• 4-H Insurance Questionnaire

  • Applicant is:

  • GENERAL INFORMATION

  • 3. Check all that apply to your operation:
  • 6. Any medical services or medical advice of any kind provided to members or to the public?
  • 7. Are any kinds of personal care or medical care services provided in any capacity?

  • EVENT INFORMATION

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  • ANIMAL INFORMATION

  • 3. Is each animal examined by a veterinarian at the start of each season?
  • 4. Do you have emergency procedures and equipment on site for animal bite? (First aid kit available.)
  • 5. Do you have a safety precaution sign? (Please provide picture of sign.)
  • 7. Do you allow visitors to feed animals? (Dry feed only) If yes, provide picture of "Don't eat animal feed" sign by feeding station.
  • 8. Do you have a hand sanitizing station with a sign requiring people to sanitize their hands after petting the animals? (Please provide picture of sign.)

  • ABUSE & MOLESTATION

  • 1. Does the applicant want abuse and molestation coverage?
  • 2. Does the applicant perform a criminal background investigation, including sexual abuse or child abuse related offenses on prospective employees and volunteers?
  • 3. Does the applicant verify employment-related references?
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  • 5. Does the applicant have knowledge of any incident which could give rise to, or result in, an allegation of sexual abuse?
  • 6. Has there ever been an allegation of sexual abuse made against the insured?

  • CAMPS

  • 1. Do you offer camps?
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  • 6. Is the camp:
  • 7. Are any meals or food provided or sold to participants?
  • 8. Is the camp co-ed?
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  • 9. Are participants (or parents) required to sign waivers? (Please attach a copy.)
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  • 9. Are participants (or parents) required to sign waivers? (Please attach a copy.)
  • 10. Is there any travel away from the camp?
  • 10c. Does the camp own any of the vehicles used?
  • 10d. Do you verify that all drivers are properly licensed adults with acceptable MVRs?
  • 10e. Is anyone under age 21 allowed to transport participants?
  • 10g. Is parent/guardian permission obtained for minors who will be transported?
  • 11. Do you offer overnight camps?
  • 11e. Do these facilities conform to life safety standards?
  • 11f. Are the premises open to the general public?

  • PROPERTY INSURANCE

  • 1. Do you need Building and/or Content Coverage?
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  • 2. Do you need Equipment Coverage?
  • 2a. If yes, total value to insure for?
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  • COMMERCIAL AUTOMOBILE INSURANCE

  • 1. Does the business title any automobiles or other operating vehicles in the business name?
  • 2. Is insurance coverage needed for owned automobiles?
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  • 3. Do any of the employees, owners or officers drive personally owned automobiles/other vehicles in the course of their work?
  • 3b. Do you verify they have liability coverage?

  • COMMERCIAL CRIME

     

  • 1. Do you desire coverage for Crime (Employee Dishonesty, Money, Forgery)?

  • COMMERCIAL UMBRELLA

     

  • 1. Do you need a Commercial Umbrella?

  • DIRECTORS AND OFFICERS & WORKERS' COMPENSATION INSURANCE

     

  • 1. Do you need Directors and Officers Liability Coverage? (If yes, please contact Kevin Morency.)
  • 2. Do you need Workers Compensation? (If yes, please contact Kevin Morency.)

  • SIGNATURE

  • The information I have provided is true and accurate to the best of my knowledge. I have not willfully concealed or misrepresented any material fact(s) or information. I understand completion of this questionnaire does not compel the company to provide coverage.

  • Questions? 877-244-9090
    Kevin Morency |  kmorency@morencyinsurance.com 

    Morency & Associates Inc.
    141 New Shackle Island Rd, Hendersonville, TN 37075
    Fax: 615-452-6580

    https://agritainmentinsurance.com/

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