Risk Management Report Card

The relationship which we desire to have with you is based on the fact that you believe you can trust us to assist you with the necessary safeguards that can help manage your risk factors in life. To enable us to be in the best position to assist you, it is critical that our relationship is based on effective, timely, and accurate communication, which is both given and received from each.

This optional form is designed to assist both of us as we work together and covers many, but not necessarily all possible risk factors you are confronted with. If there are other risk factors you feel we should consider or have questions with please let us know. This exercise can assist us to position you for the best possible premiums and less risk. Our goal is to have this completed 120 days before your insurance renewal.

Thanks for working with us as we seek to do our best to assist you in managing your risk factors that can rapidly change in our culture today.

Client information

Name:
Address:
Policy Number:
Email:
Telephone:


1	Ministry Type	City Church Country Church Church School Pre-school College Camp/retreat Denominational office Other


1	Select which property type this will apply too.	Worship Shelter house Gym School Office Mulitpurpose Fellowship Hall Residence Utility Other

[Property Risk Factors]

	Question
1	Do you have a current personal property inventory completed?	Yes No NA
2	Do you have a current schedule completed for portable equipment, items of art, or other appreciating or rare items of quality on file with our office?	Yes No NA
3	Are portable electronic devices properly secured when away from the insured location?	Yes No NA
4	Are privacy issues and data security effectively cared for with data on portable computer equipment?	Yes No NA
5	Does your pastor and staff have a current personal property inventory for their items completed and filed with our office?	Yes No NA
6	Does ministry data have effective security, integrity, and backup in place and checked regularly?	Yes No NA
7	Does ministry data have restrictive and privacy procedures effectively in place?	Yes No NA
8	Do you have effective security that protects your main computer or servers from theft, vandelism, other damage?	Yes No NA
9	Have you developed a crisis plan that could be activated in case of an emergency?	Yes No NA
10	Are staff and/or leaders trained on how to properly respond in emergency situations?	Yes No NA
11	Do you have ministry workers that are designated to watch hallways and parking lots during events for security issues?	Yes No NA
12	Do you have ministry medical workers to assist with emergency situations that set in designated seats so others know where they are?	Yes No NA
13	Have you conveniently placed flashlights that work, should a possible emergency happen that would require their use?	Yes No NA
14	Have you conveniently placed a radio with good working batteries that can assist you if needed for an emergency?	Yes No NA
15	Are all exit ways checked for a "clear exit path" and a working exit light?	Yes No NA
16	Do all people rooms have a properly placed footprint of the building noting how to exit the building several ways from that position?	Yes No NA
17	Are emergency lights working and properly placed for lighting exit ways and stairways?	Yes No NA
18	Do you have a central station alarm or local alarm that protect your mechanical units on the outside of your building?	Yes No NA
19	Do you have a central station alarm or local alarm for water damage?	Yes No NA
20	Do you have a central station alarm or local alarm for heating and cooling failures?	Yes No NA
21	Do you have central station alarm or local alarm for theft?	Yes No NA
22	Do you have central station alarm or local alarm for fire?	Yes No NA
23	Is a central station or other alarm certificate on file in our office?	Yes No NA
24	Have you inspected your sprinkler system if you have one to be sure it will effectively work when needed?	Yes No NA
25	Have carbon monoxide (CO) detectors been inspected and tested for working condition in last 12 months?	Yes No NA
26	Have smoke detectors been inspected and tested for working condition in the last 12 months?	Yes No NA
27	Have Fire extinguishers been serviced in last 12 months?	Yes No NA
27	Are Fire extinguishers located so that no building part more then 70 feet from one?	Yes No NA
28	Do you regularly check to be sure there is no torn carpeting or defective flooring that could create trips and falls?	Yes No NA
29	Are all interior handrails and stairways in good working order?	Yes No NA
30	Have you checked to be sure there is no visible interior water or mold damage?	Yes No NA
31	Good housekeeping is evident both inside and outside of your property?	Yes No NA
32	Do you regularly check refrigerators and freezers to be sure they are securely plugged into outlets and working?	Yes No NA
33	Do you have elevators? If yes, then were they inpected last and certified?	Yes No NA
34	Do you have food inspections? If yes, when was the last one?	Yes No NA
35	If you have food inspections done have all deficiencies been dealt with properly?	Yes No NA
36	If you have a commercial kitchen exhaust unit how often is the grease exhaust filter cleaned?
37	How often are your kitchen stove units used?
38	Do you have a commercial kitchen exhaust with a fire suppression system? If yes, when was the date of the most recent inspecting by a certified inspector?	Yes No NA
39	Have your heating and air conditioning units been serviced in last 12 months?	Yes No NA
40	Are all heating and mechanical rooms free of flammables or flammable items and are the rooms checked regularly?	Yes No NA
41	Are all cleaning chemicals properly stored and secured?	Yes No NA
42	Are all flammables properly stored and secured?	Yes No NA
43	Have you checked to be sure there are no exposed wires, broken outlets, or other malfunctioning electrical items present?	Yes No NA
44	Have you checked to be sure there are no improper use of extension cords or any used that are in poor condition?	Yes No NA
45	Have you checked to be sure there no over loaded outlets?	Yes No NA
46	Is there lightening protection and power surge protection for electronic equipment?	Yes No NA
47	Does all of your plumbing function properly, with no known leaks?	Yes No NA
48	Have you checked to be sure there is no visible exterior water or mold damage?	Yes No NA
49	Are all down spouts and eves in good working order and directing water away from the building?	Yes No NA
50	Is your roof in good repair with no torn, missing roofing, nails pushing up, or loose tabs? For flat roofs are there standing water spots?	Yes No NA
51	What is the age of roof?
52	Have you checked to be sure there are no tuck-points (mortar joints between bricks) needing repair?	Yes No NA
53	Have you checked to be sure there are no visible structural hazards such as cracks in walls, foundation or bowed/bulging walls?	Yes No NA
54	Is your key distribution policy adequately restrictive?	Yes No NA
55	Are exterior doors and locks in good working order and open outward?	Yes No NA
56	Are all exterior doors equipted with proper working panic door hardward?	Yes No NA
57	All windows and frames are in good repair, properly caulked, with properly working locks?	Yes No NA
58	All property building exteriors are in good repair and do not lack paint?	Yes No NA
59	Is all property free of graffiti?	Yes No NA
60	Are all scrubs and landscaping is trimmed in such a way so as not to present security issues or hiding places for criminals?	Yes No NA
61	Are all trees scrubs in good condition with no broken, dead or dying limbs?	Yes No NA
62	Are all fences in good repair?	Yes No NA
63	Are all retaining walls in good condition?	Yes No NA
64	All chimneys are clean and inspected for cracks and other defects in the last 12 months?	Yes No NA
65	Are all decks, docks, and elevated walkways in good condition?	Yes No NA
66	All exterior stairways have properly working sturdy handrails?	Yes No NA
67	All outside steps and sidewalks are in good repair with no cracking or uneven surfaces?	Yes No NA
68	Are parking areas and driveways in good repair with no potholes or other trip and fall hazards?	Yes No NA
69	Does exterior property lighting provide adequate risk management and are they properly maintained?	Yes No NA
70	Are lightening rods installed and in good working condition?	Yes No NA
71	Is ice and snow removed from walkways with 24 hours or as required by community ordinance?	Yes No NA
72	Are playground grounds check before use for sharp objects, poisonous plants or other harmful items?	Yes No NA
73	Is playground ground surface covering a proper fall-absorbing material?	Yes No NA
74	Is all playground equipment in good repair and working order?	Yes No NA
75	Is your playground surrounded with at least a 4 foot fence or higher with a locking gate to reduce child risks?	Yes No NA
76	Is your swimming pool properly maintained and fenced?	Yes No NA
77	4Are certified life guards on duty when persons are swiming?	Yes No NA
78	Do you request proof of insurance and workers comp for those that are contracted workers on your property?	Yes No NA
79	Have you made arrangements for regular and timely maintenance of your grounds?	Yes No NA
80	Are all lawn and grounds tools properly maintained?	Yes No NA
81	Do you own any self-powered lawn maintenance items such as riding mowers, lawn tractors, snow throwers, etc?	Yes No NA
82	If the answer to question 81. is "Yes" then provide details:
83	Have all property updates, additions, newly built or purchased buildings or personal property been reported to our office ?	Yes No NA
84	Has any property been remodeled recently or do you plan on doing remodeling in near future?	Yes No NA
85	Details:
86	Have ministry program additions as church plants, preschools, new out reach programs, etc been relayed to our office?	Yes No NA
87	Comments on question 86.

[Transportation Risk Factors]

	Question
1	Are all approved drivers, on your approved driver list, checked for qualifications annually?	Yes No NA
2	Is there a driver training program for your drivers before they drive?	Yes No NA
3	Is there a pre-selection procedure and screening procedure for all drivers that is kept on file?	Yes No NA
4	Is your approved driver list annually filed with our office?	Yes No NA
5	Do you require new drivers of a vehicle to drive it for about 15 to 20 minutes before hauling people the first time?	Yes No NA
6	Do you allow no more passengers in vehicles then legally allowed for each seatbelt, or seats if no seatbelts for both owned and non-owned vehicles?	Yes No NA
7	Are your drivers careful to not be impaired by alcohol or drugs when driving?	Yes No NA
8	Are your drivers careful to not be impaired by a required medication when driving?	Yes No NA
9	Do your drivers refrain from the distraction of grooming when driving?	Yes No NA
10	Do your drivers refrain from the distraction of smoking when driving?	Yes No NA
11	Do your drivers refrain from the distraction of reading maps or other printed material when driving?	Yes No NA
12	Do your drivers refrain from text messaging when driving?	Yes No NA
13	Do your drivers question about seatbelt and encourage their passengers to do the same?	Yes No NA
14	Do your drivers have a cell phone available in case of an emergency when driving?	Yes No NA
15	Have your drivers had a professional vision test in the last two years?	Yes No NA
16	Are sunglasses available in your vehicles for sun glare reduction if they need them?	Yes No NA
17	Are personal property items in your autos secured from view to deter theft when the auto is left parked?	Yes No NA
18	Do you only allow approved drivers to drive your vehicles that are listed on your ministry driver list?	Yes No NA
19	Are drivers careful to never leave a child in an unattended vehicle?	Yes No NA
20	Are the appropriate child car seats available when needed and do drivers know how to properly install them to meet the new legal requirements?	Yes No NA
21	Do drivers understand the proper child to adult ratio for owned and non-owned vehicles?	Yes No NA
22	Do you make sure your drivers have the proper amount of sleep before driving for group trips?	Yes No NA
22	How is this determined?
23	If your drivers have physical issues that can affect driving, have these been cared for before they drive?	Yes No NA
24	Do your drivers always lock the vehicles when leaving them and take the keys with them?	Yes No NA
25	Before your drivers drive vehicles do they perform an inspection of moving parts, hose, battery, belts, tires, brakes, etc for the 5 minute inspection report?	Yes No NA
26	Is there regular scheduled maintenance for each owned vehicles?	Yes No NA
27	Have you checked vehicle windshields for cracks and stone chips?	Yes No NA
28	Are the rearview mirror and side mirrors functioning properly for each owned vehicle?	Yes No NA
29	Have you inspected vehicle brakes and parking brakes on owned vehicles?	Yes No NA
30	Have you recently inspected your spare tires for proper inflation?	Yes No NA
31	Do you regularly check vehicle tires for proper inflation?	Yes No NA
32	Do you regularly check vehicle tires for unusual tire wear which can indicate tire, suspension, or drive train problems?	Yes No NA
33	Have you checked vehicle jacks to be sure they are available, in good working condition, and that drivers can safely use them?	Yes No NA
34	Do you have vehicle safety kits in each vehicle?	Yes No NA
35	Do you have a vehicle fire extinguisher in each vehicle?	Yes No NA
36	Do you have a first aid kit in each vehicle? First aid kit should not be left in extreme heat.	Yes No NA
37	Do you regularly check auto fluid levels, especially before longer trips?	Yes No NA
37	Have you recently checked the working condition of headlights, tail lights and all warning lights of vehicles?	Yes No NA
39	Have vehicle exhaust systems been inspected recently?	Yes No NA
40	Do you regularly check vehicle horns?	Yes No NA
41	Are all vehicles listed on your policy titled to the named insured properly?	Yes No NA
42	Are all drivers on your approved driver list?	Yes No NA
43	Are any vehicles parked overnight on a public street?	Yes No NA
44	Are any ministry owned vehicles used regularly for personal use by ministry staff?	Yes No NA
45	Do you own any recreational items such as campers, travel trailers, watercraft, golf carts, dune buggies, go-carts, mopeds, Segways, snowmobiles or any item capable of flight.	Yes No NA
46	If the answer to question 44 is "Yes" then provide details:
47	Do you only allow approved drivers on your approved driver list to opperate these recreational items?	Yes No NA
48	Do you maintain the items listed in question 44 as recommended by the manufacturer?	Yes No NA

[Unique ministry risk factors]

	Question
1	Have you filed with our office infomation about all ministry activities that are off location as trips, retreats, work camps, etc?	Yes No NA
2	Have you filed with our office information that covers any unique events at your location as fire works, fairs, outdoor services, etc.	Yes No NA
3	If you have foreign travel trips have you notified our office to secure proper information and insurance?	Yes No NA
4	If some one has willed property to your ministry have you notified our office so that we may secure necessary insurance for it?.	Yes No NA
5	Do you rent a camp or send persons from your ministry to such during the year?	Yes No NA
4	Do other entities use your buildings or grounds regular or from time to time?	Yes No NA
5	Do you request a use form from outside entities that ask for a certificate of insurance?	Yes No NA
6	Is your outside entity use form on file with our office?	Yes No NA
7	Has your ministry leadership kept abreast in their review of risk management by reviewing our newsletters?	Yes No NA
8	Have ministry leaders reviewed the updated version of the on deman workshops that are online with our web site?	Yes No NA
9	Have ministry leaders reviewed Reducing the Risk of Sexual Misconduct cd offerd by GuideOne?	Yes No NA
10	Does your ministry have an appointed risk manager that continually reviews the ministry risk factors?	Yes No NA
11	Has your ministry had a leadership risk workshop done with them by us?	Yes No NA
12	Have we reviewed to your satisfaction with you your ministry risks recently and how well your insurance is matched to them?	Yes No NA
13	Do you feel you effectively understand your risks and their relationship to your insurance benefits?	Yes No NA
14	Do you feel you have effectively and timely communicated all ministry risk factors to our office?	Yes No NA

[Procedural and safeguard risk factors]

	Question
1	Does your ministry have clearly written procedures for collecting, counting, depositing, and reporting finances for each aspect done by different people that are unrelated?	Yes No NA
39	Does the ministry have separate people, unrelated, that create checks, with another that signs or releases them for electronic transfers?	Yes No NA
40	Do you require double signatures on all paper checks?	Yes No NA
41	Are your books, if digital, user and password protected with distinct user accounts?	Yes No NA
2	Does your ministry have written procedures for signing of checks and dealing with ministry credit cards?	Yes No NA
3	When was the last time your ministry had an impartial audit done of ministry books by an outside CPA firm?
4	Does your ministry have an annual internal impartial ministry audit of all ministry books?	Yes No NA
5	If your ministry accepts online contributions, is the site properly secured to meet federal bank and transaction requirements for security and privacy?	Yes No NA
6	Does your ministry give a written statement annually to each financial giver of their years contributions?	Yes No NA
7	Do you use trip, medical, and parental release forms for all children's ministry trips and events especially those off location?	Yes No NA
7	Do you use written applications for all paid and unpaid staff positions?	Yes No NA
8	Do you have an annual leadership orientation meeting at which all forms and procedures are reviewed, signed off as read and agreed to, and kept on file?	Yes No NA
9	Does your ministry have clearly written job descriptions for each leader both paid employee and volunteer?	Yes No NA
10	Does your ministry have written interview and screening procedures for each employee and volunteer position?	Yes No NA
11	Do all employees and volunteers know by signed application that their position is at will?	Yes No NA
12	Do all ministry employees have background and referrence checks completed before they are employeed?	Yes No NA
13	Do all volunteer leaders that deal with persons one on one have background checks completed?	Yes No NA
14	Are all employees and volunteer leaders required to requalify themselves annually by signing a ministry risk requalifying form?	Yes No NA
15	Are all employee and volunteer working conditions reviewed regularly for safety and risk factors?	Yes No NA
16	Does your ministry have an employee and volunteer handbook on file with our office for risk factor review?	Yes No NA
17	Does your ministry have employee and volunteer applications on file with our office for risk factor review?	Yes No NA
18	Do all employees and also volunteers that deal with people one on one have completed background and referrence checks done?	Yes No NA
19	Does your ministry have written procedures for dismissal that covers all employee and volunteer positions?	Yes No NA
20	Are there written procedures that have been adopted should a sexual misconduct or child abuse issure surface?	Yes No NA
21	Are there written procedures that have been adopted should a sexual harassment, discrimination, or employment/volunteer issue surface?	Yes No NA
22	Are there written procedures that have been adopted for how claims and other such issues are to be dealt with and reported to our office and by whom?	Yes No NA
23	Does the ministry have an annual performance review procedure for all employees and volunteer leadership that is kept on file?	Yes No NA
24	Does the ministry have a ministry wide written adult/child ratio procedure that has been adopted that is required to be followed ministry wide?	Yes No NA
25	Does the ministry have adopted ministry wide data security and privacy procedures that are required to be followed?	Yes No NA
26	Does the ministry require parental involvement with their children in ministry events as much as possible and parent sign-offs for event involvement?	Yes No NA
27	Does the ministry habitually keep attendance records for all events both on and off location that on the ministry calendar including informal practice times by the adults in charge?	Yes No NA
28	Does the ministry habitually lock outside doors to prevent entry during off ministry times and days?	Yes No NA
29	Does the ministry have locked exterior doors with security, cameras, entry buzzers for entry during workdays to protect day workers?	Yes No NA
30	Does your ministry do an inventory of supplies and equipment annually?	Yes No NA
31	What is the average Sunday AM service attendance this year?
What is your current ministry employee count
32	Fulltime
33	Parttime
34	What type of ministries are included at your location?
35	Does your ministry include a latchkey program or other after school program please complete the school section below?	Yes No NA
36	Does your ministry include any type of educational entity other than sunday school please complete the school section below?	Yes No NA
37	Is your ministry a camp/retreat entity please complete the camp/retreat section below?	Yes No NA
38	Is your entity a denominational office please complete the denominaional office section below?	Yes No NA

[Other ministry Risk Factors]

	Question
1	Do we have the named insured for your property and liability policy stated on the policy the same as the registered titleholder of your property on your deed?	Yes No NA
2	Do we have all ministries listed correctly as a named insured on your policies?	Yes No NA
3	If you have leased equipment have you filed with our office paperwork so that we may let your leasing company know you have their equipment covered?	Yes No NA
4	Have you checked with the secretary of states' office to be sure your legal paperwork is up to date and in order?	Yes No NA
5	Do you have important paperwork properly secured such as, deeds, titles and other important documents organized with the location known by those that may need them?	Yes No NA
6	Is your legal paperwork properly activated and current?	Yes No NA
7	Do your insurance policies for property and vehicles properly list the title holder as the named insured?	Yes No NA
8	Are all vehicles owned and operated by your ministry listed on your auto policy?	Yes No NA
9	Have we insured all real estate, vacant land, and personal property titled to your ministry?	Yes No NA
10	Has your ministry reviewed any scheduled personal property listed with your insurance policy to see if valid for coverage?	Yes No NA
11	Has anyone recently willed any property to your ministry that we should know about to secure insurance coverage for it?	Yes No NA
12	Are there privacy issues for data on your ministry notebook and other equipment?	Yes No NA
13	When was the last time you reviewed your property, vehicle, employee benefits other insurance so that you know you are properly covered and understand new benefits and changes?
14	What do you believe as a ministry to be your greatest safety and security challenge and what actions have you taken to meet that challenge?

[Specific school risk factors for daycare, preschool, acadamy, college, or other educational entity please complete this section]

	Question
1	Please list this school year's student enrollment by grade?
2	For ministries with latchkey or other after school program please list students by grade
3	Please list Daycare student count by age that are enrolled this year
4	Please list hours of operation for your dayschool
5	Are all of your teachers state certified?	Yes No NA
6	Are your teachers certified by any other organization?	Yes No NA
7	Is your school currently state appoved?	Yes No NA
8	Do you have interscholastic sports this school year?	Yes No NA
9	Please list number of students for each sport for this school year?
10	Please list number of coaches for your sports for this school year?
11	What school sports will you include this school year?
12	Please list teacher count for this school year by grade?
13	Plesae list teacher aids for this school year that are employed?
14	Please list teacher aids by count for this school year that are volunteers?
15	Please list the total number of other staff employeed this year by the school

[Specific Camp/retreat Risk Factors]

	Question
1	Have you completed the inventory of camper days for this year?	Yes No NA
2	What activities or sports are included with your camp or retreat programs?
3	Do you do background and referrence check for all camp/retreat staff employees or volunteers?	Yes No NA
4	Do other entities rent your location?	Yes No NA
5	Do you ask for certificates of insurance?	Yes No NA

[Specific Denominational offic Risk Factors]

	Question
1	Do you have regular educational, workshops, or other meetings through out the year?	Yes No NA
2	If your answer to 1 is yes please list types, do you need certificates of insurance for any of these.
3	What is the current number of churches included with your office supervision area?

[Signature]


I declare that all of the above data given in this document regarding hazards as well as all other information contained herein, is true, complete and correct to the best of my knowledge and belief. I am aware that this statement is material to the company in determining my eligibility for insurance and applicability of available discounts. I understand that any person who submits a request for an insurance discount knowing that it contains a false or deceptive statement may be guilty of insurance fraud, which is a crime. Penalties may include imprisonment, fines and civil damages.
	Printed signature of policyholder reviewing this form:
	Date Signed

[Agent Section]

	Question
1	Year last Property Valuation Report was completed?
2	Agent comments from review of of claims history
3	Claim free status:
4	Other Agent Notes:
5	Name or signature of agency representative personally reviewing this form with the client:
6	E-mail address of agency representative personally reviewing this form with the client: