Please enable JavaScript in your browser to complete this form. - Step 1 of 3Please Upload a PDF of your existing policies before continuing * Click or drag files to this area to upload. You can upload up to 10 files. NextDo you desire a Line of Duty Accidental Death Benefit?YesNoPlease select your desired Line of Duty Death Benefit limit.$1,000$2,000$3,000$4,000$5,000$6,000$7,000$8,000$9,000$10,000Other amountCheck box if applicable. Does your organization:Operate boats greater than 100hpOperate Carnivals or field days with mechanical amusement ridesSponsor ConventionsSponsor FireworksHost a Bingo gameSponsor Motorized events (Tractor pulls, Mud bogs, Destruction derby, etc.)Own grandstands or bleachersHave a social clubHave vacant landParticipate in any sports activities on a league basisWhich best describes your organizations use of alcoholic beverages?prohibits alcohol on the premises and at sponsored functions.permits alcohol on the premises or at sponsored functions, but does not sell it.provides bartenders to serve alcohol supplied by others.Year-round (bar or club)Liquor License or permit required by the state?YesNoLiquor License or permit obtained?YesNoAnnual Gross Receipts from alcohol sales: PreviousNextHas your organization entered into any written agreements to have another entity perform fire/EMS/rescue or dispatching services for you?YesNoIf “Yes”, please forward a copy of all such contracts.Does applicant use paramedics / firefighters contracted out to applicant by a labor leasing firm?YesNoNumber of members leased on Full-Time basis Selected Value: 0Please forward a copy of all such contractsNumber of members leased on Part-Time basis Selected Value: 0Please forward a copy of all such contractsDoes your organization have a specially organized HazMat team?YesNoWhat is the level of state certification or licensing for your organization?Not state certified or licensedFirst responderBasic life supportAdvanced life supportWhat is the highest level of service provided?Non-medical onlyBasic life supportAdvanced life supportHow often are medical emergency responder's certifications checked?Who checks and maintains records of those certifications? Name and position.Does your department perform fire code and/or building code inspections?YesNoDoes applicant sponsor a junior firefighter program or explorer post?YesNoAre criminal background checks performed on all leaders?YesNoDoes your organization have written rules stating that a leader should never be alone with any member or junior member of such programs?YesNoSubmit
