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Municipal Entity Underwriting Application

1.

Number of centers operated?

2.

Number of staff providing care?

3.

Number of days open per week?

4.

Hours of Operation?

5.

Describe care provider employment requirements (experience and credentials).  

6.

Number of individuals care is provided for.  

7.

Is a minimum of two background checks for prospective employees and volunteers with documentation maintained in file?

 Yes

 No

8.

Do background checks include checks with “Sex Offender Hot-Lines, “State Police, State Dept. of Social Services or similar public agencies?

 Yes

 No

Children

Adults

Average Number Per Day

Maximum Number Per Day

9.

Is transportation provided by your entity?

If yes, please describe.  

 Yes

 No

EMERGENCY SERVICES SUPPLEMENTAL Information

LAW ENFORCEMENT

1.

Number of Full Time Armed Officers?

2.

Number of Part Time Armed Officers?

3.

Number of Full Timed Unarmed Officers?

4.

Number of Part Time Unarmed Officers?

5.

Number of Dispatchers / Clerical?

6.

Number of Police Dogs?

7.

Do District Attorneys / Prosecutors have arrest authority or arrest warrant authority?

 Yes

 No

8.

Dispatching Services.

a.

Does your entity handle its own dispatch?

 Yes

 No

b.

Does your entity dispatch for other public or private entities?

 Yes

 No

c.

How many entities?

d.

What is the total population served?

e.

Are incoming calls to dispatchers recorded?

 Yes

 No

f.

How long are tapes maintained?

g.

What services are dispatched (e.g. Emergency, Fire, Police, etc.)?

9.

Policies & Procedures Manuals.

a.

Does your entity have a policy and procedures manual?

Date of manual?

Date of last revision / update?

 Yes

 No

b.

Is the manual reviewed annually by legal counsel?

Counsel's Name?  

 Yes

 No

c.

Is the manual distributed to all personnel?

 Yes

 No

i.

Is the manual reviewed with them periodically as part of their formal training?

 Yes

 No

12 of 3410/23/2007

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