Is any of the following outdoor equipment on the premises?
- Trampolines ___ Yes ___ No
If yes, provide the diameter of each trampoline. ___________
- Playground Equipment ___ Yes ___ No
If yes, provide the height of each separate item. _____________
- Tree House ___ Yes ___ No
If yes, provide the height and dimensions. ______________
- Swimming Pool ___ Yes ___ No
If yes, complete the swimming pool supplement.
Do activities that regularly involve non-family members take place at the residence? ___ Yes ___ No
If yes, describe.
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Do any household members host a blog, group forum, or other type of Internet activity that goes beyond individual/personal usage?
___ Yes ___ No
Are there bodies of water (such as rivers, creeks, lakes, or ponds) on the premises? ___ Yes ___ No
If yes, describe the exposure and any protection that surrounds it.
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Are any other features of the applicant’s property unusually appealing yet dangerous for
children or adolescents? ___ Yes ___ No
If yes, describe the feature and measures to limit or prevent access to it.
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OFF-PREMISES EXPOSURES
What are the occupations of household members?
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Name |
Occupation |
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Occupation |
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List all organizations where household members take active roles as unpaid volunteers. Describe their job duties.
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Name |
Organization |
Job Duties |
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Does the organization provide liability and directors and officers liability coverage for its volunteers?
Does any applicant act as a trustee or executor of an estate? ___ Yes ___ No
If yes, answer the following questions:
Does the trust or estate provide a bond and other insurance for the applicant’s benefit?
___ Yes ___ No
Describe the trust or estate property.
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CONTRACTS
Does the applicant hire others for construction projects, landscaping, housekeeping, babysitting,etc.?
___ Yes ___ No
If yes, answer the following questions.
Is there a written contract? ___ Yes ___ No
Does the contractor provide a certificate of insurance for work it performs? ___ Yes ___ No
DOMESTIC HELP
Does the applicant employ domestic help? ___ Yes ___ No
If yes, answer the following:
List the name of each individual, the duties performed, if the individual lives on premises, and the number of hours the individual works per week.
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Name |
Duties performed |
Live on premises? (Y/N) |
Hours worked per week |
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Does the applicant purchase workers compensation coverage?
If yes, list the carrier’s name and the policy period.
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VACANT LAND
Does the applicant own vacant land? ___ Yes ___ No
If yes, list the vacant land’s location or legal description, a description of it, and its total acreage.
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Location/Legal Description |
Description |
Total Acreage |
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