Early Educators Supplemental Application

This application is designed for Montessori and Private Education Institutions grades K-8. Please review eligibility prior to filling out this application.

Submission Requirements

• Fully completed and signed ACORD application • A minimum of four years loss experience from prior carrier(s) including details of losses over $10K • List of all drivers, license numbers and dates of birth. MVR’s if available • Schedule of vehicles

General Applicant Information

Applicant Name: Mailing Address: Website Address: Inspection Contact: Phone Number: Years Under Current Ownership: Years Under Current Leadership: Enrollment: Maximum Daily Attendance:

Locations

Street Address Building Limit Business Personal Square Footage Construction Type Year Built Roof Age Property Limit

Losses (If Applicable) or No Losses____

Date of Loss Description Status Amount Reserve(s)

Has any policy or coverage been declined, cancelled, or non-renewed in the past five years? Yes No If Yes, Details:

Any Additional Insured:______No Additional Insured:______

Name Mailing Address Interest General Operations Information

Based on the maximum number of children enrolled, what is your actual breakdown of total staff to total number of children by age group (excluding director)?

Age Group # of Children Average Daily Attendance # of Teachers

Infants, ages 0 – 1 Toddlers, ages 1 – 2 Toddlers, ages 2 – 3 Preschoolers, ages 3 – 5 School Age Children, ages 5+

1. Is this school a Private Institution? Yes No 2. Is this a Montessori school? Yes No a. If No, Please describe type of school: 3. The number of children with an emotional or psychological disability is: 4. The number of enrolled children that require a special diet: 5. The diets include the following: 6. Is a minimum of one staff member certified in first aide pr sent at all times? Yes No 7. Optional: If male staff, provide details of: a. Length of employment: b. Any one-on-one activities: c. Duties performed, including age groups: 8. Is this school licensed? Yes No 9. If this school is licensed it expires on: 10. This school is licensed as a school with a capacity of 11. Expiration date of license is: 12. Is this school accredited? Yes No a. If yes, the accrediting organization is 13. Has the schools license or accreditation ever been revoked, suspended or issued with contingencies? Yes No 14. Have you had any repeated violations during state inspections? Yes No 15. Are there any swimming or wading pool exposures on or off premises? Yes No 16. Is this a new venture? Yes No 17. Does applicant have a day care on premises? Yes No 18. Does the applicant sponsor camps? Yes No 19. Is there a formal, written policy prohibiting the use of corporal punishment? Yes No 20. Does applicant have medical facility? Yes No 21. Does the facility dispense medication? Yes No 22. Does the facility provide only immediate care / first aid? Yes No 23. Does the facility only serve students? Yes No 24. Are written instructions from parents required prior to dispensing any medications to minors? Yes No 25. Is there any overnight care provided? Yes No 26. Is there a medical professional on staff? Yes No 27. If Yes, please indicate which of the following and how many are employed by the Applicant: a. Nurse Practitioner: Physician: 28. Does the professional carry their own malpractice insurance? Yes No a. If yes, who is the carrier and what limit is carried: 29. Are medical history and care records kept for each patient? Yes No 30. Approximately how many field trips are sponsored each year? 31. Describe the types of trips that are taken: 32. Is written permission / waiver obtained from each child’s parent or guardian? Yes No

33. If parents/volunteers or staff vehicles are used, does applicant secure background checks and waiver? Yes No

Athletics

1. Does your school participate in interscholastic athletics? Yes No a. If Yes, please describe the sports b. If No, no need to fill out remaining questions 2. Does the applicant obtain a signed release which includes a hold harmless agreement from the parents/guardians of all participants and obtained annually? Yes No 3. Are there procedures in place to verify that parents / guardians carry their own health insurance? Yes No 4. Are medical exams required for all participants in extra-curricular sports? Yes No 5. Is someone who is trained in first aid always present during practices and games? Yes No 6. Does the school have a written concussion management protocol that is compliant with current state legislation? Yes No 7. Does the applicant distribute the written protocol to coaches, parents, and players, and require the parent / guardian’s acknowledgement that they have received and reviewed? Yes No 8. Does the protocol include training in recognizing the signs / symptoms of a concussion or head injury? Yes No 9. Does the applicant utilize base line testing? Yes No 10. Is the training required for all coaches and faculty involved in physical education or sports instruction? Yes No

Location Information

1. The school is a story building and has square feet 2. The school is open hours per day; days per week; months per year 3. Is the structure a multiple occupancy facility or freestanding building? 4. Are there any individuals residing in the building? Yes No a. If Yes, please explain 5. Does the applicant have any animals on premises? Yes No 6. If there are animals on premises please list the type of animals: 7. Is this structure a converted dwelling? Yes No a. Please explain any modifications made and when: 8. Are the roof, electrical system, heating system, plumbing less than 25 years old? Yes No a. Please describe updates including year of updates: 9. Have you ever had an insurance claim for the roof? Yes No a. If Yes, please explain: 10. Is the building provided with an Automatic Fire Sprinkler System? Yes No a. If Yes, approximately what percentage (%) of the building is sprinklered? b. If Yes, what type of sprinkler system is installed? Wet-Pipe / Dry-Pipe or Both c. If Yes, when possible, is the sprinkler piping primarily run within conditioned areas designed to ensure the temperature remains above the 45°F minimum temperature? Yes No d. If No, please describe freeze prevention measures (e.g. temperature monitoring, heat trace, full insulation on piping or roof ): e. If Yes, is the testing & inspection by qualified sprinkler contractor completed within past 12 months & includes a formal winterization review? Yes No 11. Are water shutoff valves (domestic and AS water lines) marked and readily accessible? Yes No 12. Are water shutoff valves exercised (closed and reopened) at least annually? Yes No 13. Is the staff qualified to respond and shut off the water main during normal business hours and off hours? Yes No 14. Does applicant have a formal process to turn off and drain domestic water lines for these spaces? a. Unheated Areas (attics, crawl spaces, exterior wall joists) Yes No b. Are all domestic water lines located in areas heated to at least 45°F? Yes No c. Please describe freeze prevention measures (e.g. temperature monitoring, etc.) 15. Do you have a written emergency / security plan in place? Yes No 16. Do you have a written evaluation plan in place? Yes No 17. Are parents required to sign in and sign out student daily? Yes No 18. Are all visitors to the school required to sign in and out? Yes No 19. Describe your policy on releasing or signing-out children into the custody of others: 20. What security measures are in place at your locations: Electronic door locks, Alarmed doors, security cameras, armed guards, unarmed guards, please describe: 21. Does the school have a playground? Yes No a. If Yes, i. Is the playground fenced-in and secured? Yes No ii. Is the playground equipment organized so that it is age appropriate Yes No iii. Are there any concealed or tunneled aspects of the playground including slides? Yes No iv. Is there ground cover to protect a child in the event of a fall? Yes No v. Is the playground equipment inspected weekly? Yes No

Management Experience and Procedures:

Describe each Owner/Operator/Director of the School:

Name Duties Degree(s) Education Experience 1. 1. 1. 1.

2. 2. 2. 2.

3. 3. 3. 3.

4. 4. 4. 4. Please provide employee count:

Full Time Part-time

Certified Teaching Faculty:

Non-certified Teaching Faculty:

Non-Professional:

Administration:

Counselors / Psychologists:

Volunteers:

Security / Law Enforcement:

Other:

Total:

Who within the management team is responsible for the following: a. Issuing and training staff on policies and procedures. Name and position of person: b. Abuse awareness training. Name and position of person: c. Record and contract keeping. Name and position of person: d. Employment process including selection, training and monitoring of new hires. Name(s) and position: 1. Is any staff under 18 years if age? If yes, please describe duties: 2. Are background checks are required of each employee, volunteers and prospective employees? Yes No 3. Are new staff members serve a probationary period? Yes No 4. Has entity been criticized by the state board of education? Yes No 5. Has the educational entity or any of the educational entity’s academic programs lost accreditation, been placed on probation or been deemed unable to gain accreditation? Yes No a. If yes, please provide additional information:

Transportation

1. Does your school transport children between their homes and the school? a. If YES, what is the average distance traveled? b. Any major highways used? Yes No 2. Does your school transport children on field trips? Yes No a. If YES, on average how far from the facility are the trips? b. Any major highways used? Yes No 3. Does the school have a post-travel routine to verify all children have exited bus? Yes No 4. Do all children wear safety restraints in the vehicle? Yes No 5. Does the applicant have a formal driving policy in place with MVR standards? Yes No a. If YES, what action is taken if an “unacceptable” driver is identified? 6. Are all vehicles titled to the school? Yes No a. If no, please explain? 7. What is the percentage of personal use for any private passenger type vehicles? 8. Are all vehicles garaged at the school? Yes No a. If no, youthful drivers or a spouse in the household of where the vehicle is garaged? Yes No 9. Do you have a fleet or driver safety program in place? Yes No a. If YES, please describe: 10. Do you have a fleet maintenance program in place? Yes No 11. Do any of the employees transport children in their cars? Yes No a. If YES, please describe: 12. Does the school require proof of auto liability insurance? Yes No a. What are the minimum limits required? 13. Do any of the parents transport children in their cars on field trips? Yes No a. If YES, does the school require proof of liability insurance? b. What are the minimum limits required? 14. Does the applicant use an independent school bus contractor to transport students? Yes No a. If yes, are Certificates of Insurance required from the contractor? Yes No b. Is the school an additional insured on the contractor’s policy? Yes No 15. Does the applicant hire or borrow vehicles for non-busing purposes? Yes No a. If yes, please describe purpose and length of time vehicles are hired or borrowed: b. Approximately how many cars are hired or borrowed annually? 16. Are any vans or buses leased or loaned to others or used by outside organizations? 17. Number of employees using their own vehicles for school business (occasional or full-time use): a. For those employees who use their own vehicles for school business, either full-time or occasionally, does the school require the employee to carry primary insurance? Yes No b. If yes, what is the minimum limit the Applicant is requiring them to carry? 18. Is driving policy communicated in writing to all employees? Yes No a. Does the policy prohibit the use of cellphones / electronic messaging while driving? Yes No b. Is a signed acknowledgement form kept on file? Yes No

Abuse & Molestation

Polices & Procedures: 1. Does your school have a formal written policy regarding abuse or molestation? Yes No 2. Does your school have a formal training program on identifying and reporting incidents of abuse or molestation? Yes No 3. Are volunteers trained in policies and procedures relating to abuse or molestation? Yes No 4. Does your organization have written policies that require known or suspected abuse incidents to be reported to the proper authorities? Yes No 5. During new staff orientation, does the applicant discuss child/sexual abuse, how to recognize the signs and what to do if a child reports that someone molested him or her? Yes No 6. Have you developed and publicized to employees and volunteer’s abuse, molestation and sexual harassment reporting and investigation procedures? Yes No 7. Are employees and volunteers required to sign an acknowledgement of receipt and understanding of the abuse and sexual harassment policy? Yes No 8. Is documentation maintained on annual training regarding abuse, molestation and sexual assault? Yes No 9. Does the Applicant’s supervision plan monitor staff in day-to-day relationships with children both on and off premises? Yes No 10. How is the staff monitored? Video, Windows, Other______11. Are there operable surveillance cameras in all classrooms and inside and outside play areas? Yes No a. If Yes, is the video saved? Yes No b. If Yes, for how long? 12. Is there a policy on cell phone, camera, smart watch (camera, video, text, and phone capabilities) eliminating the use while in the presence of students? Yes No 13. Does the applicant contract with any vendors who have contact with any children in your care? Yes No a. If yes, please explain: 14. Are there any other circumstances where adults, who are not the Applicant’s employees, have access to any child in your care? Yes No a. If yes, please explain: 15. Are there any blind spots or areas within the schools, classroom and playground including slides, sleeping areas, etc. that are not open to general viewing by all parties? If Yes, Please Explain 16. Does the applicant’s employment process (for employees, volunteers, and independent contractors) include verification of whether the individual has ever been convicted of any crime, including sex-related or child abuse related offenses, before an offer of employment is made? Yes No 17. Does the employment application include questions regarding convictions of any crimes, including child abuse offenses or any crimes of a sexual nature? Yes No 18. Has your school or anyone working on behalf of the school ever had an incident or allegation of abuse or molestation? Yes No 19. Have any public authorities ever investigated you, your school(s) or your past or present employees / volunteers relating to abuse or molestation? Yes No 20. Have any allegations or civil or criminal actions been brought against you, your school(s) or your past or present employees / volunteers relating to abuse or molestation? Yes No 21. Are you aware of any incidents, circumstances or actions, which may lead to an allegation of child abuse or molestation, being filed against your school? Yes No 22. Has the applicant including owners, management or employees ever had any abuse or molestation (including sexual misconduct or sexual molestation) allegation or claim? Yes No 23. Does your school perform criminal background checks on all employees including management, volunteers, and independent contractors? Yes No 24. How long has the Applicant been performing these checks? 25. Does the applicant conduct a personal interview? Yes No 26. Does the applicant verify employment-related references? Yes No 27. For how many years does the Applicant keep these records on file after employee leaves 28. Does your school have written policies that require known or suspected abuse or molestation incidents to be reported to the proper authorities? Yes No

Fraud Warning Statements

NOTICE TO ALABAMA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. NOTICE TO ARKANSAS, LOUISIANA, RHODE ISLAND AND WEST VIRGINIA APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO COLORADO APPLICANTS: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies. NOTICE TO DISTRICT OF COLUMBIA APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits, if false information materially related to a claim was provided by the applicant. NOTICE TO FLORIDA APPLICANTS: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete or misleading information is guilty of a felony of the third degree. NOTICE TO KANSAS APPLICANTS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written, electronic, electronic impulse, facsimile, magnetic, oral, or telephonic communication or statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act. NOTICE TO KENTUCKY APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. NOTICE TO MAINE APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. NOTICE TO MARYLAND APPLICANTS: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NOTICE TO MINNESOTA APPLICANTS: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime. NOTICE TO NEW JERSEY APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NOTICE TO NEW MEXICO APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NOTICE TO NEW YORK APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. NOTICE TO OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud. NOTICE TO OKLAHOMA APPLICANTS: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. NOTICE TO OREGON APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, may be committing a fraudulent insurance act, which may be a crime and may subject the person to criminal and civil penalties. NOTICE TO PENNSYLVANIA APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. NOTICE TO VERMONT APPLICANTS: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under state law. NOTICE TO TENNESSEE, VIRGINIA AND WASHINGTON APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. NOTICE TO ALL OTHER APPLICANTS: Any person who knowingly and with intent to defraud any insurance company or another person, files an application for insurance or statement of claim containing any materially false information, or conceals information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties

Signature

Signed: (must be Officer of Applicant) Print Name & Title: Date (MM/DD/YY): Email/Phone:

Chubb is the marketing name used to refer to subsidiaries of Chubb Limited providing insurance and related services. For a list of these subsidiaries, please visit our website at www.chubb.com. Insurance provided by ACE American Insurance Company and its U.S. based Chubb underwriting company affiliates. This document is advisory in nature and is offered as a resource to be used together with your professional insurance advisors in maintaining a loss prevention program. The material presented herein is not intended to provide legal or other expert advice as to any of the subjects mentioned, but rather is presented for general information only. No liabilities or warranties are assumed or provided by the information contained in this document. Form LD53613 (07/20)