GENERAL APPLICANT INFORMATION

Name of Applicant: ____________________________________________________________________________________________

Website Address: ______________________________________________________________________________________________

Risk Management Contact: ____________________________________________________ Email: __________________________

Phone: _______________

GENERAL INFORMATION

1. Institution Accreditation

a. What was the date of most recent review: _______________ Date of next review: _______________

b. What was the outcome of the most recent review:

Accreditation Continued Accreditation Continued — follow-up report requested Warning

Probation Show cause Withdrawal of Accreditation

Denial of Accreditation Appeal Other (provide details); _____________________________________

2. Please provide your total enrollment:

Undergraduate students: Full-Time ______ Part-Time ______ E-Learning ______

Graduate Students: Full-Time ______ Part-Time ______ E-Learning ______

Other: Full-Time ______ Part-Time ______ E-Learning ______

3. Please provide total number of personnel employed:

POSITION OR ACTIVIT Y FULL-T IME PART-TIME

Officers, Administrators, Managers

Teaching Faculty (all levels)

Nurses, Counselors, Psychologists, Athletic Trainers, Other professional Staff

Security / Law Enforcement

All other Employees

Total Employees

4. Employee/Volunteer Hiring or Selection Procedures: Indicate all practices followed by the administration:

Signed employment applications are obtained for all potential employees

Complete personal references are checked

Criminal background checks on all employees are required Local Federal None Conducted

Criminal background checks on volunteer workers are obtained (involvement with children)

Background Checks include search of National Crime Information Center

Background Checks include search of multi-state sex offender registry

Documentation of employment applications and background/reference checks maintained

An employee orientation is conducted covering all Written Policies with documentation kept in file

Written employee handbook (provide copy)

R E N E W A L S U P P L E M E N T A L A P P L I C A T I O N

Hanover Higher Education

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5. Does the application include questions concerning any prior abuse or molestation allegations, incidents, convictions, or pleadings of guilty or “no contest” to a misdemeanor or felony? Yes No

6. Does the application include acknowledgement that a background check may be conducted? Yes No

7. Does application require the applicant’s signature and include a warning that untruthful answers are grounds for non-employment or dismissal? Yes No

LIABILITY INFORMATION

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

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

b. Do Emergency Response Services (police, fire/rescue, and medical) participate in planning? Yes No

c. Does the plan include provisions identifying alternate facilities if building becomes unusable? Yes No

2. Does the school have any Campus Security? Yes No

Indicate the number of personnel providing security services:

a. Employed # _______ Unarmed # _______ Armed

Contracted # _______ Unarmed # _______ Armed

Off duty local police officer # _______ Unarmed # _______ Armed

b. Do you permit staff, volunteers or visitors to carry open or concealed firearms on your premises? Yes No

If Yes, please provide details: __________________________________________________________________________

If No, does your Weapons Ban Policy have any exceptions (provide details): ________________________________

3. Do you require the contracted security firm to carry General Liability and Law Enforcement Professional Liability coverage? Yes No

If Yes, what is the minimum liability limit required $ ___________________________________________________________

a. Are certificate of insurance required and retained? Yes No

4. Are hold harmless/indemnification agreements in your favor required from the contractor? Yes No

CONCUSSION MANAGEMENT PROGRAM NA

1. Do you have a formal, written concussion management program in place for all athletic programs? Yes No

2. When was it implemented? ________________________________________________________________________________

3. Does your institution perform/record at least annually baseline TBI or concussion assessment? Yes No

If Yes, describe the tool(s) used for baseline assessment (check all that apply)

Symptom checklist Neuropsychological testing

Standardized cognitive and balance assessments Other _________________________________________________

4. Is it consistently implemented and enforced for all athletic programs? Yes No

5. Does your institution train and educate all athletes at least annually:

i. Risks of concussion Yes No

ii. Signs and Symptoms of concussions Yes No

iii. Potential consequences of concussions over time and if not treated properly Yes No

iv. Athletes responsibility to report “possible TBI or concussion” to a trainer or medical staff Yes No

v. General prevention and preparedness efforts to keep athletes safe Yes No

6. Does it require athletes to sign a concussion injury information/training sheet? Yes No

7. Do you require training in recognizing the signs/symptoms of a concussion to all coaches/staff? Yes No

8. Does the protocol when a concussion is suspected require:

i. Removing the athlete/student from play? Yes No

ii. Evaluation by an appropriate healthcare professional? Yes No

iii. Informing the athlete/student’s parents or guardians about the possibility of a concussion and giving them information about concussions? Yes No

iv. Keeping the athlete/student out of play until an appropriate healthcare professional certifies that he or she is symptom-free and gives the approval for them to return to play? Yes No

9. Does the concussion protocol include a post-concussion progressive physical activity program before being allowed to return to full game play? Yes No

10. Does the concussion protocol provide for adjusted classroom activities during recovery? Yes No

SEXUAL MISCONDUCT LIABILITY NA

Prevention of Abuse or Molestation Policies/Procedures:

1. Do you have a written abuse prevention policy (including training) addressing abuse, molestation, and sexual harassment in all of its forms (anti-abuse, anti-molestation, anti-harassment)? Yes No

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

All Employees? Yes No

All Students? Yes No

All Volunteers? Yes No

3. Does your written policy manual include the following:

i. Contain procedures for immediate and proper reporting and investigation of all sexual or other abuse allegations? Yes No

ii. Identifies who is considered mandatory reporters by law and outline requirements Yes No

4. Are the policies/procedures relating to abuse or molestation, reviewed by counsel? Yes No

Abuse or Molestation Training:

Do your employee/volunteer training procedures:

1. Have documented training in place that clearly indicates “zero tolerance” of any type of abuse or molestation and outline what action will be taken in the event of any such abuse? Yes No

2. Include training in the recognition of sexual/physical abuse symptoms and include procedures to follow if a peer is suspected of such abuse? Yes No

3. Periodically schedule refresher training for all employees/volunteers? Yes No

4. Document all training for content and frequency? Yes No

5. Do you train all students on sexual assault, including prevention and resources? Yes No

Appointed Officer/Coordinator:

1. Has a Title IX Compliance Coordinator been appointed by the Insured to receive and investigate complaints of abuse, molestation, and/or harassment? Yes No

2. Does your web page contain information/resources on Title IX and Sexual Misconduct policies? Yes No

3. Has the institution adopted policies and procedures to address sexual assault that comply with OCR guidance? Yes No

4. Have you trained designated employee(s) to investigate sexual assaults or contracted with a qualified investigator? Yes No

5. Have you established procedures to handle complaints within 60 days? Yes No

6. Have you developed and publicized the reporting options and procedures? Yes No

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DIRECTORS, OFFICERS AND ENTITY LIABILITY NA

1. Provide a list of all direct and indirect subsidiaries or any other entity or organization you control:

NAME/ T YPE OF BUSINESS PERCENT YOU OWN/CONTROL

DATE CREATED/ ACQUIRED

FOR PROFIT NON-PROFIT

2. Are the entities requesting coverage recognized as 501(c)(3) tax exempt organizations Yes No

3. Total Gross Assets (including endowments): _________________________________________________________________

4. If you have endowment fund, is it managed or reviewed annually by an independent auditor? Yes No

If No, who manages or reviews your endowment fund? ________________________________________________________

5. Does the Board have “conflict of interest” guidelines for business dealings between the school and Board members or firms in which the Board members have a significant financial interest? Yes No

6. Has any person proposed for coverage been the subject of, or involved in, any of the following in the past 5 years? Explain all “Yes” answers below:

i. Any disciplinary action by any regulatory agency or association? Yes No

ii. Any administrative proceedings charging violation of a federal or state law or regulation? Yes No

iii. Any anti-trust, copyright or patent litigation? Yes No

iv. Any action for suspensions or revocation of a license, authority or for any professional disciplinary sanction? Yes No

v. Any other criminal actions? Yes No

If Yes, please provide details: _______________________________________________________________________________

7. Does your Board direct or request any individual to serve as director, officer or trustee of any other entity? Yes No

If Yes, please provide details: _______________________________________________________________________________

EMPLOYMENT PRACTICES LIABILITY NA

1. Within the past 24 months has your counsel or outside employment counsel completed an audit regarding the:

a. The payment of wages, including equal pay and overtime pay? Yes No

b. The classification of individuals as exempt vs. non-exempt or independent contractors? Yes No

2. Do you offer tenure? Yes No

If Yes, please advise the following:

a. What percentage of employees are tenured or on a “tenure track”? _____%

b. Are there clear written guidelines regarding awarding of tenure? Yes No

c. Is policy training conducted annually for all individuals involved in tenure decisions? Yes No

Employee Turnover and Terminations

1. Please provide the following employee turnover figures each of the last three years:

NUMBER OF TERMINATIONS YEAR YEAR YEAR

Voluntary

Involuntary

Layoffs/Downsizing

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2. Do you anticipate any school closings, layoffs or restructuring resulting in workforce reduction in the next 24 months? Yes No

If Yes, please provide details:_______________________________________________________________________________

3. Do you require that all employment terminations or cancellations of contracts of professional, teaching or management positions be reviewed prior to discharge by a qualified employment lawyer? Yes No

Human Resources

1. Do you have a Human Resources department? Yes No

If Yes, how many employees? _______

2. Do you have an employee handbook that is distributed to all employees? Yes No

3. Are employees required to acknowledge, by signature, receipt of such employee handbook? Yes No

LAW ENFORCEMENT PROFESSIONAL LIABILITY NA

General Applicant Information

1. Total number of personnel in following categories:

School Resource Officer _______ Unarmed _______ Armed

Contracted Security _______ Unarmed _______ Armed

Employed Security _______ Unarmed _______ Armed

Contracted Security: If contracted security exposure exists, please complete the following:

1. Please provide the name of firm or department: ______________________________________________________________

2. Is a formal written agreement in place for services? Yes No

3. Does the school obtain “Certificate of Insurance” from security firm? Yes No

4. Describe minimum requirements and training for security personnel: ____________________________________________

5. Do you require them to carry General Liability and Law Enforcement Professional insurance? Yes No

i. If Yes, what is minimum liability limit you require? _________________________________________________________

ii. Are hold harmless/indemnification agreements in your favor required form the contractor? Yes No

iii. Do you require a Certificate of Insurance? Yes No

iv. Are you listed as an Additional Insured on the contractor’s policy? Yes No

DECLARATION AND SIGNATURE

Authorized Entity Representative DesignationThe 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/Position: _________________________________________________ Date: _____________________________________

AttestationThe 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 AuthorizedEntity Representative: _________________________________________ Date: _____________________________________

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FRAUD WARNINGS

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.

114-10044 (2/17)

hanover.com

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653

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