Number of Employees: Number of Volunteers: Do the employees or volunteers use own vehicles on behalf of the organization? Yes No If yes, enter the approximate number of employees/volunteers that use their own vehicle for organization business: Occasionally: Frequently: How many drivers run errands using their own vehicles for company business? How many drivers transport clients in own vehicles for company business? Do you obtain copies of insurance policies for volunteers and employees who use their own vehicles? Yes No Do you require insurance limits of at least 100/300/100? Yes No If No, what limits do you require? Are MVR’s checked on volunteers/employees? Yes No Do you have a driver safety program? Yes No Are seat belts required to be worn by all occupants? Yes No In order to obtain non-owned coverage, it is required for your own protection that all employees/volunteers who use their own vehicles regularly maintain personal auto limits of 100/300/100 with a copy of current insurance limits on file with the non-profit. Are you willing to follow this procedure to protect the non-profit? Yes No your employees and volunteers employees volunteers Independent Please provide the number of each type of caregivers and annual annual payroll Contractor payroll for each category ft pt ft pt $ Clergy, social worker LPN, Sonographer, radiology tech., certified nursing assistance, $ other medical tech. $ rn $ Medical Director $ Executive director $ Psychologist, licenced professional counselor $ Nurse Practitioner, Physician Assistant, Paramedic, EMT Medical Doctor / D.O. $ (attach Physician Information sheet for each) $ Administrative/clerical Only $ Other (Client Contact only) Your Physician(S) Please have all physicians complete a physician application Name Description of Duties Date of Hire
Number of Employees: Number of Volunteers: Do the employees or volunteers use own vehicles on behalf of the organization? Yes No If yes, enter the approximate number of employees/volunteers that use their own vehicle for organization business: Occasionally: Frequently: How many drivers run errands using their own vehicles for company business? How many drivers transport clients in own vehicles for company business? Do you obtain copies of insurance policies for volunteers and employees who use their own vehicles? Yes No Do you require insurance limits of at least 100/300/100? Yes No If No, what limits do you require? Are MVR’s checked on volunteers/employees? Yes No Do you have a driver safety program? Yes No Are seat belts required to be worn by all occupants? Yes No In order to obtain non-owned coverage, it is required for your own protection that all employees/volunteers who use their own vehicles regularly maintain personal auto limits of 100/300/100 with a copy of current insurance limits on file with the non-profit. Are you willing to follow this procedure to protect the non-profit? Yes No your employees and volunteers Please provide the number of each type of caregivers and annual payroll for each category employees volunteers Independent Contractor annual payroll ft pt ft pt Clergy, social worker $ LPN, Sonographer, radiology tech., certified nursing assistance, other medical tech. $ rn $ Medical Director $ Executive director $ Psychologist, licenced professional counselor $ Nurse Practitioner, Physician Assistant, Paramedic, EMT $ Medical Doctor / D.O. (attach Physician Information sheet for each) $ Administrative/clerical Only $ Other (Client Contact only) $ Your Physician(S) Please have all physicians complete a physician application Name Description of Duties Date of Hire
package_app_0514.docx