General Information

Organization Name

Doing Business As (if applicable)

FEIN

Year Established

Type

How many board members?

Mailing Address

Street Address City State ZIP Code

Is the Physical address is different than Mailing Address?

Yes

Physical Address

Street Address City State ZIP Code

Website

Contact

Name

Office Phone

Cell Phone

Can we text you?

Yes

Services

Do you offer any of the following services?

Adoption

Adult day care

Alzheimer’s

Anxiety disorder

Attention deficit

Autism

Boot camp

Child day care

Crisis stabilization

Correctional facility

Counseling services / therapy

Court designated criminally insane

Depression

Detoxification

Eating disorders

Ex-Offender

Family therapy

Fire starters

For profit program

Foster care

Home based hotline

Jail diversion

Juvenile justice

Learning disorders

Lock down facility

Manic disorder

Medication assisted treatment

Mental health

Mobile crisis

Pedophile treatment

Personality disorder

Post traumatic stress

Public clinic

Rape counseling

Residential care

Schizophrenia

School based

Sexual aggression

Sheltered workshop

Shock therapy

Smoking cessation

State hospitals / institutions

Other

What % of the overall operation is related to Adoption?

What % of the overall operation is related to Adult day care?

What % of the overall operation is related to Alzheimer’s?

What % of the overall operation is related to Anxiety disorder?

What % of the overall operation is related to Attention deficit?

What % of the overall operation is related to Autism?

What % of the overall operation is related to Boot camp?

What % of the overall operation is related to Child day care?

What % of the overall operation is related to Crisis stabilization?

What % of the overall operation is related to Correctional facility?

What % of the overall operation is related to Counseling services / therapy?

What % of the overall operation is related to Court designated criminally insane?

What % of the overall operation is related to Depression?

What % of the overall operation is related to Detoxification?

What % of the overall operation is related to Eating disorders?

What % of the overall operation is related to Ex-Offender?

What % of the overall operation is related to Family therapy?

What % of the overall operation is related to Fire starters?

What % of the overall operation is related to profit program?

What % of the overall operation is related to Foster care?

What % of the overall operation is related to Home based hotline?

What % of the overall operation is related to Jail diversion?

What % of the overall operation is related to Juvenile justice?

What % of the overall operation is related to Learning disorders?

What % of the overall operation is related to Lock down facility?

What % of the overall operation is related to Manic disorder?

What % of the overall operation is related to Medication assisted treatment?

What % of the overall operation is related to Mental health?

What % of the overall operation is related to Mobile crisis?

What % of the overall operation is related to Pedophile treatment?

What % of the overall operation is related to Personality disorder?

What % of the overall operation is related to Post traumatic stress?

What % of the overall operation is related to Public clinic?

What % of the overall operation is related to Rape counseling?

What % of the overall operation is related to Residential care?

What % of the overall operation is related to Schizophrenia?

What % of the overall operation is related to School based?

What % of the overall operation is related to Sexual aggression?

What % of the overall operation is related to Sheltered workshop?

What % of the overall operation is related to Shock therapy?

What % of the overall operation is related to Smoking cessation?

What % of the overall operation is related to State hospitals / institutions?

Please Select

Sexual offenders?

Sexual predators?

Fire starters?

Please describe other services:

Do you have any special events planned for the next 12 months?

Yes

Current Insurance

Do you currently have insurance?

Yes

Please explain

When does your insurance renew?

MM slash DD slash YYYY

Who are you insured with?

How long have you been insured with that company?

Have you had any claims in the last five years?

Yes

Please explain

Do you currently have Professional Liability coverage?

Yes

Type

Retroactive date

MM slash DD slash YYYY

Do you currently have Abuse and Molestation coverage?

Yes

Type

Retroactive date

MM slash DD slash YYYY

Property

Physical address	Building description:	Year built	Total building square footage	Total building square footage	Roof type	Heating source?	Basement?	% Finished	% Unfinished	Number of stories	Distance from Fire Station	Distance from Fire Hydrant	Type of alarm	Sprinkler system?	Actions

There are no Entries.

Maximum number of entries reached.

Do you own or have on premises any of the following?

Art

Individual electronic valued over $2,500

Machinery (Riding lawnmower, snowplow, etc.)

Swimming Pools

Trailer(s)

Financials

What was last year’s revenue?

What is this year’s projected revenue?

Projected total payroll for this year?

Number of clients/customers served each year?

Does you keep more than $5,000 in cash on premises at any time?

Yes

Is the organization more than 25% owned by a private equity fund structure?

Yes

Private Equity Firm Name

Does the organization offer any of the following?

Employee Welfare Benefit Plan

Defined Contribution Plan

Defined Benefit Plan

Other

Employee Welfare Benefit Plan

Plan Name	Year Established	Assets/Contributions	Participants	Administrator	Actions

There are no Entries.

Maximum number of entries reached.

Defined Contribution Plan

Plan Name	Year Established	Assets/Contributions	Participants	Administrator	Actions

There are no Entries.

Maximum number of entries reached.

Other

Plan Name	Year Established	Assets/Contributions	Participants	Administrator	Actions

There are no Entries.

Maximum number of entries reached.

Defined Benefit Plan

Plan Name	Year Established	Assets/Contributions	Participants	Administrator	Actions

There are no Entries.

Maximum number of entries reached.

Staff and Volunteers

Staff and Volunteers List

Position Description	Class Code	# of Employees – FT or PT	# of Contracted – FT or PT	Volunteer Hours	Annual Payroll	Actions

There are no Entries.

Maximum number of entries reached.

What percentage of employees or volunteers use their own vehicle for work related business?

Please enter a number greater than or equal to 0.

Describe use

Does your employment process include verification of whether the individual has ever been convicted of any crime, including sex related or child-abuse related offenses, before an offer of employment is made?

Yes

Do you have a written crisis plan in place?

Yes

Do you have an employee handbook?

Yes

Is there formal staff training for volunteers and staff on child/sexual abuse, including how to recognize the signs?

Yes

How often is training conducted?

Are there procedures prohibiting closed door one-on-one meetings / counseling?

Yes

Have any incidents resulted in an allegation of sexual abuse or workplace violence?

Yes

Please explain

Was the case settled?

Yes

Was the case taken to trial?

Yes

Amount paid for damages to the victim?

Special Events

Events

What type of event?	Other type of event	Event date	Hours of operation	Total anticipated revenue	Held on your premises?	Address of where it is being held	Number of participants	Number of staff members / volunteers needed	Are certificates of insurance obtained from everyone providing products / services?	Do participants sign a waiver?	Will you be offering/selling alcohol?	Actions

There are no Entries.

Maximum number of entries reached.

Transportation

Does the organization own any vehicles?

Yes

Do you require employees and volunteers to carry and show evidence of personal insurance?

Yes

What limits are required?

Do you have a driver safety program?

Yes

Do you transport clients?

Yes

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