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  •   Big Brothers Big Sisters Renewal 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 application, please call us for help.

  • Has there been any change in your operation during the past year?*
  • Please indicate the number of matches:
  • Community Based Matches:
     
  • Percentage of matches included in above:
  • Does the affiliate agency adhere to the Big Brothers Big Sisters Standards of Practice for:
  • One-To-One Service in its completeness
  • 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?
  • Are you aware of ANY claims, allegations, and/or incidence (including abuse & molestation) made against your organization, or against anyone working on your behalf that may give rise to a claim?
  • Fundraising Events
  • Date
     - -
  • Alcohol Served
  • Add another event ?
  • Date
     - -
  • Alcohol Served
  • Add another event ?
  • Date
     - -
  • Alcohol Served
  • Add another event ?
  • Date
     - -
  • Alcohol Served
  • Add another event ?
  • Date
     - -
  • Alcohol Served
  • Add another 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
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  • Should be Empty: