PACKAGE / UMBRELLA FORMS

Transcription

1 2801 Slater Road Suite 220 Morrisville NC OFFICE FAX redwoodsgroup.com PACKAGE / UMBRELLA FORMS Please complete and return the included forms to your underwriter: New Business Questionnaire Business Income Worksheet Automobile Driving Record Worksheet Van Action Plan You can fill in these forms electronically, save and print. You will need to print out the forms in order to sign them. Please return completed and signed forms by fax, or scan and to your underwriter. Contact your underwriter if you have any questions. Thank you for considering The Redwoods Group as your partner

2 NEWBUSINESSCAMPQUESTIONNAIRE Please&complete&form.& CAMPNAME: FEIN# EXECUTIVESTAFF NameofCEO: YearsasCEO: TotalyearswiththisCamp: NameofExecutiveDirector: TotalyearswiththisCamp: PROFESSIONALSOCIALSERVICESTAFF NumberofLicensed/CertifiedSocialWorkers: NumberofLicensed/CertifiedCounselors: OTHERPROFESSIONAL/STAFF Numberofstaffworkinginthefollowingcapacities: EMT s EmployedNurses PhysicalTherapists VolunteerNurses PersonalTrainers ContractedNurses RegisteredDieticians/Nutritionists Staffwhohandlemoney Physicians VolunteerPhysicians OPERATIONS _ Volu Listindividuallocationsandgiveabriefdescription(i.e.% %day/resident%camp,%offsite%programs,%offices,%etc.):& LocationName(orattachschedule) City,State Description IsyourCampACAAccredited?YES NO if YES,whatisthedateofthelastvisit? AnnualRevenue Totalnumberofemployees: Fulltime: Parttime: Totalnumberofvolunteers: Ratiomaintainedatalllocationsofcounselorstocampersis:# counselorsfor# campers Numberofdamslocatedontheinsuredproperty Numberofdwellingslocatedontheinsuredproperty howmanyareoccupiedyearyround? TotalnumberofsaunasatyourCamp howmanyhavesprinklersinstalledinthem? HastheCamphadanabuse/molestationincident(s)and/orclaiminthepast10years?:YES NO If YES Pleasedescribe: Withrespecttoyourcampmedicalfacility/healthcenter: Arewritteninstructionsfromparentsrequired? YES NO Doesstaffadministerallmedications? YES NO Isalogkepttorecordeachtimeamedicationortreatmentisadministered?YES NO

3 PROGRAMS Totalnumberofresidentcamps: DatesofOperation: ADDRESSOFEACHCAMPLOCATION (ORATTACHSCHEDULE) AVERAGEDAILY ATTENDANCE #OFDAYSCAMPIS OPEN AGERANGEOF CAMPERS Totalnumberofdaycamps: DatesofOperations: ADDRESSOFEACHCAMPLOCATION (ORATTACHSCHEDULE) AVERAGEDAILY ATTENDANCE #OFDAYSCAMPIS OPEN AGERANGEOF CAMPERS ModesofOperation(circleallthatapply): UserGroups/Rentals Trip/Travel SpecialNeedsSocialServiceProgramCampgrounds SeasonsofOperation(circleallthatapply): Summer Fall Winter Spring Doyourentyourcampfacilitiestooutsidegroups?YES NO If YES,answerthefollowing: Pleaseprovideannualgrossreceiptsforallrentals: Isawrittenlease/contractrequiredforallusergroups?YES NO ApproximatenumberofuserWgroupparticipants: Describethelevelofsupervisionprovidedbycamp: CircleALLActivitiesOfferedatCampLocations: GENERAL: WINTERSPORTS: ADVENTUREPROGRAMS: EQUESTRIAN: Archery Snowboard LowRopesCourse Riding SkatePark AlpineSki HighRopesCourse Grooming Riflery/BB CrossCountrySki ClimbingWall PonyRides Boating IceSkating ZipLine Jumping Swimming SnowMobiles AlpineTower Vaulting Trampolines TubingHill OffWsiteAdventureActivity RodeoActivities Listanyotheractivitiesnotlistedabove: Docamperssignawaiverofliability? YES NO WhatpercentofactivitiesareoffYsite? % Numberofboatsinuse: Sailboats26feetandover: Sailboatsunder26feet: MotorBoatsunder26hp:MotorBoats26hpandover: PleaseanswerthefollowingregardingEquestrianexposure: NumberofsaddleanimalstheCampowns: NumberofsaddleanimalstheCampleases: Thosewhohandlethehorses:CampStaff# Contractors# Whatcertifications/trainingarerequiredofequestrianstaff? IsthereaseparateEquestrianWaiver?YES NO Ifwildernesscamping,doyouhaveanemergencycommunicationplan?YES NO If YES,pleasedescribe:

4 SPECIALNEEDS(Ifspecialneedscamping,pleaseanswerthefollowing): Percentofcamperswithspecialneeds: % Percentofstaffwithrelevantexperiencetothespecialneedsbeingserved: % Arestaffinformedoftheabilitiesofthecamperswithspecialneedsregardingactivities,sleeping arrangements,diet,medicalrequirements,etc.?yes NO Areindependentcontractorsusedtosupervise/instructcamperswithspecialneeds?YES NO If YES,isacontract/agreementwithwaiverlanguagesigned?YES NO SWIMMINGPOOLSANDWATERFRONTS Totalnumberofpoolsand/oroutdoorbodiesofwaterusedforswimmingactivityatyourCamp: LOCATIONADDRESS #OFINDOORPOOLS #OFOUTDOORPOOLS #OFBODIESOFWATER Pleasecheckanyandallofthefeaturesavailableattheabovelistedpools/bodiesofwater: Waterslide LazyRiver CurrentChannel FlowWRider VortexPool SprayGround DivingBoard SplashPad WaterTrampoline ScubaDiving RopeSwing Blob Listanyotherfeaturesnotlistedabove: HowmanypoolsareNOTVGBcompliant? MANAGEMENTCONTROLS Approximate#ofcampcounselorsemployedeachseason:Summer Fall Winter Spring Numberofinternationalstaff: isanagencyused?yes NO if YES,attachcontract Arestaffmemberstrainedinchildabuseprevention?YES NO If YES,uponhiring?Y/N and/orduringemployment?y/n howoften? DoestheCampinstructstaffmemberstoavoidbeingalonewithachild?YES NO DoestheCampoperateprogramswherestaffmayworkoneYonYonewithacamper?YES NO If YES,describeprogram(s) ADACONTROLS HasyourCamp(includingalllocations/operations)hadaformalADAauditbyaqualifiedconsultant? YES NO If YES,wereformalrecommendationssubmitted?YES NO HasyourCamp(includingalllocations/operations)receivedanywrittenADArelatedcomplaintsfrom participants,patrons,guestsand/oremployeesinthepast5years?yes NO If YES,isarecordkeptofsuchcomplaintsandtheirresolution?YES NO Haveyouremployeesand/orvolunteersbeentrainedtoreportanynonYwrittenADArelatedcomplaints? YES NO If YES,isarecordkeptofsuchreportsandtheirresolution?YES NO HowoftendoesyourCamp(includingalllocations/operations)reviewcurrentADArelatedpoliciesand procedures,facilityaccess,jobdescriptions,jobaccommodationprocess,andtrainingformanagersand staff?

5 COMMERCIALCOOKING Listlocationswherecommercialcookingisperformed: Address(orattachschedule) Isthereasuppression system? AutomaticFuel ShutOff? Iscleaningofhoodand duckcontractedout? (circle)yesno YESNO YESNO (circle)yesno YESNO YESNO (circle)yesno YESNO YESNO AUTOMOBILE Arevolunteersand/orstaffallowedtodriveCampvehicles? YES NO AreMVRscheckedonalldrivers?YES NO If YES,howoften?Athireonly Annually AreinternationalstaffallowedtodriveonCampbusiness? YES NO Arechildrentransported? YES NO If"YES" Describe: Howmanyvehiclesareused? Typesofvehiclesused: Whodrivesthevehicles(i.e.Campstaff,contracted,etc.)? Otherthanthedriver,isthereadditionalstaffonvehicletosuperviseriders?YES NO AreCertificatesofInsuranceobtainedonallvolunteers/staffthatdrivetheirautoforCampbusiness? YES NO If YES Whatautomobilelimitsaretheyrequiredtocarry? DoesyourCampeveroutsourcetransportationtolocaltransportationcompanies?YES NO if YES,whatistheannualcostofhire? AreCertificatesofInsuranceobtainedfromthetransportationcompany?YES NO PERSONCOMPLETINGTHISQUESTIONNAIRE %%At%this%point,%please%print%the%electronically%completed%portion%of%the%form%(if%applicable)%and%fill;in/sign%below. PrintName: Signature: Title: Date

6 AUTOMOBILE DRIVING RECORD WORKSHEET Organization Name: Date Completed: Driving records for all drivers should be checked as part of the hiring process and on an annual basis thereafter to a written non-discriminating organizational policy. Please provide the following information regarding driver experience. 1. Person responsible for managing driving records: Name Title 2. Total number of power units: 3. Total number of drivers: 4. Total number of MVRS ordered: 5. Number of drivers with type "A" violations (3 years): 6. Number of driver with 3 or more type "B" violations (3 years): Name of person completing this form: TYPE "A" VIOLATIONS - MAJOR VIOLATION * DUI, DWI, OUI, OWI * Refusing a substance test * Driving with an open container of alcohol * Reckless driving * Hit and run * Fleeing a police officer * Racing * Driving while license is revoked or suspended * Manslaughter - by motor vehicle * Felony - death by motor vehicle TYPE "B" * Speeding * Improper lane change * Failure to yield * Failure to obey a traffic signal * Failure to obey a sign * License suspension * At fault accident Eligible drivers must: 1. Be at least 18 years old 2. Have an acceptable driving record 3. Have a valid license 4. Be familiar with the vehicles to be used or given instruction prior to driving your vehicles. 5. Have a recent criminal background check on file. The Redwoods Group P F Y_ADRW_5.08

7 12 & 15- PASSENGER VAN ACTION PLAN Organization Name: Plan Date: CEO Signature: CVO Signature: We currently have no 12- or 15-passenger vans used to transport people (some may have been converted to cargo vans) We agree that neither we nor our volunteers will rent, lease, borrow, or use any 12- or 15-passenger van to transport people in conjunction with programs or on organization business and that we will not accept them as gifts. We agree to announce this position to all staff, volunteers, and donors annually. - OR- No purchase, rental, lease, loan, or use of additional 12/15 passenger vans Implement vehicle safety measures provided by Redwoods - Remove any roof-racks / remove tow-balls - Remove the backseat from all 12/15 passenger vans Implement driving safety policies provided by Redwoods - Do not drive on limited access roadways - Do not exceed 45-mph maximum driving speed - Do not carry more than 10 passengers - Do not carry luggage on the roof or in a towed trailer - Keep heavy storage low, secure and ahead of the rear axle - Check tire pressures daily to conform to manufacture guidelines - Inspect van before and after every trip (inspection form attached) Implement administrative safety policies provided by Redwoods - Implement training and testing for all new drivers - Implement semi-annual update training for all van drivers ACTION GOAL DATE COMPLETION - Restrict drivers to those who are thoroughly familiar with the handling and response of a 12/15 passenger van and who have received appropriate training - Maintain at branch and association office current list of these drivers (attached) - Keep and maintain records of vehicle inspection forms Limit use of vans to local use only (outsource or use minivans on all trips requiring highway usage until all vans can be replaced by minivans, buses or mini-buses) Begin transition to buses or mini buses by replacing existing vans when necessary with buses. (By-vehicle timeline attached) Eliminate use of 12/15 passenger vans for transportation THE REDWOODS GROUP P F