Abuse and Molestation Insurance Application

Step 1 of 4

25%

SAM Insurance Limits

What SAM coverage limits do you need?(Required)

Any limit (not specified, just need it to be included)

$50,000

$100,000

$500,000

$1M Each occ / $1M Aggregate

$1M Each occ / $2M Aggregate

$1M Each occ / $3M Aggregate

Other Limit

Enter the SAM limits you are required to have:(Required)

Do you have a copy of the insurance requirements or contract that ask you to carry the SAM limits you requested above?(Required)

A copy of the insurance requirements or contract requesting SAM limits of $1M/$2M or higher will be required by the carrier to approve these limits. Without those requirements, a SAM quote may not be provided. If you don’t have the requirements now, you can still proceed with the application, but before a quote is released, you will need to provide a copy of the contract or SAM insurance requirements.

Yes

Are you required to carry SAM insurance?(Required)

If you answer yes, we will ask additional questions in the final step of this application.

Yes

Upload your insurance requirements here:(Required)

Drop files here or

Max. file size: 512 MB.

Customer Details

Named Insured(Required)

This is the name that will be listed on your insurance policy and certificate of insurance. If you have a DBA, state it as follows: for example, ABC Inc DBA XYZ Services.

Business Entity Type(Required)

Individual

Partnership

LLC

Corporation

Non-Profit

Other

Entity Type – OTHER – please provide details:(Required)

Tax Exempt Status(Required)

Yes

Customer Contact

Primary Contact or C/O(Required)

First Last

Email Address(Required)

Phone(Required)

Website

Physical Address (No PO Box):(Required)

Street Address Address Line 2 City State ZIP Code

Is your mailing address same as physical?(Required)

Yes

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

What is the square footage occupied at your physical address?(Required)

What is your annual gross payroll for owners, W-2 employees, and 1099 subcontractors?(Required)

What is your annual gross revenue?(Required)

Underwriting

Select Your Business Category:(Required)

You can start typing to find your category. If you can’t find it, select “ALL OTHER PROFESSIONAL SERVICES AND PROFESSIONS”.

Describe Your Operations, Products and Services:(Required)

Please provide a description with a minimum of 10 words.

Applicant is a New Entity with No Prior Insurance Coverage (Required)

Yes

How many years of experience in the industry do you have?(Required)

Year business established:(Required)

Applicant Has Experienced a Loss In the Last Five Years for a Coverages Being Requested(Required)

Yes

Applicant Has Been Involved in Bankruptcy, Criminal or Civil Proceedings(Required)

Yes

Applicant Has Had Insurance Denied, Cancelled, or Non-Renewed by an Insurance Company in the Last 5 Years for a Coverage Being Requested(Required)

Yes

If you services require a license, do you have a valid license?(Required)

Yes

N/A (License is not required)

Staff are Trained in Non-Violent Crisis Intervention and De-Escalation Procedures (Required)

Yes

Insured has Detailed Procedures in Hiring Including Verifying the License is Current and has Never Been Suspended or Revoked(Required)

Yes

Have Claims, Allegations, or Charges of Abuse, Molestation or Sexual Misconduct Been Made Against or on Behalf of the Applicant?(Required)

Yes

Applicant has Formal New-Hire Screening Process(Required)

Yes

Process Encompasses Criminal Background Checks, National Sex Offender Registry Search, Verification of Personal References, and Interviews(Required)

Yes

Applicant Has a Formal Written Abuse Policy(Required)

Yes

Policy Prohibits One-On-One Contact, Identifies Grooming Behaviors, and Outlines Reporting Procedures if Abuse is Suspected(Required)

Yes

Applicant Has a Written Response Plan in Place for Handling Allegations of Abuse Including Dealing With Employees, Victims, Parents and Authorities(Required)

Yes

How many staff members (including owners, W-2 employees, and 1099 subcontractors) do you have?(Required)

About the participants of your programs

How many participants are aged 12 and under?(Required)

How many participants are aged 13-15?(Required)

How many participants are aged 16-18?(Required)

How many participants are over age 18?(Required)

Average Number of students per day:(Required)

Any volunteers? If yes how many. If none enter "0":(Required)

Final Step

Got it. Here is a clean and simple version: SAM insurance requirements can vary depending on the entity requesting it. To make sure everything is handled quickly and correctly, we need the contact person for the entity that requires SAM insurance. We will send them your certificate, confirm their requirements, and make any updates if needed so it gets accepted without delays. Please share their contact details and we will keep you in the loop.

Name(Required)

Contact Phone Number(Required)

Email(Required)

Untitled

Due to the nature of your operations, we require an additional SAM Insurance Supplemental application to be completed in order to secure SAM quotes for the risk presented. Click “Submit” and you will be redirected to a form you need to fill out so we can work on the insurance quotes for you. If you have any questions, call 877-239-0067.