiredAuto5 Limits: OffResFacilities1: OffRiskMgmt10 FT: HiredAuto3 Cost: DonatedVeh NA: OffDonatedVeh1 NA: OffDonatedVeh1 Veh: OffDonatedVeh1 Boat: OffDonatedVeh1 Plane: OffDonatedVeh1 Other: OffDonatedVeh2: OffDonatedVeh2 Staff: OffDonatedVeh2 Client: OffDonatedVeh2 Other: OffDonatedVeh1 OtherFill: HiredAuto3 #: HiredAuto4 RegUse FT: HiredAuto4 RegUse PT: HiredAuto4 RegUse Vol: HiredAuto4 Occas FT: HiredAuto4 Occas PT: HiredAuto4 Occas Vol: HiredAuto4 Trans PT: HiredAuto4 Trans Vol: HiredAuto4 Trans FT: HiredAuto5 MinLimit: HiredAuto5 Purpose: ResFacilities1 Insp: Automobile NA: OffResFacilities NA: OffResFacilities2 Acute: OffResFacilities2 Aged: OffResFacilities2 GrpHome: OffResFacilities2 Hospice: OffResFacilities2 IndLvg: OffResFacilities2 CrisisCare: OffResFacilities2 LowInc: OffResFacilities2 Respite: OffResFacilities2 Detox: OffResFacilities2 Shelter: OffResFacilities2 TrHouse: OffResFacilities2 Outpatient: OffResFacilities2 School: OffResFacilities2 Daycare: OffResFacilities2 YouthRec: OffResFacilities2 SexOff: OffResFacilities2 Reentry: OffResFacilities2 Hotline: OffResFacilities2 HotlineSuicide: OffResFacilities2 HotlineOther: OffResFacilities2 Voc: OffResFacilities2 Other1: OffResFacilities2 Other2: OffDonatedVeh2 OtherFill: ResFacilities2 AcuteBed: ResFacilities2 AgedBed: ResFacilities2 GrpHomeBed: ResFacilities2 HospiceBed: ResFacilities2 IndLvgBed: ResFacilities2 CrisisCareBed: ResFacilities2 LowIncBed: ResFacilities2 RespiteBed: ResFacilities2 SchoolBed: ResFacilities2 DaycareAdultBed: ResFacilities2 DaycareChildBed: ResFacilities2 YouthRecBed: ResFacilities2 SexOffBed: ResFacilities2 ReentryBed: ResFacilities2 HotlineSuicideBed: ResFacilities2 HotlineOtherBed: ResFacilities2 TrHouseBed: ResFacilities2 OutpatientBed: ResFacilities2 DetoxBed: ResFacilities2 ShelterBed: ResFacilities2 ShelterDescrip: ResFacilities2 VocBed: ResFacilities2 Other1Descrip: ResFacilities2 Other1Bed: ResFacilities2 Other2Descrip: ResFacilities2 Other2Bed: ResFacilities1 Deficiency: AbuseMol11 08: AbuseMol11 918: AbuseMol11 18+: ResFacilities3

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Supplemental Application - Hanover InsuranceCentral Station Yes No • Central Station Yes No • Smoke Detectors Yes No Are smoke detectors: hard wired battery operated 5. Are evacuation