Hanover School Renewal Supplemental Application 8.17.2011



AVENUES EDUCATIONAL ADVANTAGE PROGRAM

RENEWAL SUPPLEMENTAL APPLICATION

Named Insured:                          

Agency:                           Agency Code:           

|GENERAL INFORMATION |

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|1. Please provide your total enrollment: |

|Pre-school /Day Care            K-8            9-12            |

|Adult Education            Industrial Arts/Vo-Tech            |

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|2. Please provide number of personnel employed: |

|Administrators       Teaching Faculty       Student Teachers       |

|Counselors/Psychologists       Nurses       Athletic Trainers       |

|Nonprofessional Employees       Volunteer Workers       Security Personnel       |

|Teacher Aides       Bus Drivers       All other       |

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|3. Indicate any of the following Hiring Practices followed by the administration: |

|Signed employment applications are obtained for all potential employees |

|Employee referrals are used |

|Complete personal references are checked |

|Criminal background checks on all employees are required |

|Criminal background checks on volunteer workers are required |

|Documentation of employment applications and background/reference checks maintained |

|An employee orientations are conducted covering all Written Policies with documentation kept in file |

|Written employee handbook (provide copy) |

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|4. Does the educational institution plan to close any schools over the next 12 months? Yes No |

|If yes, please provide details of for each school closure:            |

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|5. Does the school own any buildings that are vacant or unoccupied? Yes No |

|Please provide details for each building including future plans for structure:                 |

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|6. Are there any buildings of historical value or listed on a historic register? Yes No |

|If yes, provide details:                 |

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|SAFETY/SECURITY |

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|1. Do you have an “all-hazards” emergency response plan in place? Yes No |

|Does your plan include response procedures to disease/pandemic outbreaks? Yes No |

|Does your plan require compliance with CDC and/or USDOE guidance? Yes No |

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|2. Is there a security force on campus? Yes No |

|If yes, whose employees? the school Independent Contractor Auxiliary of local police |

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|3. Do the local Police patrol regularly? Yes No If yes, what is the frequency?            |

|4. Does the emergency plan include provisions identifying alternate facilities if part or all of a building |

|becomes unusable? Yes No |

|Please indicate if you have any of the following operations &/or activities |

| Foreign Travel Hall Rental Church or any Other House of Worship |

|Fund Raising Activities Before &/or After Care Dormitories / Housing |

|Radio Station Television Station Campus Newspaper |

|Work Study Programs Swimming Pool(s) Trampolines Events with liquor sales |

|Does your website comply with current state and federal privacy statues/regulations? Yes No |

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|Please provide details of operations for each activity indicated above:                           |

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| SEXUAL MISCONDUCT LIABILITY N/A |

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|POLICIES/PROCEDURES |

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|1. Do you have a written policy (including training) addressing abuse, molestation, and sexual harassment in all of its forms (i.e. anti-abuse, |

|anti-molestation, anti-harassment)? Yes No |

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|2. If “Yes”, are the policies communicated annually to: |

|a. Staff? Yes No |

|b. Students? Yes No |

|c. Volunteers? Yes No |

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|3. Is documentation of the communication of the policies prohibiting abuse, molestation, and sexual harassment maintained? Yes No |

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|5. Do you have written policies and guidelines for reporting suspected abuse, neglect, or molestation of students? |

|Yes No |

|If “Yes” are these guidelines communicated to all employees and volunteers? Yes No |

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|6. Are the Insured’s policies/procedures relating to abuse, molestation, and harassment reviewed by counsel and updated on a periodic basis? |

|Yes No |

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|EDUCATORS ERRORS & OMISSIONS LIABILITY N/A |

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|Number of students receiving special education services            |

|Does the Education Institution anticipate any reduction in force of professional or non-professional staff during the next twelve (12) months? Yes No If |

|yes what % of employees will be impacted       |

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|BUDGET/BOND INFORMATION |

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|Budget |

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|YEAR |

|REVENUES |

|EXPENDITURES |

|Surplus (+) |

|Deficit (-) |

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|Current year |

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|Prior year |

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|If deficit exists, indicate cause of deficit and how it will be eliminated:                      |

|What is entity’s bond rating: Current            Previous:            |

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|4. Has the entity had any on-site monitoring by State or Federal Agencies? Yes No |

|If yes, describe:                                                         |

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|LAW ENFORCEMENT / SECURITY PROFESSIONAL LIABILITY N/A |

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|EXPOSURE INFORMATION |

|1. Total number of law enforcement/security personnel            |

|2. Total annual payroll/expense for law enforcement/security personnel            |

|3. Number of personnel in following categories: |

|a. School Resource Officer       b. Full-time Employees       |

|c. Part-time Employees       d. Volunteers       |

|e. Independent Contractors       f. Employees with firearms       |

|g. Employees with h. Personnel employed by |

|arrest authority       outside security firm or |

|police department       |

|4. If personnel from outside security firm or police department are used, please indicate name of firm or department: |

|                                              |

|a. Does school obtain “Certificate of Insurance” from security firm? Yes No |

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DECLARATION AND SIGNATURE

Authorized Entity Representative Designation

The person named herein is authorized and designated to give and receive any and all notices on behalf of the entity and all insureds from the entity or their authorized representative(s) concerning this insurance.

Named individual:                      Title or Position:                          

Attestation

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 it 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 the Hanover Insurance Group, Inc. to offer, nor the authorized signer to accept insurance, but it is agreed 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 a policy be issued.

Signature of Authorized Entity Representative

                                    Date:           

NOTICE TO ARIZONA AND MISSOURI APPLICANTS: Claim Expenses are Inside the Policy Limits. All claim expenses shall first be subtracted from the limit of liability, with the remainder, if any, being the amount available to pay for damages.

NOTICE TO ARKANSAS, LOUISIANA 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 provide false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder 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 HAWAII APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or imprisonment, or both.

NOTICE TO IDAHO AND OKLAHOMA APPLICANTS: 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 KENTUCKY 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.

NOTICE TO MAINE, 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 MARYLAND APPLICANTS: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and 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 MICHIGAN AND MINNESOTA APPLICANTS: Any person who knowingly and with intent to defraud an insurance company or another 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 act, which is a crime and subjects the person to criminal and civil penalties.

NOTICE TO NEW JERSEY APPLICANTS: Any person who knowingly includes any false or misleading information on an application for an insurance policy or files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO AND RHODE ISLAND 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 OHIO APPLICANTS: Any person who, with intent to defraud or knowing that he 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 OREGON APPLICANTS: Any person who knowingly and with intent to defraud or solicit another to defraud any insurance company: (1) by submitting an application, or (2) by filing a claim containing a false statement as to any material fact, may be violating state law.

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.

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