• Image field 2
  •   Big Brothers Big Sisters Supplemental Application

  • Thank you for completing this application. It is being returned to John L Kirby & Associates for immediate processing so we may provide your quote. Your progress will be saved at any point, to complete the application at a later time you must restart from the same computer using the same browser. Your data will be saved for a maximum of 5 days. If you have any questions concerning this questionnaire, please call us for help.

  • Expiration Date of your Insurance
     - -
  • Has your agency changed it's name anytime after your retro date?
  • Has your agency discontinued any programs after your retro date
  • Please indicate the number of matches:
  • Community Based Matches:
     
  • Does the affiliate agency adhere to the Big Brothers Big Sisters Standards of Practice for:
  • One-To-One Service in its completeness
  • Does the affiliate agency utilize the following screening practices with every volunteer prior to being matched with a child?
  • In person interview?
  • Professional staff conducts an assessment in the volunteer"s home environment by in-home-visits?
  • Conducts a 50-State criminal and sex registry background check?
  • Completes three or more personal references?
  • Is at least one of the personal references from a relative of a volunteer?
  • Complete at least one professional reference?
  • Does the affiliate agency’s casework manual contain policies and procedures on how to recognize, prevent, and train volunteers on child sexual abuse, misconduct, or child endangerment issues?
  • Does the closure process include a questionnaire or interview with the child’s guardian that includes inquiry about concerns related to possible inappropriate conduct?
  • Please indicate
  • AGENCY STAFFIndicate the number of staff, contracted professionals, and volunteers:
  • Any Medical Professionals?
  • Please indicate number of people:
  • Any Social Workers?
  • Please indicate number of people:
  • Any Clerical / Administrative?
  • Please indicate number of people:
  • Any Other?
  • Please indicate number of people:
  • If contracted professionals are used, does the affiliate agency require them to sign a hold harmless or indemnification agreement?
  • Are Certificates of Insurance required and kept on file for those contracted professionals?

  •  

    Potential Claim Acknowlegdement

    Has any employee, volunteer, officer/director or independent contractor been reprimanded, suspended or dismissed as a result of alleged, suspected or actual physical abuse, sexual abuse or acts/errors/omissions related to professional services?

    Incidents reported, allegations or claims made, investigations made, or criminal/civil actions brought against your organization or its employees, volunteers, officers/directors or independent contractors for alleged, suspected or actual physical abuse, sexual abuse or acts/errors/omissions related to professional services that are not described on loss runs?

    Do you have knowledge or information of any facts, circumstances or situations that might reasonably be expected to give rise to a claim of physical abuse, sexual abuse or acts/errors/omissions related to professional services?

  • Please indicate yes or no*
  • Site Based Programs
  • Will there always be an adult, other than the volunteer, present while each program is taking place?
  • Will volunteers use their personal auto to transport children in connection with the program?
  • Does any aspect of this program involve any unsupervised one-to-one contact between a volunteer and a child, including transportation?
  • Are release forms, stating that there is to be no contact between the child and volunteer outside the agency-arranged program, signed by the parents or legal guardians and the volunteers?
  • Hired and Non-Owned Auto Liability
  • Do you want coverage for these non-owned/hired autos?
  • Does this agency have a procedure in place to verify that all employees and volunteers transporting children, using their personal vehicles for agency business, maintain personal auto insurance.
  • Indicate how evidence of adequate limits are verified for each employee and volunteer:
  • Does the agency verify auto coverage for each employee and volunteer at least annually?
  • Does the affiliate agency hire any vehicle for transporting affiliate agency employees, volunteers, or children?
  • Fund Raising and Special Events
  • Will any of the following activities be part of any event?
  • DECLARATION AND SIGNATURE
  • The person named herein is authorized and designated to give and receive all notices on behalf of the entity and all Insured"s from the entity or their authorized representative(s) concerning insurance.
     
  • 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 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 or offer any insurance, nor commit the authorized signer to accept insurance, but it is agreed that 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 the policy be issued.
     
  • Date Signed
     - -
  •  
  • Should be Empty: