SAM Insurance Application

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Jigsaw Risk Management is a risk purchasing group administered by Risk Placement Services Inc (RPS). RPS is a licensed insurance intermediary, BOKRIM is not. Jigsaw/RPS and BOKRIM are unrelated.

If you would like Jigsaw/RPS to explore the SAM insurance market for SAM liability insurance terms for you, please complete the application form below as fully as possible.

When you submit the completed form, Jigsaw/RPS will use the information you provide to try to obtain a quotation for SAM insurance for you.

If you have any questions for BOKRIM about this arrangement, please call (415) 598-4255. Because BOKRIM is not a licensed insurance intermediary, they will not be able to answer any insurance-related questions.

If you would like to RPS about SAM insurance or this application, please call (630) 285-3790. RPS are wholesale insurance intermediaries and will be able to help you find an agent who can help you with any insurance-related questions you may have.

1The Applicant

2Minors and vulnerable adults

3Adults

4Activities

5SAM risk management

6SAM insurance

7SAM claims

8Review and submit

Information about the adults who work with or for the applicant
How many individuals fall into each category below?
Can or do work with minors or vulnerable adults Should not work with minors or vulnerable adults
You should include all employees, all contractors, all forms of consultant, and all volunteers who work for or with the applicant in this calculation. Someone who can or does work with minors or vulnerable adults is someone applicant foresees will work regularly or occasionally with minors or vulnerable adults. Someone who should not work with minors or vulnerable adults is someone the applicant doesn't foresee ever working with minors or vulnerable adults.
How many individuals in each category below are male?
Can or do work with minors or vulnerable adults Should not work with minors or vulnerable adults
You should include all employees, all contractors, all forms of consultant, and all volunteers who work for or with the applicant in this calculation. Someone who can or does work with minors or vulnerable adults is someone applicant foresees will work regularly or occasionally with minors or vulnerable adults. Someone who should not work with minors or vulnerable adults is someone the applicant doesn't foresee ever working with minors or vulnerable adults.
What is the annual employee turnover percentage?

Annual turnover percentage is the average number of employees over last year, divided by the number of employees who left last year, multiplied by 100.
Provide total headcount of all individuals who have worked with or for the applicant in each of the last five years
-1 -2 -3 -4 -5
How many educators working with or for the applicant are...
Teachers
...and how many of the teachers are male
Substitute teachers
...and how many of the substitute teachers are male
Teachers' assistants
...and how many of the teachers' assistants are male
Coaches
...and how many of the coaches are male
Counselors
...and how many of the counselors are male
Clergy
Clergy are formal leaders in religious organizations.
...and how many of the clergy are male
Religious
Religious are individuals such as Nuns or Monks who are devoted to religious life but are not clergy
...and how many of the religious are male
Office staff
...and how many of the office staff are male
Volunteers
...and how many of the volunteers are male
"Others" in education
Describe "others" in education
...and how many of the "others" in education are male
How many individuals fall into each of the following categories:
Corporate staff Drivers Volunteers
...and how many in each category are male:
Corporate staff Drivers Volunteers
How many people working with or for your non-profit organization are...
Doctors
... and how many doctors are male
Physician assistants
... and how many physician assistants are male
Nurses
... and how many nurses are male
Counselors
... and how many counselors are male
Clergy
Clergy are formal leaders in religious organizations.
... and how many clergy are male
Religious
Religious are individuals such as Nuns or Monks who are devoted to religious life but are not clergy
... and how many religious are male
Office staff
... and how many office staff are male
Volunteers
... and how many volunteers are male
"Others" in non-profit
Describe "others" in non-profit
... and how many "others" in non-profit are male
How many people working with or for your healthcare organization are...
Doctors
... and how many doctors are male
Physician assistants
... and how many physician assistants are male
Nurses
... and how many nurses are male
Counselors
... and how many counselors are male
Office staff
... and how many office staff are male
Volunteers
... and how many volunteers are male
Clergy
Clergy are formal leaders in religious organizations.
... and how many clergy are male
Religious
Religious are individuals such as Nuns or Monks who are devoted to religious life but are not clergy
... and how many religious are male
"Others" in healthcare
Describe "others" in healthcare
... and how many "others" in healthcare are male
How many people working with or for your religious organization are...
Clergy
Clergy are formal leaders in religious organizations.
... and how many clergy are male
Religious
Religious are individuals such as Nuns or Monks who are devoted to religious life but are not clergy
... and how many religious are male
Coaches
... and how many coaches are male
Counselors
... and how many counselors are male
Office staff
... and how many office staff are male
Missionaries (outside of domicile)
... and how many missionaries (outside of domicile) are male
Foreign missionaries (visitors)
... and how many foreign missionaries (visitors) are male
Volunteers
... and how many volunteers are male
"Others" in religious
Describe "others" in religious
... and how many "others" in religious are male
How many people working with or for the applicant are...
Customer service
... and how many in customer service are male
Management
... and how many in management are male
Doctors
... and how many doctors are male
Nurses
... and how many nurses are male
Office staff
... and how many office staff are male
Counselors and therapists
... and how many counselors and therapists are male
Coaches
... and how many coaches are male
Masseurs
... and how many masseurs are male
Volunteers
... and how many volunteers are male
"Others" in leisure
Describe "others" in leisure
... and how many "others" in leisure are male
How many people working with or for the applicant camp organization are...
Clergy
Clergy are formal leaders in religious organizations.
... and how many clergy are male
Doctors
... and how many doctors are male
Nurses
... and how many nurses are male
Office staff
... and how many office staff are male
Counselors or therapists
... and how many counselors or therapists are male
Coaches
... and how many coaches are male
Kitchen, maintenance, or housekeeping
... and how many in kitchen, maintenance, or housekeeping are male
Volunteers
... and how many volunteers are male
"Others" in camp
Describe "others" in camp
... and how many "others" in camp are male
Describe 'other'

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Information about incident response and claim handling and about past claims
Describe how you handle allegations or suspicions of any form of sexual abuse or misconduct:
Has applicant had any claim for any form of sexual abuse or misconduct made against it in the last 10 years?
- Yes
- No
Please furnish the past 10 years first dollar loss history for all sexual abuse and misconduct claims
Year # of circumstances # of claims Total loss paid Total expense paid Total current loss reserves Total current expense reserves Total incurred (paid + reserves)

A circumstance involves knowledge of any information that would lead a reasonable person to suspect that a claim of a type potentially covered by sexual abuse or misconduct insurance could be made in the future, even though full information is not then available. A claim involves receipt of a suit demanding damages or other relief.
Please provide a complete description of each individual claim and how it was resolved.
We will require the following information: The alleged victim/claimant; The alleged perpetrator/defendant; Their ages; The venue; When the abuse is alleged to have occurred; When the claim was made; The nature of the claim and allegations; The name of your defense attorney and law firm; The name of the plaintiff attorney and law firm; If closed, how much was paid in defense and settlement; If open, claimant's demand, insurer reserve, defense costs incurred to-date, your settlement offer, and your estimate of the settlement amount; Details of remedial actions taken to prevent a recurrence. Please use the upload button below if this helps provide more detail.
If the information on past claims is more easily shared by uploading a document or spreadsheet, please do so here.
Accepted file types: pdf, doc, xls, Max. file size: 256 MB.
Has any individual working for or with the applicant, now or in the past, ever been accused or suspected of any form of inappropriate sexual behaviour of any kind?
- Yes
- No
Please provide a complete description of the accusation or suspicion and how the situation was resolved.
Has anyone who works for or with the applicant ever been the subject of a claim or suit alleging or involving any type of inappropriate sexual behaviour?
- Yes
- No
Please provide a complete description of the claim or suit and how the situation was resolved.
Are you aware of any situation or circumstance that could lead to a claim for any type of inappropriate sexual behaviour being made against the applicant or any individual working for or with the applicant?
- Yes
- No
The
Please provide full details of any situation or circumstance that could lead to a claim for any type of inappropriate sexual behaviour being made against the applicant or any individual working for or with the applicant.
If you need to up-load documents to us, so we understand all your answers fully, please upload them here.
Drop files here or

Accepted file types: pdf, doc, xls, Max. file size: 256 MB.
Phone number
If you are happy for us to call you, please provide the best number to call you on, in case we have questions about this application. If you have questions for us, you can email your question or phone number (or both!) to info@jigsawrisk.com

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SAM Insurance Application – from BOKRIM

Information about the Applicant

Information about the minors and vulnerable adults the applicant works with

Information about the adults who work with or for the applicant

Further information about the applicant's activities

Information on SAM prevention, identification, and mitigation

Information about SAM insurance

Information about incident response and claim handling and about past claims

Please review the information you have provided before submitting this application.

Year	# of circumstances	# of claims	Total loss paid	Total expense paid	Total current loss reserves	Total current expense reserves	Total incurred (paid + reserves)